Health inspection·February 7, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect one of one residents (Resident 1) from sexual abuse when a Certified Nursing Assistant (CNA1) engaged in a consensual sexual act with a resident. This failure placed Resident 1 at risk for emotional distress, psychological trauma, mistrust of health care providers, and disruption in the patient's ability to receive proper medical care. Findings: On 1/14/25, the California Department of Public Health (CDPH) received a facility reported incident from the facility to report an incident in which CNA 1 had sexual relations with Resident 1 inside his bedroom. On 1/24/25 at 9:30 A.M. an on-site visit was conducted by CDPH to investigate the incident. According to the admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses which included bipolar disorder (a mental illness that causes extreme shifts in moods) , post-traumatic stress disorder ( a condition in which a person has difficulty recovering after experiencing or witnessing a terrifying event), schizoaffective disorder (a disorder that includes symptoms such as hallucinations, delusions with mood disorder symptoms). A review of Resident 1's Electronic Health Record indicated Resident 1 was placed under conservatorship (a legal status in which a court appoints a person to assume guardianship over an adult) on 7/8/24. According to the History and Physical dated 8/9/24, [Resident 1] does not have capacity to make medical decisions . A review of the Minimum Data Set (MDS, an assessment tool) dated 11/13/24 indicated Resident 1 was cognitively intact with a BIMS (a tool to measure cognition) score of 14. On 1/24/25 at 9:44 A.M. an interview was conducted with Resident 1. Resident 1 stated he met CNA 1 after he was admitted to the facility. Resident 1 stated, .after a couple weeks we developed a friendship. We talked about books . Resident 1 stated CNA 1 visited him at the facility on days when she was not scheduled to work. In addition, Resident 1 stated CNA 1 gifted him with three books and wrote messages for him on the inside cover of the books. Resident 1 stated he had asked her to perform a sexual act on him and .we were like friends with benefits. Page 1 of 2 555887 555887 02/07/2025 Lakeside Special Care Center 11962 Woodside Avenue Lakeside, CA 92040

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/24/25 at 12:36 P.M. a telephone interview was conducted with CNA 1. CNA 1 stated, Basically, I developed feelings for [Resident 1] and he developed feelings for me . CNA 1 stated she had frequent conversations with Resident 1 that were unrelated to her role as his caregiver. CNA 1 stated I know it's against policy .We shouldn't be talking to residents in a way that doesn't have to do with my job . CNA 1 acknowledged purchasing books for Resident 1 as gifts. In addition, CNA 1 stated she wrote Resident 1 a letter to let him know, I daydream about hanging out with him. CNA 1 stated she started having a personal relationship with Resident 1 around late November 2024. CNA 1 stated she performed a sexual act with Resident 1 at the facility, inside his bedroom. CNA 1 stated, .I know it was wrong because it was unprofessional to have a personal relationship with a patient. That's why I confessed, I felt guilty . CNA 1 stated she believed she had an in-service at the facility regarding inappropriate relationships with residents but does not remember the date of training. A record review on 1/24/25 of CNA 1's employee file indicated 8/19/24 as the date of hire. The employee file indicated CNA 1 was given an Abuse in-service on 8/19/24 and completed the Compliance and Ethics Program on 12/6/24. On 1/24/25 at 1:09 P.M. a telephone interview was conducted with CNA 2. CNA 2 stated she was aware that CNA 1 had sexual relations with Resident 1. CNA 2 stated, [CNA 1] verbalized that she [performed a sexual act] to [Resident 1] .she told me, and I reported it to the abuse coordinator .because it sounds like sexual abuse. On 1/24/25 at 2:03 P.M. an interview was conducted with the Director of Staff Development (DSD). The DSD stated, I was very shocked, I never thought it was in [CNA 1]'s character [to perform a sexual act on a resident] . The DSD stated, [CNA 1] should have known better .you have to maintain boundaries for the benefit of the residents .because of the situation, you know, that it was between a CNA and a resident, I'd say it was abuse. On 2/6/25 at 11:30 A.M. an interview was conducted with the Director of Nursing (DON). The DON stated her expectation was for staff to always maintain professionalism with residents. The DON stated any sexual relationship between a staff member and resident is never acceptable, per the facility's policy and Code of Conduct. A record review was conducted on 1/24/25. According to the facility's undated Employee Handbook, Standards of Conduct .All employees are expected to act in a mature, professional manner at all times .19. Resident Relationships. Unauthorized socializing, to include socializing through written or on-line communication, with current or former residents within or outside the Facility, which is beyond that of meeting the resident's needs and which serves no rehabilitative purpose . A record review was conducted on 1/24/25. A review of the facility's policy titled Sexual Conduct of Residents revised 9/2023 did not provide guidance regarding interpersonal and/or sexual relations between residents and staff members. A record review was conducted on 1/24/25. A review of the facility's policy titled Abuse Prevention Program, dated 7/1/20 indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from .mental, sexual or physical abuse . 555887 Page 2 of 2