Health inspection·December 15, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record and policy and procedure review, the facility failed to protect one of three sampled residents (Resident 1) from sexual abuse, when Resident 2 who had a known history of inappropriate sexual comments and gestures was sitting in close proximity to her with no staff supervision. This failure resulted in Resident 2 rubbing Resident 1's inner thigh and placed other vulnerable residents residing in the facility at risk for abuse. Findings: According to the admission record, Resident 1 was admitted to the facility early this year with diagnoses which included anxiety disorder (excessive and persistent worry and fear about everyday situation) and Parkinson's disease (a progressive disease of the nervous system characterized by shaking, stiffness, and difficulty with mobility). A review of the Minimum Data Set (MDS, an assessment tool) dated, 9/12/23 indicated Resident 1 scored 7 out of 15 on the cognitive assessment, which indicated she had severe memory impairment and cognitive skills for daily decision making. A review of Resident 1's care plan dated 9/25/23, indicated that the resident had a memory/recall problem. The care plan directed staff to provide a calm atmosphere and safe environment. A review of Resident 1's nursing progress note dated 12/3/23, at 5:10 p.m., indicated Resident 2 was observed rubbing [Resident 1's] inner thigh up to her groin area when they were sitting beside each other near the nursing station. The nurse documented that the incident was witnessed by two Certified Nursing Assistants (CNA 1 and CNA 4). A review of Resident 1's care plan dated 12/3/23, indicated that the resident experienced sexual abuse from another resident and had the potential for emotional distress and impaired coping. A review of Resident 2's admission record indicated he was admitted to the facility in 2023 with multiple diagnoses which included anxiety. A review of Resident 2's MDS dated [DATE] indicated the resident had severe and impaired cognitive skills for daily decision making. A review of Resident 2's care plan initiated on 10/24/23 indicated the resident was displaying Page 1 of 4 555209 555209 12/15/2023 Adventist Health Sonora - D/P Snf 179 South Fairview Lane Sonora, CA 95370

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sexual behaviors toward female and male staff with comments and gestures. The interventions addressing the resident's sexual behaviors were to redirect and reorient the resident and notify the family if Resident 2's behaviors were to be an issue. The care plan did not contain interventions to protect vulnerable residents residing in the facility from his sexual behaviors. A review of the physician progress notes dated 12/1/23, indicated that the Resident 2 had increased behavioral issues, some inappropriateness towards staff members and other residents, and is repetitive and persistent .with difficulty redirecting him at times. A review of a nursing progress note dated 12/3/23, and timed at 5:10 p.m., indicated Resident 2 was started on alert charting for sexual abuse toward other resident and was a perpetuator. The note indicated the nurse reported the incident to the local police department. During an interview on 12/13/23, at 11:55 a.m., with CNA 1 who witnessed the incident, she stated the incident happened on 12/3/23 toward the end of day shift. Resident 1 and Resident 2 were sitting next to each other by the nursing station, while staff were further away down the hall. CNA 2 added, I looked over where they were sitting and could not believe my eyes, [I] saw that [Resident 2] was rubbing [Resident 1's] inner thigh. CNA 1 stated CNA 2 was walking by, and she alerted him to what was happening. CNA 1 stated both residents were separated immediately. During a concurrent observation and interview on 12/13/23, at 12 p.m., Resident 1 was in her bed in the room. Resident 1 smiled when the Department called her name. Resident 1 stated, I don't remember when asked about the incident of being touched inappropriately by another resident. Resident 1 was unable to provide information related to the incident of inappropriate touching by Resident 2. During an observation and interview on 12/13/23, at 12:10 p.m., Resident 2 was walking in the hall by the activity room. Resident 2 responded in a language other than English. CNA 1 assisted with interpretation. According to CNA 1, Resident 2 was unable to recall the incident when staff witnessed him touching Resident 1 inappropriately and was unable to provide information related to the incident. During a telephone interview on 12/15/23, at 12:50 p.m., CNA 4 stated on 12/3/23, he was walking in the hall and noted both residents sitting across from the nursing station. CNA 4 stated there was no staff nearby. CNA 4 explained, When I looked that way, I saw [Resident 2's] hand was between [Resident 1's] legs and he was rubbing her inner thigh. Neither of them were talking . I alerted other staff, and they were separated without much commotion. CNA 4 stated he was aware of Resident 2's history of inappropriate gestures toward some staff. CNA 4 added, Aware that he is being sexual .had a prior history of inappropriate sexual advances toward staff. Always reminded him not to do it. CNA 4 stated that the facility was aware of Resident 2's sexual comments and inappropriate behaviors. During a concurrent interview and record review on 12/13/23, at 11:05 a.m., the Director of Nursing (DON) stated the incident when Resident 2 inappropriately touched and rubbed Resident 1's thigh on 12/3/23 was witnessed by CNA 1 and CNA 2. The DON stated that Resident 1 was not able to recall the incident and Resident 2 denied the allegation of inappropriate touching. The DON acknowledged that Resident 2 had a history of innappropriate behaviors and making sexual comments towards staff. The DON explained the interventions included redirecting Resident 2, setting boundaries for his comments and gestures of sexual nature, and he was placed on alert monitoring and charting for 72 hours after each incident of inappropriate behaviors. The DON agreed that Resident 2 could exhibit inappropriate behaviors and gestures toward vulnerable residents who were easy targets because they were not able 555209 Page 2 of 4 555209 12/15/2023 Adventist Health Sonora - D/P Snf 179 South Fairview Lane Sonora, CA 95370

F 0600 Level of Harm - Minimal harm or potential for actual harm to defend themselves. When the DON was asked what measures the facility took to keep residents safe and prevent Resident 2's further sexual behaviors she stated the facility started monitoring Resident 2 for his sexual behaviors after the incident with Resident 1. The DON stated Resident 2 did not have one-on-one continuous staff supervision due to staffing problems. The DON did not respond when asked how the facility ensured a safe environment for Resident 1. Residents Affected - Few A review of the facility's undated policy titled, Abuse and Neglect Prevention and Investigation indicated its purpose was to ensure that residents were free from abuse. The policy stipulated, The resident has the right to be free from verbal, sexual, physical and mental abuse .Abuse .of .residents by anyone, including .other residents .is not condoned by the facility.'' 555209 Page 3 of 4 555209 12/15/2023 Adventist Health Sonora - D/P Snf 179 South Fairview Lane Sonora, CA 95370

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to submit a summary of investigation of an alleged sexual abuse to the Department within five (5) working days of an incident for one of three sampled residents (Resident 1). Residents Affected - Few This failure placed Resident 1 at potential risk for further abuse. Findings: Resident 1 was admitted to the facility early this year with diagnoses which included anxiety disorder (excessive and persistent worry and fear about everyday situation) and Parkinson's disease (a progressive disease of the nervous system characterized by shaking, stiffness, and difficulty with mobility). Resident 2 was admitted to the facility in 2023 with multiple diagnoses which included anxiety and heart disease. A review of Resident 1's nursing progress note, dated 12/3/23 and timed at 5:10 p.m., indicated Resident 2 was observed rubbing [Resident 1's] inner thigh up to her groin area when they were sitting beside each other near the nursing station. The nurse documented the incident was witnessed by two Certified Nursing Assistants (CNA 1 and CNA 4). The note indicated the writer reported the incident to the resident's physician, family, the Director of Nursing (DON), the Department, and police. A review of the Resident 1's medical record reflected a document titled, Abuse and Neglect Reporting and Investigation Checklist. The document listed steps to be taken by the facility staff when an abuse was identified. The document indicated that the Director of Nursing or the designee were responsible for the investigation of abuse allegations and were to complete the report and send it to the Department within five days. During an interview on 12/13/23, at 11:20 a.m., the DON stated the investigation was completed by social services, but the results of investigation were not reported to the Department. The DON stated she was aware of the five working day requirement for the report to be submitted to the Department. A review of the facility's undated policy and procedure titled, Abuse and Neglect Prevention and Investigation, indicated, When an incident of abuse .is suspected or determined .an immediate investigation will be made by the Director of nursing or designee and a copy of the findings of such investigation will be provided to . [Department] within five working days of occurrence of such incident. 555209 Page 4 of 4