Other·July 23, 2021

The following reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint: 725496 Representing the Department: 42638, HFEN A State Class B Citation was written. California 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 requirement of this section shall be a class "B" violation. (c) For purposes of this section, "abuse" shall mean any of the conduct described ins subdivisions (a) and (b) of Section 15610.07 of the Welfare and Institutions Code. On 2/16/21 at 12 PM, an unannounced visit was conducted at the facility to investigate a complaint of suspected sexual assault between Resident 1 and Resident 2 that was not reported to the Department. This resulted in both residents being at risk for sexual abuse. The facility failed to report an episode of suspected sexual abuse to the Department as required by law. Resident 1 is a 64-year-old female admitted to the facility on 11/2/17 with dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and behavioral disturbances. Resident 2 is a 90-year-old male admitted to the facility on 8/30/20 with heart and lung disease, as well as dementia. During an interview of 2/16/21, at 12:20 PM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated, on the morning of 2/12/21, CNA 1 found Resident 1 in Resident 2's bed, with Resident 1's pants down, but with a brief on, while Resident 2 was standing near the bed. CNA 2 stated, Resident 2 was "messing" with Resident 1's brief. CNA 1 stated, the situation appeared to be of a sexual nature. CNA 1 stated, that she immediately notified the Charge Nurse (CN). CNA 1 stated she did not notify anyone outside of the facility. CNA 1 stated, Resident 1 "has a habit of getting into other people's beds and in their underwear." During an interview on 2/16/21, at 12:30 PM, with CNA 2, CNA 2 stated, on the morning of 2/12/21, while escorting Resident 1 out of Resident 2's room, Resident 2 stated he and Resident 1 were "having a little fun." CNA 2 stated that Resident 2 has severe cognitive impairment and sometimes erroneously believes Resident 1 is his wife. CNA 2 stated, she immediately reported this incident to the CN, who then assessed Resident 1. During an interview on 2/16/21, at 1:10 PM, with the Social Services Director (SSD), SSD stated, CN examined Resident 1, and there was possibly blood near Resident 1's genitalia. SSD stated, "It is pretty much an every-day thing that she [Resident 1] winds up in the wrong bed." SSD stated that Resident 1 is normally dressed in overalls to make dis-robing more difficult, but "on the day it happened, Resident 1 was in regular pants." SSD stated that when questioned, Resident 1 was non-verbal, and Resident 2 had no memory of the event. During an interview of 2/16/21, at 12:45 PM, with the Director of Nursing (DON), the DON stated, the facility did not report this incident to the Department was because the facility did not believe any sexual abuse occurred. During an interview on 2/20/21, at 11:18 AM, with CN, the CN stated that Resident 1 was found in Resident 2's bed. CN stated she performed a physical exam with no signs of abuse. During a review of Resident 1's "Progress Notes," dated 2/12/21, at 12:41 PM, it indicated "There was a small amount of blood noted to [Resident 1's] vagina. . .DON notified. [Responsible Party] notified." The entry was written by CN. Resident 1's "Progress Notes," dated 2/15/21, at 10:17 AM, it indicated Resident 1 was being monitored by facility staff for "Possible Sexual Interaction." During a review of Resident 1's "History & Physical Examination," dated 11/9/17, it indicated Resident 1 had dementia and "does NOT have the capacity to understand and make decisions." During a review of the facility's policy and procedure titled, "Reporting Abuse to State Agencies and Other Entities/Individuals," dated 10/10, it indicated, "All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other agencies or individuals as may be required by law." It further stated the facility ". . .will promptly notify the following persons or agencies (verbally and/pr written) of such incident: (a) The State Licensing/certification agency responsible for surveying the facility[.]" In violation of the above cited standards, the facility failed to report suspected sexual abuse to the state agency (the Department) and this violation had a direct or immediate relationship to the health, safety, or security of residents. Page 2 of 2