Health inspection·August 15, 2025

HSC 1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a patient of the facility to the department immediately, or within 24 hours. HSC 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. It was determined that the facility failed to report an allegation of sexual abuse involving a patient (Patient 1) and a Certified Nursing Assistant (CNA 1), to the California Department of Public Health (CDPH) immediately or within 24 hours. The facility was made aware of the sexual abuse allegation involving Patient 1 on June 1, 2021. This failure had the potential for delayed investigation which placed Patient 1 and the other patients in the facility at risk for further sexual abuse while at the facility. On June 7, 2021, Patient 1's record was reviewed. Patient 1 was admitted to the facility on May 9, 2021, with diagnoses which included atherosclerosis of coronary artery with bypass grafts (heart disease requiring open heart surgery). A review of Patient 1 s History and Physical dated May 9, 2021, indicated Patient 1 has the capacity to understand and make decisions. On June 7, 2021, at 11:45 a.m., during an interview, Patient 1 stated she was receiving a shower about a week and a half ago when the CNA (CNA 1) touched her inappropriately. The patient stated as the CNA was wiping her bottom, he (CNA 1) inserted a finger into her private part. Patient 1 stated she felt the CNA (CNA 1) did it on purpose, as the CNA inserted only one finger into her private part. The patient stated she told another CNA (CNA 2) about the incident, and the CNA (CNA 2) came back with a supervisor to ask her about the incident. On June 7, 2021, at 12:24 p.m., during a concurrent interview and record review of the facility shower log, CNA 2 stated while she was giving Patient 1 a shower, the patient stated she did not want the "ponytailed guy" (referring to CNA 1) to provide care for her anymore. CNA 2 stated when she asked the patient why, Patient 1 stated CNA 1 touched her inappropriately on her privates. CNA 2 verified she provided a shower for Patient 1 in the morning of June 1, 2021, and she notified the Director of Staff Development (DSD) about the allegation of sexual abuse. CNA 2 stated the DSD reported the alleged sexual abuse to the Director of Nursing (DON) and the Administrator. On June 7, 2021, at 12:47 p.m., during an interview with the DSD, she stated CNA 2 reported that Patient 1 alleged CNA 1 of touching her inappropriately during shower. The DSD stated she notified the Administrator who was the abuse coordinator. The DSD stated the Administrator spoke with Patient 1 after she reported the alleged abuse. She stated all allegations of abuse are reported to the abuse coordinator and should be reported to CDPH within two hours. On June 7, 2021, at 1:37 p.m., during an interview, a payroll personnel member stated she was the translator for Patient 1 when the Administrator interviewed the patient (Patient 1) on June 1, 2021. She stated Patient 1 reported that CNA 1 inserted his finger into her private part while being showered. She stated the allegation of sexual abuse should have been reported to CDPH. On June 7, 2021, at 2:16 p.m., during an interview, the Social Services Director (SSD) stated she was informed of Patient 1 s allegation of sexual abuse on June 4, 2021. The SSD stated Patient 1's allegation of abuse should have been reported to CDPH when CNA 2 was made aware of the sexual abuse allegation on June 1, 2021. On June 7, 2021, at 2:30 p.m., an interview was conducted with the Administrator. The Administrator stated he had a payroll personnel staff member, translate when he interviewed Patient 1 on June 1, 2021, regarding the patient s allegation of sexual abuse. The Administrator stated Patient 1 told him CNA 1 "inappropriately touched" her while he was showering her. He stated Patient 1 told him the touch was accidental. He stated the police came to investigate the allegation of abuse on June 4, 2021, and he reported the allegation of abuse to CDPH the same day. The Adm stated he should have reported the allegation of abuse to CDPH on June 1, 2021, and he did not. A review of the facility document titled, "Abuse Prohibition," effective date February 23, 2021, indicated, ...Employees are designated as mandated reporters and are obligated to immediately report any suspicion of a crime against a resident. Reporting of a crime on to an immediate supervisor does not meet the obligation to report...Upon receiving information concerning a report of suspected or alleged abuse...the designee will perform the following...report...within 2 hours...Notify local law enforcement, Licensing Boards and Registries, and other agencies as required Based on interview and record review, it was determined that the facility failed to report an allegation of sexual abuse involving Patient 1 and CNA 1, to the CDPH immediately or within 24 hours. The facility was made aware of the sexual abuse allegation involving Patient 1 on June 1, 2021. This failure had the potential for delayed investigation which placed Patient 1 and the other patients in the facility at risk for further sexual abuse while at the facility. The above violation had a direct or immediate relationship to the health, safety, or security of the patients.