Health inspection·May 7, 2025

Title 42, F600, Free from Abuse and Neglect Section, 483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. (a) The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Title 42, F606, Employ/Engage Staff with Adverse Actions, Section 483.12 (a) The facility must- (3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. Title 42, F610, Investigate/Prevent/Correct Alleged Violations, Section 483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Title 42, F609, Reporting of Alleged Violations Section 483.12(c)(1) (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Health and Safety Code, Section 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. Title 22, Nursing Service - Patient Care, Section 72315 (a) No patient shall be admitted or accepted for care by a skilled nursing facility except on the order of a physician. (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. Title 22, Administrative Policies and Procedures, Section 72521 (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. (b) All policies and procedures required by these regulations shall be in writing and shall be carried out as written. They shall be made available upon request to patients or their agents and to employees and the public. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the governing body or licensee. (c) Each facility shall establish at least the following: (1) Personnel policies and procedures which shall include: (A) Written job descriptions detailing qualifications, duties and limitations of each classification of employee available (F) Verification of licensure, credentials and references. Title 22, Patients' Rights, Section 72527 (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. On 1/30/25 at 1:42 p.m. an unannounced visit was conducted at the facility to investigate sexual abuse regarding multiple residents by a staff member. The Department determined the facility failed to protect the residents' right to be free from sexual abuse by a staff member for one of ten sampled residents (Resident 1) when: - Certified Nursing Assistant 1 (CNA 1) sexually assaulted (sexual contact upon a person without their consent or on a person who is incapable of providing consent. Includes rape, unwanted sexual touching, oral sex and exposure) Resident 1, - The facility knowingly employed CNA 1 with a history of a criminal misdemeanor (an offense punishable under criminal law), - The facility failed to thoroughly investigate staff to resident allegations of sexual abuse after the facility's initial investigation, and - The facility failed to report immediately to the Department the allegation of sexual abuse for Resident 1 when the Department received the facility's reports of alleged sexual abuse after two hours of occurrence. These failures caused the resident anxiety and put him at risk for long term psychosocial trauma such as social isolation, emotional instability, post-traumatic stress disorder, suicidal risk and resulted in the facility not identifying or reporting all victims of abuse in a timely manner which delayed counseling, monitoring and increased the risk for unmet emotional trauma. On 2/21/25 at 7:25 p.m. an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADM) and the Regional Director of Operations (RDO). The IJ began on 12/10/24 when the facility hired CNA 1 with a known criminal history of abuse. The ADM and RDO were informed of the facility's failure to have systems in place to ensure all residents were protected from sexual abuse. On 2/24/25 at 3:35 p.m. during an onsite visit, the Department verified and confirmed the IJ was removed after the facility presented an acceptable plan of action (POA, interventions to correct the deficient practice) on 2/21/25 at 9:21 p.m. which included: - Immediate suspension of CNA 1 on 1/24/25 - Physician visits to residents subjected to abuse - Activity Director visits to residents subjected to abuse - Psychosocial assessments, and trauma assessment completed for all victims - Every shift monitoring of victims by nursing staff, reviewed by ADM or designee - Audit of all current employee files for history of abuse, adverse actions on background - In-service on preventing abuse and reporting abuse - Physical assessment and interview of all victims Findings: During an interview on 1/30/25 at 1:42 p.m. with the ADM and Director of Nursing (DON), the ADM stated she first learned of the incident with CNA 1 and Resident 1 during the evening of 1/24/25. The ADM stated they suspended CNA 1, and he left the building at 9:15 p.m. on 1/24/25. The ADM stated CNA 1 was hired 12/10/24. The ADM stated, "We do an initial interview, we check references and do a background check." The ADM stated CNA 1's background check was completed, and she "believed" the DSD (Director of Staff Development) checked references. During a concurrent interview and record review on 1/30/25 at 2:30 p.m. with the ADM of CNA 1's "BACKGROUND SCREENING REPORT [BSR]," dated 12/3/24 the BSR indicated, "County Criminal History in [name of county] ...INFORMATION FOUND...Charge KNOWLINGY TOUCH WITH INTENTION TO INJURE/INSULT/PROVOKE PERSON...Crime Type MISDEMEANOR...Disposition PLEA OF GUILTY OR RESPONSIBLE; SENTENCE IMPOSED Filing date 10/23/2019..." The ADM confirmed she was aware of the BSR prior to CNA 1 being hired and stated, "He did explain to the DSD that it was a fight between he and his husband..." During an interview on 1/30/25 at 3:08 p.m. with the ADM, the ADM was asked if the staff had voiced any concerns regarding CNA 1 and stated, "...he came in to work one day with a black eye..." During an interview on 1/30/25 at 3:18 p.m. with the DSD, the DSD stated, "...On Friday the 24th he had been late to his shift...He did have two blackened eyes and a small cut on his cheek..." When asked about CNA 1's BSR misdemeanor, the DSD stated, "[CNA 1] came forward on 12/3/24 about the information on his BSR incident dated 2019. He mentioned that he had several job opportunities and had no problem getting them after he explained what happened..." During an interview on 2/3/25 at 10:28 a.m. with the DSD, the DSD stated she did not contact CNA 1's previous employer [skilled nursing facility] she was "not able to reach them...called and left messages, but they did not return the call." During a concurrent interview and record review on 2/4/25 at 10:45 a.m. with the DSD of text message between the DSD and CNA 1, the DSD was asked what reference she called and stated, "There are no specifics of who I call...I will do personal and professional..." The DSD provided a document which contained CNA 1's text message on 12/3/24 to the DSD which indicated, "...I [CNA 1] received an email for the background check...It's a long story, to shorten it down called the cops on myself. Due to the nature of the situation, I was arrested and later charged. It was involving me and my husband..." The DSD stated she brought the information to the ADM on 12/3/24 and the ADM and DSD called CNA 1 on 12/3/24 who gave further details of the charges. During an interview on 2/4/25 at 2:30 p.m. with the ADM and DON, the ADM confirmed she was aware of CNA 1's previous charges and chose to hire him and stated, "... [CNA 1] explained it as a domestic abuse." The ADM stated her expectations, "Residents are treated with dignity and respect. They are not to be abused." A review of Resident 1's clinical record indicated Resident 1 was admitted to the facility in early 2022 with diagnoses which included muscle weakness, encephalopathy (a medical condition that affects the brain's function), and intracranial injury (injury to the brain). During a review of Resident 1's Minimum Data Set (MDS, federally mandated resident assessment tool) dated 11/23/24, the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 4/15, which indicated severe cognitive impairment. During a review of Resident 1's "Order Summary Report [OSR]," order date 3/28/22, the OSR indicated, "Resident is incapable of making health care decisions..." A review of the facility's document titled, "Report of Suspected Dependent Adult/Elder Abuse," indicated the report was faxed to the Department on 1/25/25 at 12:21 a.m. The report further indicated the alleged abuse occurred on 1/24/25 around 8:30 p.m. and Resident 1 acknowledged that Certified Nursing Assistant 1 (CNA 1) was shirtless in his room. During a review of Resident 1's "Progress Notes [PN]," dated 1/27/25 at 6:56 p.m. the PN indicated, "On 1/24/25 at approximately [8:30 p.m.] CNA [CNA 2] notified this nurse that a male CNA [CNA 1] assigned to the resident has no shirt on when doing care to the resident..." During a review of the police report (Interview of CNA 1), dated 1/28/25, the report indicated CNA 1 confirmed he had [sexually assaulted] Resident 1. During a review of Resident 1's PN, dated 1/29/25 at 7:15 a.m. the PN indicated, "Resident is noted to keep one hand in his brief covering his private area. CNA's [Certified Nursing Assistant] are having trouble with ADL [Activities of Daily Living: basic tasks such as bathing, toileting] care. They are able to do care but takes reassurance." During an interview on 2/3/25 at 9:30 a.m. with Police Officer (PO 1) in the police department, PO 1 confirmed CNA 1 admitted to [sexual assault] on Resident 1. During a concurrent observation and interview on 2/3/25 at 1:12 p.m. with Resident 1 in his bedroom, Resident 1 was sitting in a reclining wheelchair, he was unable to reposition himself or stand. Resident 1 was unable to have any meaningful conversation. During an interview on 2/3/25 at 3:19 p.m. with CNA 2, CNA 2 stated, "I was doing my rounds [evening shift of 1/24/25]...I saw that Resident 1's door was closed, and I was confused because I was his CNA...the curtain was all the way closed [around Resident 1's bed] ...I saw heels of shoes from under the curtain like they were kneeling...I saw [CNA 1] with Resident 1's bed all the way to the floor. [CNA 1's] shirt was off. Resident 1's brief [adult incontinence undergarment] was all the way off. [CNA 1's] hands were on [Resident 1's] [groin area] ..." During an interview on 2/4/25 at 11:23 a.m. with CNA 3, CNA 3 stated since the incident with CNA 1 she has had difficulty providing care for Resident 1 "[Resident 1] would cover his penis with his hands when I am assisting him with his brief. This is new behavior." During an interview on 2/4/25 at 11:43 a.m. with CNA 4, CNA 4 stated, "[Resident 1's] appetite has not been the same... [Resident 1] has been constantly trying to hold and cover himself [indicated to groin], even when he is eating." During an interview on 2/4/25 at 12:31 p.m. with Licensed Nurse (LN 2), LN 2 stated, "We have to do STD [sexually transmitted disease] testing on all the residents. It's a lot for the residents." During review of the facility's five day follow up for Resident 1 dated 1/29/25, the facility unsubstantiated the allegations of abuse. During a concurrent interview and record review on 2/21/25 at 12 p.m. with the ADM of Resident 1's "Report of Suspected Dependent Adult/Elder Abuse," the ADM confirmed the report was sent to the Department more than two hours after facility was made aware of the alleged abuse incidents and stated it should have been reported within two hours to ensure residents' safety and to meet the requirements of abuse reporting. During a review of the facility's policy and procedure (P&P) titled, "Abuse, Neglect and Exploitation," dated 2023, the P&P indicated, "It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse...'Abuse' means the willful infliction of injury...Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse...[Criminal sexual abuse]...serious bodily also includes sexual intercourse with a resident who is incapable of declining to participate in the sexual act or lacks the ability to understand the nature of the sexual act...'Physical Abuse' includes, but is not limited to hitting, slapping...[Sexual abuse] is non-consensual sexual contact of any type with a resident...Establish policies and procedures that: prohibit and prevent abuse...Establish policies and procedures to investigate any such allegations... Potential employees will be screened for a history of abuse...Background, reference, and credentials' checks shall be conducted on potential employees...Possible indicators of abuse include, but are not limited to: sudden unexplained changes in behavior and/or activities such as fear of a person or place, or feelings of guilt and shame... An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur...Identifying and interviewing all involved persons...Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause...The