Health inspection·January 30, 2025

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. Based on interview, and record review, the facility failed to protect against physical abuse for one of three sampled female residents (Resident 1) when a male resident (Resident 2) kissed Resident 1 on the mouth and fondled her (to touch in a sexual way) when Resident 1 did not have the capacity to consent. This failure had the potential to cause Resident 1 to suffer psychological distress, anxiety, and shock. Findings: An unannounced visit was made to the facility on January 29, 2025, at 10:45 AM, to investigate a facility reported incident regarding an allegation of physical abuse. A review of Resident 1 ' s face sheet (a document that gives a summary of resident ' s information), undated, indicated an admission date of January 4, 2021. Resident 1 had diagnoses that included dementia (a brain disorder that causes a decline in mental abilities, such as memory, thinking, reasoning, and problem-solving) and quadriplegia (a condition characterized by the loss or severe impairment of motor function, sensation, and nervous system functions in all four limbs--arms and legs). A review of Resident 1 ' s physician ' s history and physical (H&P-a formal assessment of a patient's health that includes a medical history, physical exam, and a summary of any testing), dated March 30, 2024, indicated, Patient Informed of Medical Condition: No, Patient Capable of Admitting Self: No, Patient Capable of Making Decisions: No. During an interview with Resident 2 on January 29, 2025, at 11:41 AM, Resident 2 stated he kissed Resident 1 on the mouth and put his hands on Resident 1 ' s breasts. Resident 2 stated Resident 1 had asked him to stop, so he stopped and that was when the nurse told him to step away from Resident 1, so I walked away. During an interview with Resident 1 on January 29, 2025, at 12 PM, Resident 1 stated she had called Resident 2 over as he passed in the hallway and kissed him. Resident 1 stated Resident 2 was receptive to her advance and began touching her breast. Resident 1 stated she told Resident 2 that was a far as he could go, and Resident 2 stopped. Resident 1 stated that was when the nurse came and told Resident 2 move away from her. Resident 1 stated she had wanted the sexual contact and Resident 2 had been receptive to her. During an interview with a Certified Nursing Assistant (CNA 1) on January 29, 2025, at 12:30 PM, Page 1 of 2 555773 555773 01/30/2025 Indian Canyon Post Acute 57333 Joshua LN Yucca Valley, CA 92284

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few CNA 1 stated she was standing at the nursing station, the 400 hallway was behind her, and as she turned around, she saw Resident 2 leaning over Resident 1 with his hand down inside her shirt. CNA 1 stated Resident 1 was in her Geri chair (large, padded chair with a wheeled base) positioned in the hallway and Resident 2 was leaning over her and she said to Resident 2 to step away, back away from Resident 1. CNA 1 stated Resident 1 and Resident 2 looked up at her with shocked expressions and did not say anything and Resident 2 began walking down the hallway away from Resident 1. CNA 1 stated she stood next to Resident 1 to provide protection and flagged down another staff person to get the Charge Nurse for the 400 hallway, the Charge Nurse came, and she gave report of the situation. CNA 1 stated Resident 1 seemed to laugh it off as the Charge Nurse asked her questions about what had happened, and Resident 1 did not appear to be upset by the situation. During an interview with the Director of Nursing (DON) on January 29, 2025, at 1:43 PM, the DON stated Resident 1 did not have the capacity to consent to sexual contact and sexual contact had occurred between Resident 1 and Resident 2. The DON stated the facility had not protected Resident 1 from physical abuse. A review of the facility ' s policy and procedure (P&P) titled, Resident Rights, dated December 2021, indicated, Policy Interpretation and Implementation:1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation . 555773 Page 2 of 2