Health inspection·June 14, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 interviews and record reviews, facility staff failed to protect Residents 1, 2, 3, 4, and 5, five out of five sample residents from inappropriate touching by Resident 6 and wandering unsupervised into other resident ' s room. Review of facility documents indicated Resident 6 touched these residents inappropriately: 1. Resident 1 on 07/12/2021. 2. Resident 2 on 01/29/2022. 3. Resident 3 on 06/23/2022. Review of facility documents indicated Resident 6 was found unsupervised in these resident ' s room: 1. Resident 4 ' s room on 08/02/2022. 2. Resident 5 ' s room on 05/07/2023, and Resident 5 alleged that Resident 6 touched her .all over . Failure to manage Resident 6 ' s inappropriate behavior and/or supervising him around vulnerable/dependent residents, did not ensure vulnerable/dependent residents were protected from sexual abuse. These failures have severe consequences, as Resident 3 reported experiencing nightmares, feeling unsafe, and having to sleep with the lights on due to the traumatic experience of being touched by Resident 6. Findings: Resident 1 Review of Resident 1 ' s record titled admission RECORD, printed on 06/20/2023, indicated she was admitted with multiple diagnoses including: left thigh bone fracture, generalized muscle weakness, difficulty walking, dementia (memory loss and deterioration of thinking ability due to brain disease or brain injury), and cerebral infarct (blockage of blood supply to brain, resulting in death of brain cells). Page 1 of 6 555657 555657 06/14/2023 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0600 Level of Harm - Minimal harm or potential for actual harm Review of Resident 1 ' s MDS (Minimum Data Set, a standardized resident assessment tool), dated 08/12/2021, indicated her BIMS (Brief Interview for Mental Status, a tool to assess thinking and memory) score was 5 out of 15. A score of 0-7 indicates severe impairment in cognition (serious decline in thinking and memory). Her MDS indicated she required extensive assistance from one staff with: bed mobility, transfers, walking in room, moving around the unit, dressing, toilet use, and personal hygiene. Residents Affected - Some Review of Resident 1 ' s records titled Progress Notes, dated 07/12/2021, indicated .At .(4:30 PM), witnessed by .staff, was found with .(Resident 6 ' s) hands underneath resident's gown touching her chest & breast area.(Resident 6) was instructed immediately to step away from .(Resident 1) and return to his room.(Resident 1) was not harm and did not exhibit any signs of physical injury.At this time, .(Resident 6) was removed moved away from victim immediately & transferred to room . with staff assistance; order given from administrator via phone. Resident 2 Review of Resident 2 ' s record titled admission RECORD, printed on 06/20/2023, indicated he was admitted with multiple diagnoses including: weakness, depression, and dementia. Review of Resident 2 ' s MDS, dated [DATE], indicated his BIMS score was 4 out of 15 (serious decline in thinking and memory). His MDS indicated he required extensive assistance from two staff with: bed mobility, transfers, dressing, and toilet use. His MDS indicated he required extensive assistance of one staff for personal hygiene and limited assistance of one staff for moving around on the unit. Review of Resident 2 ' s records titled Progress Notes, dated 01/29/2022, indicated .(staff) reported entering room and observing .(Resident 6) with hand underneath bedspread of .(Resident 2).(staff) told .(Resident 6) to leave the room. The Administrator and Nurse visited the victim and asked what happened ' Resident answered he touched my penis ' .Denies injury- No injury observed Stated ' I don't want that to happen again ' . Resident 3 Review of Resident 3 ' s record titled admission RECORD, printed on 06/20/2023, indicated he was admitted with multiple diagnoses including: generalized muscle weakness, obesity (overweight due to body fat), and urine retention. Review of Resident 3 ' s MDS dated [DATE], indicated his BIMS score was 15 out of 15 (no problem with thinking and memory). His MDS indicated he required limited assistance from one staff with: bed mobility, transfers, walking in room, moving around the unit, dressing, and personal hygiene. His MDS indicated he required extensive assistance of one staff for personal hygiene and limited assistance of one staff for toilet use. Review of Resident 3 ' s record titled Progress Notes, dated 06/23/2022, indicated .Resident remains alert and verbal. At .(12:15 PM) today . (Resident 3) reported to . (staff) that he was awaken from his sleep because he felt something on his private part, when he opened his eyes he saw .(Resident 6) touching his ' penis' and asking him ' do you like it ' ? .(Resident 3) then press the call light and the .(staff) immediately answered and saw .(Resident 6) in the room, .(staff) immediately took .(Resident 6) out of the room and put him back to his room .(Resident 3) verbalizes that he does 555657 Page 2 of 6 555657 06/14/2023 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0600 not want a room change. Will continue to monitor. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/20/2023 at 11:34 AM, Resident 3 stated I ' m still suffering from it. One night I woke up and he was in his wheelchair by my bedside and touching my groin. Rubbing it. I don ' t know how long he was there and rubbing me before I woke up. Now I sleep with the lights on. I thought I was in a safe place. I never thought that somebody could just come in and molest you. (crying) I have nightmares because of this. I finally got out of that place. They weren ' t monitoring him. Once in a while you would see staff trying to chase him down and redirect him. They try to restrict him to his room, but they are pretty lax in monitoring him, especially at night. There ' s less foot traffic and those nurses at night are behind the nurse ' s station, they can ' t see him. This happened again to my roommate. There was a power outage, it was at night, and it was dark, and I heard this noise, I pull open the curtain and there he was over there touching my roommate. I immediately yelled for help. That ' s when staff came and got him out of there. After the 2nd incident I thought they were going to move him. But I think it ' s just talk. I still see him later on going up and down the hallway to where some of the ladies lived. Making sexual comments to them. Residents Affected - Some Resident 4 Review of Resident 4 ' s record titled admission RECORD, printed on 06/20/2023, indicated he was admitted with multiple diagnoses including: complete to partial paralysis of the left side of the body, and dementia. Review of Resident 4 ' s MDS dated [DATE], indicated he had severe problems with making decisions and severe problems with memory. His MDS indicated he was totally dependent on two staff with: bed mobility, transfers, dressing, and toilet use. His MDS indicated he was dependent on one staff for moving around the unit, and personal hygiene. Review of Resident 4 ' s record titled Progress Notes, dated 08/02/2022, indicated .(Resident 4 ' s roommate) was .(calling for staff). (The roommate) was shouting in a loud voice and immediately .(staff) went to the room . It was noted that .(Resident 6) was in the room by the foot (of Resident 4 ' s bed), and right away .(staff, brought Resident 6) out of the room. Resident 5 Review of Resident 5 ' s admission record, printed on 06/13/2023, she was admitted with multiple diagnoses including: schizoaffective disorder-bipolar type (mental illness that negatively impact your mood, thoughts, and behaviors), and diabetes (blood sugar control disease). Review of Resident 5 ' s Minimum Data Set (MDS, a standardized resident assessment tool), dated 06/21/2023, indicated she was severely impaired in her cognition (problems with reasoning, decision making and memory). Additionally, her MDS indicated she required extensive assistance from two staff with: bed mobility, dressing and personal hygiene. She was totally dependent on two staff for transfers and toilet use. Resident was assessed as having hallucinations (hearing voices and seeing things not based in reality), rejection of care, verbal, and physical inappropriate behaviors toward others (yelling, cursing, hitting, scratching) Review of Resident 5 ' s record titled Progress Notes, dated 05/07/2023, indicated .(Resident 6) was seen by . (staff) in the .(Resident 5 ' s) bedroom facing the sink, past 6 in the evening, .(staff) assisted .(Resident 6) outside the room and lead .(Resident 6) to his own room.(staff) asked 555657 Page 3 of 6 555657 06/14/2023 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some .(Resident 5) how she is and .(Resident 5) said get him out of this room, and also allegedly said he touched me everywhere. Resident 6 Review of Resident 6 ' s MDS, dated [DATE], indicated he was admitted on [DATE] and had multiple diagnoses including: dementia, and depression. His BIMS score was 8 out of 15. A score of 8 out of 15 indicated moderate cognitive impairment. Moderate cognitive impairment is characterized by early stage of memory loss or other cognitive ability loss (such as trouble finding the right words or reasoning). His MDS indicated he required: supervision of one staff for 1. walking in the corridor 2. moving around the unit limited assistance from one staff for 1. transfers 2. walking in his room. extensive assistance of one staff for 1. bed mobility 2. dressing 3. personal hygiene 4. toilet use Review of Resident 6 ' s record titled Behavior Care Plan, initiated on 07/12/2021, indicated . Goal . The resident will not have any new incidences of actual or suspected inappropriate touching .Interventions .one on one caregiver visual monitoring .Observe resident where abouts and always remind not to go inside other residents' room . Resident will be accompanied by .staff . if wanted to ambulate for safety . The resident will be the only one to use the .(shared) bathroom, making sure that he cannot pass thru to the other door of the .(shared) bathroom which opens to the next room . Review of facility documents faxed to this Department (California Department of Public Health, CDPH, San Francisco) indicated the facility was aware of Resident 6 ' s pattern of inappropriate sexual behavior and unsupervised wandering into other resident ' s room. Furthermore, these documents recorded a pattern of failed attempts to monitor Resident 6, failed attempts at discharging Resident 6, and failed attempts to prevent Resident 6 from abusing other residents. On 02/04/2022, the facility sent a fax to this Department .Both . (Resident 2) and .(Resident 6) 555657 Page 4 of 6 555657 06/14/2023 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some were interviewed by . (Social Service Director) following incident of abuse on 1/29/22. (Resident 6) has been separated from .(Resident 2) and closely monitored by staff to make sure he has not had any incidents of wandering into other's rooms. On 06/28/2022 the facility sent a fax to this Department . Since the incident on Thursday 6/23/22 involving .(Resident 6)and .(Resident 3) . Social Services has been actively in touch with [NAME] .(police department) and Ombudsman Services with the goal of finding placement elsewhere for .(Resident 6) as this has not been his first incident of sexual impropriety and he poses danger to other residents in the building. Facility is actively looking for options to find a facility or place that would be safer for him to go to. In the meantime, staff are logging a visual monitoring for him every shift and work to keep him at a safe distance from other residents. On 08/02/2022 the facility sent a fax to this Department .(Resident 6) has engaged In Inappropriate behavior in the past and . was observed loitering in .(other residents ' room) . In the meantime, he will be confined to his room and closely supervised at all times by facility personnel. During an interview on 6/16/2023 at 12:50 PM, the Medical Director of the facility stated .I heard reports that .(Resident 6) had been molesting another .(residents). When we heard about it we tried to get him out of the area. I think the facility move residents away (to other rooms). They tried to isolate him in his own room. They were keeping an eye on him. But he was ambulatory, and he would move around. They had him in a private room had people watching out for him to redirect him. They did have a Velcro barrier sign . (across his door) that says stop. But anybody can take that off. They did try to put surveillance on him. Earlier this year, I heard that he molested somebody .I deemed that surveillance was not effective. Because he was seen in a patient ' s room by a .(staff).I talked to the administrator and told them that they need eyes on him 24/7 (24 hours and seven days a week). They did not have the staffing initially, but they did find staffing later. They finally put that in place, and they finally moved him out of the facility. They were able to discharge him. The Medical Director was asked if Resident 6 was appropriate for a skilled nursing facility setting? The Medical Director stated No he would have been better off at a geriatric psych facility with more intense monitoring. He would have been better off at a different place.Looking back on, hindsight we should have had a 1-1 on him (one staff to monitor him on a continuous basis). During an interview with the Administrator (ADM) and the Director of Nursing (DON) on 06/15/2023 at 11:15 AM, the ADM agreed that sexual abuses should never happen in a nursing home. The DON identified visual monitoring every 30 minutes, two psychiatric consults with medication recommendations, relocating residents to another room and attempts at discharging Resident 6 as interventions in managing Resident 6 ' s inappropriate sexual behavior. The ADM stated these inteventions were not 100% effective and the latest incident was Resident 6 was found in a vulnerable/dependent resident ' s room on 05/07/2023. During the interview, the ADM and DON were asked to provide a policy on residents who are sexually abusive. The facility stated via an email to this Department on 6/20/2023 that they do not have a policy regarding residents who are sexually abusive. Review of facility policy titled Abuse Prevention & Reporting, not dated, indicated .ensure that residents are free from abuse, neglect, and misappropriation of property. The facility has a ZERO TOLERANCE for any/all types of abuse directed toward any resident, patient or dependent adult within its care. 555657 Page 5 of 6 555657 06/14/2023 Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some B. To provide guidelines to all staff regarding their roles and responsibilities in the prevention and reporting of resident abuse, neglect, and misappropriation of property. Sexual abuse: includes, but is not limited to, sexual harassment, sexual coercion, sexual assault, . (dependent adult): any person over the age of 18 who has physical or mental limitation which restricts his or her ability to carry out normal activities or to protect his or her own rights, including but not limited to, persons who have physical or developmental disabilities or whose physical or mental abilities have diminished because of age. 555657 Page 6 of 6