Health inspection·May 15, 2025

The following reflects the findings of the California department of Public Health during the investigation of a facility reported incident number 948405. Health & Safety Code §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. On 3/6/25, an announced visit was conducted at the facility to investigate a facility reported incident regarding alleged abuse towards one long-term care resident (Resident 1). Resident 1 was a 48-year-old female, admitted to the facility on 1/3/2024. Resident 1's diagnoses included hemiplegia (muscle weakness or partial paralysis [unable to move body] on one side of the body that can affect the arms, legs, and facial muscles) and hemiparesis (is weakness on one side of the body, often affecting the arm, leg, and potentially the face) following cerebral infarction (is a condition where blood flow to the brain is blocked, leading to brain tissue damage) affecting left non-dominant side and general anxiety disorder (a mental health condition characterized by persistent and excessive worry about everyday things, making it difficult to control and significantly impacting daily life). Based on interview and record review, the facility failed to ensure the allegation of sexual abuse for one of three sampled residents (Resident 1) was reported timely to California Department of Public Health (CDPH-local stated agency) and local ombudsman (representatives assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences). This failure had the potential for Resident 1 not to be protected from further abuse and resulted in emotional distress. During a review of the facility provided document titled, "Incident Investigation For (Resident 1)," dated 2/25/25, the document indicated, "Interview conducted by Director of Nursing (DON) on 2/24/25 with (Resident 1) . . .(Resident 1) has a BIMs (Brief Interview for Mental Status) of 15 (a score of 13 to 15 suggests the resident is cognitively intact). . . (Resident 1) reported on the night of 02/19/2025 (Licensed Vocational Nurse [LVN] 1) went into her room and kissed her on the corner of her mouth. . . (Resident 1) stated, "It made me feel uncomfortable and very unsafe." . . . Staff member (LVN 1) suspended on 02/24/2025" During a concurrent interview and record review, on 3/6/25 at 10:21 a.m. with Director of Nursing (DON), the "SOC 341 (Report of Suspected Dependent Adult/Elder Abuse)," dated 2/25/25 was reviewed. DON confirmed the SOC 341's were faxed to CDPH and local ombudsman on 2/25/25. During an interview on 3/6/25 at 11:07 a.m. with Resident 1, Resident 1 stated LVN 1 entered her room on 2/19/25 and kissed her on the corner of her mouth which made her feel uncomfortable. Resident 1 stated she did not have a close relationship with LVN 1 where kisses or hugs were acceptable. Resident 1 stated she had seen LVN 1 once after the incident. During an interview on 3/19/25 at 3:54 p.m. with LVN 2, LVN 2 stated she was working on 2/19/25 at around 7 p.m. she noted LVN 1 entered the facility with her husband, baby and dog, so she texted the DON because she thought it was unusual for LVN 1 to show up to the facility after her shift was over and visit the staff and residents. LVN 2 stated Resident 1 reported to her LVN 1 kissed her by her lips (2/19/25). LVN 2 stated Resident 1 stated she felt "drunk raped." LVN 2 stated Resident 1 told her LVN 1 smelled like alcohol and LVN 1 made her (Resident 1) feel uncomfortable. LVN 2 stated she reported the information to the DON on 2/19/25. LVN 2 stated after the incident with LVN 1 Resident 1 was more anxious (feelings of worry, tension, and fear, often in anticipation of future events or situations) than usual and quieter. LVN 2 stated Resident 1 was prescribed hydroxyzine (medication used to help control anxiety and tension caused by nervous and emotional conditions) for the anxiety after the incident. During a review of Resident 1's "Psychiatric Follow Up Evaluation," (PFUE) dated 2/25/25, the PFUE indicated, "Emergency Encounter: . . . (Resident 1) states that a nurse, who was unscheduled, arrrived [sic] at the facility and entered her room and kisssed [sic] her neat [sic] the mouth. . . She does claim that for the past week she has been having some anxiety and would like some medication that she ccan [sic] take when she is feeling anxious At this time, Hydroxyzine has been ordered to help with her anxiety. . ." During a review of Resident 1's "Medication Administration Record," (MAR) dated February 2025, the MAR indicated, Resident 1 was administered Hydroxyzine on 2/26/25 and 2/27/25 for anxiety. During a review of the facility's policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating," revised September 2022, the P&P indicated, "All reports of resident abuse . . . are reported to local, state and federal agencies. . . 1. If resident abuse, . . .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2.The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; . . . 3."Immediately" is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 4. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone." During a review of the facility provided document titled, "SOC 341," revised 2/2024, the document indicated, "Report Of Suspected Dependent Adult/Elder Abuse General Instructions . . . Reporting Responsibilities And Time Frames: . . . In all other of abuse that occurred in a Long-Term Care (LTC) facility . . . a verbal report shall be made by telephone to the local law enforcement agency immediately and no later than two (2) hours after observing, obtaining knowledge of, or suspecting physical abuse. Send the written report to local law enforcement agency, the local Long-Term Care Ombudsman Program (LTCOP), and the appropriate licensing agency (for long-term health care facilities, the California Department of Public Health . . . within twenty-four (24) hours of observing, obtaining knowledge of or suspecting physical abuse." In violation of the above cited, the facility failed to ensure staff reported an abuse allegation timely. This failure resulted in a delay of the investigation, Resident 1 not to be protected from further abuse and resulted in emotional distress. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1 and constitutes a class "B" citation.