Health inspection·June 4, 2025

REGULATION VIOLATIONS: Code of Federal Regulations, Title 42, Section 483.12(c)(1)(4) (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials(including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (c)(4) Report the results of all investigations to the administrator or his or her designated representative and to their officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Health and Safety Code section 1418.91(a) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a Patient of the facility to the department immediately, or within 24 hours. Health and Safety Code section 1418.91(b) (b) A failure to comply with the requirements of this section shall be a class "B" violation. California Code of Regulations, Title 22, Section 72523(a) (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. California Code of Regulations, Title 22, Section 72523(b) (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. California Code of Regulations, Title 22, Section 72527(a) (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. California Code of Regulations, Title 22, Section 72527(b) (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. Findings: On 4/8/2025, an unannounced visit was conducted at the facility to investigate a complaint regarding Patient 1 being sexually abused by Patient 2 on 4/4/2025 in the presence of multiple staff members and other Patients. The facility did not notify the state survey agency (CDPH, California Department of Public Health) of the sexual abuse incident that occurred on 4/4/2025. Additionally, during record review and subsequent interviews, the survey team found that on 3/26/2025, Patient 1 reported to staff being raped while out at a general acute care hospital (GACH). The facility failed to report the rape allegation to law enforcement, the ombudsman, and to CDPH as required for potential sexual abuse violations. The facility failed to ensure multiple allegations of sexual abuse involving Patient 1 were reported to the required authorities when: 1. The facility did not notify local law enforcement, the Ombudsman (independent advocate who protects the rights and ensures the well-being of patients in long-term care facilities), the state survey agency (CDPH, California Department of Public Health), and the facility's Administrator (ADMIN) immediately, but not later than 2 hours after the allegation was made, when one of five sampled Patients (Patient 1) reported an allegation of rape. The facility failed to treat Patient 1 with consideration, respect, and full recognition of her dignity and individuality when her rape allegations were discounted as "not really true" and not "counted as an abuse allegation." 2. The facility did not notify the state survey agency (CDPH) immediately, but not later than 2 hours after the allegation was made, when Patient 1 was sexually abused by Patient 2 in the common area, witnessed by staff. The facility failed to treat Patient 1 with consideration, respect, and full recognition of her dignity and individuality when it determined that Patient 2 kissing Patient 1's face and grabbing her breast did not warrant reporting to CDPH. 3. The facility failed to establish and implement written policies and procedures to ensure Patients rights to be free from abuse are not violated when it established a protocol that abuse incidents caused by a Patient diagnosed with dementia that do not result in serious bodily injury do not need to be reported to CDPH. 1. A review of Patient 1's Face Sheet (demographics), dated 4/8/2025, indicated Patient 1 was admitted with diagnoses including unspecified dementia (decline in mental ability) with behavioral disturbances (persistent and/or repetitive behaviors that differ significantly from social norms), psychotic symptoms (psychotic symptoms such as delusions [a persistent, false belief held with absolute certainty despite evidence]) and severe recurrent major depressive disorder with psychotic symptoms (severe form of depression where a person experiences symptoms of major depression and psychotic symptoms such as delusions). During an interview on 4/8/2025 at 4:27 PM with the Therapeutic Activities Staff (TAS), the TAS stated on the morning of 3/26/2025, Patient 1 verbalized being raped while out at the GACH. The TAS stated Patient 1 verbalized that while she was unconscious at the GACH, she would get raped. The TAS stated he reported it to the Social Worker (SW) on 3/26/2025 and denied reporting it as an abuse allegation to the ombudsman, local law enforcement, and CDPH. During a concurrent interview and record review on 4/8/2025 at 4:59 PM with the SW, Patient 1's Clinical Notes, dated 3/26/2025 were reviewed. The note indicated, SW was "informed by [TAS] that [Patient 1] has been verbalizing delusion of being pregnant recently, as well as making accusations of rape while at [the GACH] for treatment." The SW stated Patient 1 did not bring up the rape allegation when the SW checked in with Patient 1. The SW stated she did not think the report from Patient 1 counted as an abuse allegation, so she did not fill out an SOC 341 (official state form used to report suspected dependent adult/elder abuse form). The SW confirmed she was made aware of the allegation on 3/26/2025 and that she did not report it as an abuse allegation to local law enforcement, the Ombudsman, CDPH, and the ADMIN. During an interview on 4/8/2025 at 5:28 PM with the Supervising Registered Nurse (SRN), the SRN stated Patient 1 had paranoid behavior (irrational and excessive distrust and suspicion of others, often with the belief that they are trying to harm or deceive them) and delusional thinking. The SRN stated Patient 1's accusations was not new behavior, but confirmed it was the first time Patient 1 reported being raped. The SRN stated if she had felt it was "really true" and that Patient 1 had really been raped, she would have reported it "right away." The SRN confirmed that she did not report it as an abuse allegation to local law enforcement, the Ombudsman, CDPH, and the ADMIN. During an interview on 4/9/2025 at 8:44 AM with the Ombudsman, the Ombudsman confirmed she did not receive an SOC 341 or any type of verbal or written report regarding Patient 1 alleging being raped at the GACH. During an interview on 4/9/2025 at 2:06 PM with the Director of Nursing (DON), the DON stated staff "had to have reasonable suspicion before reporting." The DON stated, "If an alert and oriented Patient claimed rape at an outside hospital, I would have reported it right away." The DON stated staff had to take Patient 1's mental condition into account to "determine reasonable suspicion." During an interview on 4/9/2025 at 3:44 PM with the Staff Nurse Instructor (NI), the NI stated staff needed to consider for dementia patients if there's a history of unfounded claims. The NI stated that for a Patient with full capacity, a SOC 341 would be filled out and reported, but for a Patient with dementia, it would be hard to know whether this really happened and "you don't want to get somebody in trouble." During a concurrent interview and record review on 4/10/2025 at 9:25 AM with the ADMIN, the facility's policy & procedure (P&P) titled, "Elder Abuse Prevention and Response," dated 5/1/2024 was reviewed. The P&P indicated, "Any mandated reporter, who, ... is told by an elder or dependent adult that he/she has experienced behavior constituting abuse ... shall report the known or suspected instances of abuse immediately." The ADMIN stated he was the abuse coordinator (responsible for ensuring staff are trained adequately regarding abuse prevention and reporting) for the facility. The ADMIN stated that he was not notified of every instance of abuse, and sometimes only found out abuse occurred once investigators were onsite. The ADMIN stated the staff needed to make sure the allegation was credible by investigation before reporting because Patient 1 had dementia with a history of delusions about being pregnant. The ADMIN confirmed that he was not notified of the alleged sexual abuse reported by Patient 1 to the staff on 3/26/2025. 2. A review of Patient 1's Clinical Notes, dated 4/4/2025, the notes indicated, the Registered Nurse (RN) was notified on 4/4/2025 "at approximately 1405 ...by the activity staff and CNA that [Patient 1] was witnessed being sexually abused by [Patient 2] during activity in the common area." During an interview on 4/8/2025 at 11:14 AM with the RN, RN stated she reported the incident to the Ombudsman and to local law enforcement on 4/4/2025 but not to CDPH because the facility trained the staff that reporting abuse to CDPH was not required when the abuse was caused by a Patient with dementia and if there was no serious bodily injury. During an interview on 4/9/2025 at 9:51 AM with the Activities Coordinator (AC), the AC stated that on 4/4/2025, she witnessed Patient 2 walking through the common area and stopping behind Patient 1 who was seated in a chair. The AC stated she witnessed Patient 2 lean down forward to kiss Patient 1, Patient 1 tried to move her head away, and Patient 2 ended up kissing Patient 1 on the right side of the face. During an interview on 4/9/2025 at 10:16 AM with the Certified Nursing Assistant (CNA), the CNA stated that on 4/4/2025 she was alerted by the AC that Patient 2 kissed Patient 1 and when she tried to redirect Patient 2 away from Patient 1, she witnessed Patient 2 grab Patient 1's right breast. During an interview on 4/9/2025 at 11:06 AM with the Supervising Registered Nurse (SRN), the SRN stated Patient 1 was not capable of consenting to a kiss or touch because she was very confused and has dementia. The SRN stated the incident counted as sexual abuse. The SRN confirmed the RN reported the sexual abuse to the Ombudsman and law enforcement on 4/4/2025, but not to CDPH. During a concurrent interview and record review on 4/10/2025 at 9:24 AM with the ADMIN, the facility's procedure form titled, "Mandated Reporter [undated]," was reviewed. The form indicated the facility's protocol for abuse reporting did not conform with the federal or state requirement to report allegations of abuse to the state survey agency, CDPH. The form indicated abuse incidents caused by a Patient diagnosed with dementia and did not result in serious bodily injury did not need to be reported to CDPH. The ADMIN stated he was the abuse coordinator (responsible for ensuring staff are trained adequately regarding abuse prevention and reporting) for the facility. The ADMIN confirmed the facility's practice and staff training included not reporting to CDPH if the incident was "caused by Patient diagnosed with dementia" and there were "no serious bodily injury." During a review of the facility's policy & procedure (P&P) titled, "Elder Abuse Prevention and Response," dated 5/1/2024 indicated, "Each Resident has the right to be free from verbal, sexual, physical, financial, and mental abuse, corporal punishment, and involuntary isolation." 3. During an interview on 4/10/2025 at 9:24 AM with the ADMIN, the ADMIN stated he was the abuse coordinator (responsible for ensuring staff are trained adequately regarding abuse prevention and reporting) for the facility. The ADMIN confirmed the facility's practice and staff training included not reporting to CDPH if the incident was "caused by Patient diagnosed with dementia" and there were "no serious bodily injury." During a review of the facility's policy & procedure (P&P) titled, "Elder Abuse Prevention and Response," dated 5/1/2024 indicated, "Any mandated reporter, who, ... is told by an elder or dependent adult that he/she has experienced behavior constituting abuse ... shall report the known or suspected instances of abuse immediately." The facility failed to ensure multiple allegations of sexual abuse involving Patient 1 were reported to the required authorities when: 1. The facility did not notify local law enforcement, the Ombudsman (independent advocate who protects the rights and ensures the well-being of patients in long-term care facilities), the state survey agency (CDPH, California Department of Public Health), and the facility's Administrator (ADMIN) immediately, but not later than 2 hours after the allegation was made, when one of five sampled Patients (Patient 1) reported an allegation of rape. The facility failed to treat Patient 1 with consideration, respect, and full recognition of her dignity and individuality when her rape allegations were discounted as "not really true" and not "counted as an abuse allegation." 2. The facility did not notify the state survey agency (CDPH) immediately, but not later than 2 hours after the allegation was made, when Patient 1 was sexually abused by Patient 2 in the common area, witnessed by staff. The facility failed to treat Patient 1 with consideration, respect, and full recognition of her dignity and individuality when it determined that Patient 2 kissing Patient 1's face and grabbing her breast did not warrant reporting to CDPH. 3. The facility failed to establish and implement written policies and procedures to ensure Patients' rights to be free from abuse are not violated when it established a protocol that abuse incidents caused by a Patient diagnosed with dementia that do not result in serious bodily injury do not need to be reported to CDPH. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or Patients.