Health inspection·August 9, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement its abuse reporting policy when it had knowledge of an allegation of genital exposure by Resident 3 to Resident 4 and did not report it to the State Agency (SA). This failure resulted in continued proximity of Resident 4 to Resident 3 who was the alleged aggressor, and prevented investigation by the SA. Resident 3 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder bipolar type (a mental illness that can affect your thoughts, mood and behavior) and schizophrenia (a mental disorder characterized by disruptions in thought processes). Resident 4 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia (a pattern of behavior where a person feels distrustful of others and behaves accordingly) and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread and uneasiness). On 7/16/24 at 12:20 P.M. an interview was conducted with Resident 4 who stated, (Resident 3) exposed his genitals to me and the staff aren ' t doing anything about it. On 7/16/24 at 12:39 P.M. an interview was conducted with the Director of Nursing (DON) who stated, (Resident 3) doesn ' t have any history of hypersexualization (a person ' s inability to control their sexual behavior and impulses). On 7/19/24 a review of Resident 3 ' s Imperial County Behavioral Health Services psychiatric note dated 5/22/24 indicated Resident 3 had history of hypersexual – stuck tongue out at female staff twice. On 7/22/24 at 10:37 A.M. a follow up telephone interview and concurrent record review was conducted with the DON who stated, I didn ' t see this in the record before now. On 7/19/24 a review of Resident 3 ' s Communication note dated 7/8/24 at 8:13 A.M. indicated, Female resident (Resident 4) pointed to male resident (Resident 3) claiming he exposed himself to her in the lunchroom near lunch hour. On 7/19/24 a review of Resident 4 ' s Communication Note dated 7/11/24 at 8:36 A.M. indicated, Writer check in with both the resident and fellow female resident (Resident 4) on claim made by Page 1 of 2 555919 555919 08/09/2024 Imperial Manor 100 East 2nd Street Imperial, CA 92251

F 0609 (resident 4) on 7/8/24 about the resident exposing himself to her. Level of Harm - Minimal harm or potential for actual harm On 7/19/24 at 2:14 P.M. a follow up telephone interview was conducted with the Social Worker (SW) who stated, I didn ' t report what (Resident 4) said because I wasn ' t here when it happened. Residents Affected - Few On 7/16/24 at 12:39 P.M. an interview was conducted with the DON who stated, It was not reported to the SA. A review of the facility policy entitled Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating revised September 2022 indicated, All reports of resident abuse . are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. A review of the facility policy entitled Abuse, Neglect, Exploitation and Misappropriation Prevent Program revised April 2021 indicated, Protect residents from any further harm during investigation. 555919 Page 2 of 2