Health inspection·February 28, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to report one incident of resident abuse to authorities within the required two-hour time frame after the allegation was made. Residents Affected - Some This failure to report an allegation of abuse within the Federally mandated requirement of two hours, had the potential to result in ongoing resident abuse and physical, mental, and /or emotional harm, and prevented the State Agency from conducting a timely investigation into the allegation. Findings: Record Review of admission Record for Resident 1 indicated admission was on 12/13/23 and pertinent diagnoses are Other Specified Fracture of Unspecified Pubis, Subsequent Encounter for Fracture with Routine Healing and Anxiety Disorder Unspecified. During an interview on 2/20/24 at 12:14 p.m. with the Director of Nursing (DON), the DON stated Licensed Nurse A received an order for Resident 1 for a catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) collection of urine for a urinalysis (a lab test of urine to determine the presence of a urinary tract infection) on 12/27/23. During an interview on 2/20/24 at 12:14 p.m. with the DON, the DON further stated that Resident 1's Family Member 1 reported at a Care Conference (meeting of facility management staff, resident and family, if indicated) on 12/29/24 that Resident 1 believed she was sexually assaulted during the catheter procedure. During an interview on 2/20/24 at 12:30 p.m. with the Administrator, the Administrator stated he talked with Licensed Nurse A after he was notified that resident 1 believed she was sexually assaulted during the catheter procedure. Administrator stated he was the Abuse Coordinator, and he did not routinely report alleged abuse until after he had investigated it. Administrator stated he did not believe any abuse occurred, so he did not report the allegation. During an interview on 2/20/24 at 1:25 p.m. with the Assistant Director of Nursing (ADON), the ADON stated she became aware during a Care Conference on 12/29/23 of Resident 1's allegation that she was sexually assaulted during a catheter procedure. The ADON stated she investigated the allegation. During an interview on 2/20/24 at 1:45 p.m. with the Administrator, the Administrator stated he did an internal investigation of the allegation. Administrator further stated he had 24 hours to report abuse to the State Agency. Page 1 of 4 555349 555349 02/28/2024 Vacaville Convalescent & Rehab 585 Nut Tree Court Vacaville, CA 95687

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 2/21/24 at 10:20 a.m. with Family Member 1, Family Member 1 stated he visited Resident 1 on 12/28/23 and Resident 1 told him she had been held down and sexually assaulted during the night. Family Member 1 stated he was the Responsible Party (decision maker) for Resident 1. During an interview on 2/21/24 at 10:20 a.m. with Family Member 1, Family Member 1 stated he attended a Care Conference for Resident 1 on 12/29/23. The Care Conference was attended by Family Member 1, Family Member 2, the ADON, the Social Services Director, and the Physical Therapy Manager. Family Member 1 expressed concerns about Resident 1's sexual assault allegation. Family Member 1 stated that Resident 1 continued to suffer trauma from the event. During an interview on 2/21/24 at 10:55 a.m. with the Director of Social Services (DSS), the DSS stated she was present at the Care Conference for Resident 1 on 12/29/23. The DSS stated Family Member 1 discussed Resident 1's allegation of sexual assault during the meeting. During an interview on 2/21/24 at 3:58 p.m. with the Manger of PT Services (MPT), the MPT stated she attended a Care Conference for Resident 1 on 12/29/23. The MPT stated during the Care Conference Family Member 1 stated Resident 1 told him she was held down and then assaulted. During an interview on 2/22/24 at 12:15 p.m. with Licensed Nurse B, an employee of a Home Health Agency, Licensed Nurse B stated Resident 1 was her Home Health client after she left the facility. Licensed Nurse B stated Resident 1 said she may have been sexually assaulted at the facility. Resident 1 reported this to Licensed Nurse B on 2/6/24. Licensed Nurse B stated Resident 1 appeared to be traumatized. Licensed Nurse B reported the abuse allegation to Adult Protective Services on 2/6/24. During an interview on 2/22/24 at 2:20 p.m. with Licensed Nurse A, Licensed Nurse A stated she reported allegations of abuse to the DON. Licensed Nurse A stated she had 24 hours to report alleged abuse. During an interview on 2/22/24 at 2:32 p.m. with the DON, the DON stated we reported alleged abuse right away if we felt it needed to be reported. DON stated regulations said to report within 24 hours. A record review of a policy and procedure, titled Abuse Training and Reporting Policy dated May 2003, Paragraph #7, Part A states, The Administrator and or designee will oversee the abuse policy, conduct a thorough investigation, and notify the appropriate agencies within 24 hours .The required ' State of California Report of Suspected Dependent/Elder Abuse (SOC 341)' form will be submitted to the appropriate agencies within 2 working days. Record received from the Administrator who indicated it was the current policy. 555349 Page 2 of 4 555349 02/28/2024 Vacaville Convalescent & Rehab 585 Nut Tree Court Vacaville, CA 95687

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 maintain documentation that an alleged abuse violation was thoroughly investigated. Residents Affected - Few This failure to maintain documentation of an abuse investigation had the potential to delay implementation of corrective action(s) to protect the resident from further abuse and/or emotional harm. Findings: Record Review of admission Record for Resident 1 indicated admission was on 12/13/23 and pertinent diagnoses are Other Specified Fracture of Unspecified Pubis, Subsequent Encounter for Fracture with Routine Healing and Anxiety Disorder Unspecified. During an interview on 2/20/24 at 12:14 p.m. with the Director of Nursing (DON), the DON stated Licensed Nurse A received an order for Resident 1 for a catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) collection of urine for a urinalysis (a lab test of urine to determine the presence of a urinary tract infection) on 12/27/23. During an interview on 2/20/24 at 12:30 p.m. with the Administrator, the Administrator stated he talked with Licensed Nurse A after he was notified that resident 1 believed she was sexually assaulted during the catheter procedure. Administrator stated he was the Abuse Coordinator, and he did not routinely report alleged abuse until after he had investigated it. Administrator stated he did not believe any abuse occurred, so he did not report the allegation. Administrator stated he did not have any written record of his investigation. During an interview on 2/20/24 at 1:25 p.m. with the Assistant Director of Nursing (ADON), the ADON stated she became aware during a Care Conference on 12/29/23 of Resident 1's allegation that she was sexually assaulted during a catheter procedure. The ADON stated she investigated the allegation. The ADON and the facility did not provide any documentation of an investigation. During an interview on 2/20/24 at 1:45 p.m. with the Administrator, the Administrator stated he did an internal investigation of the allegation. During an interview on 2/21/24 at 10:55 a.m. with the Social Services Director (SSD), SSD stated she attended the Care Conference for Resident 1 on 12/29/23. DDS stated the alleged abuse of Resident 1 was discussed. SSD stated the Assistant director of Nursing (ADON) took notes during the meeting. SSD further stated that each discipline documented their own notes. A record review of a document titled Interdisciplinary Team Conference Notes dated effective 12/29/23 at 11:03 a.m. and signed by the ADON, included a summary of discussion for each discipline. Under paragraph V., section 1. Nursing summary states .reviewed all family .concerns and follow up in place . No further documentation of abuse allegation was provided by the facility. A record review of a policy and procedure, titled Abuse Training and Reporting Policy dated May 2003, Paragraph 5, Investigation states, Staff members will be trained to report anything that may cause injury toa resident .If abuse is suspected, the Administrator and /or Abuse Coordinator must be notified and an investigation is initiated. Record received from the Administrator who indicated it 555349 Page 3 of 4 555349 02/28/2024 Vacaville Convalescent & Rehab 585 Nut Tree Court Vacaville, CA 95687

F 0610 was the current policy. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555349 Page 4 of 4