Health inspection·July 30, 2025

HSC 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. 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 ensure an allegation of sexual abuse involving Patient 1 was reported to the California Department of Public Health (CDPH) immediately or within 24 hours of the facility’s knowledge of the allegation. The facility was made aware of the alleged abuse on May 17, 2025. This failure had the potential to result in delayed investigation of abuse, delayed implementation of appropriate actions and delayed provision of protection for Patient 1 and had the potential to place the patients at the facility at risk for further abuse. A review of Patient 1’s Admission Record indicated Patient 1 was admitted to the facility on September 26, 2024, with diagnoses which included dementia (memory loss) and protein-calorie malnutrition (deficient intake of protein and calories to meet the body’s energy and tissue-building needs). A review of Patient 1’s “HISTORY AND PHYSICAL EXAMINATION,” dated September 29, 2024, indicated Patient 1 does not have the capacity to understand and make decisions. A review of Patient 1’s “Nurse’s Note,” dated May 17, 2025, at 7 p.m., as documented by Registered Nurse (RN) 1, indicated, “…LN [Licensed Nurse] reported resident (Patient 1) alleging sexual assault, patient had made prior claim previously out of confusion…she stated sexual assault happened 9 months ago…” A review of Patient 1’s “IDT [Interdisciplinary Team] NOTE,” dated May 20, 2025, at 10:44 a.m., documented by the Director of Nursing (DON) indicated, “…Presented to IDT regarding this behavior of having a rapist roaming around at night…Investigation was made regarding this matter, and resident (Patient 1) mentioned this again on 5/17/25, same name presented to the nurse and happened 9 months ago…” Further review of the progress notes did not indicate documentation that the allegation of sexual abuse on May 17, 2025, involving Patient 1 was reported to CDPH. On June 27, 2025, at 1:35 p.m., during an interview, the DON stated on May 17, 2025, Patient 1 reported being raped multiple times by a man. The DON stated this incident was not reported to the local state agency or CDPH because it was not considered an allegation due to patient’s history of confusion and allegations. The DON stated according to protocol; any allegation of abuse should be reported to CDPH within two hours. The DON stated, in these instances, the facility determined that the reports did not constitute actual allegations and therefore were not reported. On June 27, 2025, at 2:56 p.m., during interview, Licensed Vocational Nurse (LVN) 1 stated she documented Patient 1’s statement that the patient was raped in the past. LVN 1 stated Patient 1’s statements were very specific and consistent, but they were interpreted as behavioral in nature rather than an allegation of abuse. LVN 1 stated, she did not report the incident to CDPH at that time. LVN 1 stated all allegations of abuse should be reported to CDPH within two hours. On June 27, 2025, at 3:12 p.m., during a concurrent interview and review of Patient 1’s nurses notes dated May 17, 2025, with the RN, the RN stated LVN 1 reported on May 17, 2025, that the patient (Patient 1) alleged being sexually assaulted. RN 1 stated, she informed the Administrator and the DON, but the incident was not reported to CDPH. The RN stated, she is a mandated reporter and is required to report any allegation of abuse to CDPH within two hours. A review of the facility policy and procedure titled, “Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating,” dated September 2022, indicated, “…Reporting allegations to the Administrator and Authorities…If resident abuse…is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law…The administrator or the individual making the allegation immediately reports his suspicion to the following persons or agencies…the state licensing/certification agency…The local/state ombudsman…’immediately’ is defined as…within two hours of an allegation involving abuse…” Based on interview and record review, it was determined that the facility failed to ensure an allegation of sexual abuse involving Patient 1 was reported to the CDPH immediately or within 24 hours of the facility’s knowledge of the allegation. The facility was made aware of the alleged abuse on May 17, 2025. This failure had the potential to result in delayed investigation of abuse, delayed implementation of appropriate actions and delayed provision of protection for Patient 1 and had the potential to place the patient and other patients at risk for further abuse. This violation had a direct or immediate relationship to the health, safety, or security of patients.