Health inspection·July 8, 2024

The following reflects the findings of the California Department of Public Health during an Abbreviated Standard Survey facility reported incident #892636. The inspection was limited to the specific facility reported incident investigated during an Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the Department: 48901, HFEN A deficiency was written for Facility Reported Incident #892636 at F-Tag 600/G F600 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. On 4/8/24, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding an alleged abuse toward one long-term care resident (Resident 1). Resident 1 is an 84-year-old female, who was admitted at the facility in 2015 with diagnoses that included Major Neurocognitive Disorder (a significant decline in at least one of the domains of cognitive which include executive function, complex attention, language, learning, memory, perceptual-motor, or social cognition). Resident 2 is a 69-year-old male, who was admitted at the facility in 2023. At the facility, Resident 2 has a history of multiple inappropriate behaviors. On 3/30/24, A Certified Nursing Assistant (CNA) found Resident 1 laying on her bed with her briefs down to her ankle and Resident 2 was standing facing Resident 1's on her right side of the bed. Resident 2 sexually violated Resident 1 by touching Resident 1's breasts and perineal area. Based on observation, interview, and record review, the facility failed to protect one of two sampled residents from abuse (Resident 1) when Resident 2, who had a history of inappropriate behavior, was not adequately supervised. This failure resulted in abuse when Resident 2 touched Resident 1's breasts and perineal area. Findings: During a review of Resident 1's clinical record the "Record of Admission" (ROA) indicated Resident 1 was admitted on 12/30/15. The "SOAP [Subjective, Objective, Assessment and Plan - method of documentation used by healthcare workers] Note" dated 3/14/22 at 11:09 a.m., indicated, "Major neurocognitive disorder [decreased mental function and loss of ability to do daily tasks] due to dementia [a group of symptoms affecting memory, thinking and social abilities], R/O [rule out] Alzheimer's disease [a progressive disease that destroys memory and other important mental functions]." The Minimum Data Set (MDS) Assessment dated 3/15/24 indicated, Resident 1's Brief Interview for Mental Status (BIMS -screening tool to identify the cognitive condition of a resident with a scoring of 0 to 15, 15 being cognitively intact) assessment score was 4 which indicates the resident has severe impaired cognitive ability. The MDS assessment dated 3/15/24 indicated the resident is in a wheelchair and is not ambulatory. During a review of Resident 1's Plan of Care, dated 3/30/24, the Plan of Care indicated, "Victim: Resident [1] was inappropriately touched by another resident [Resident 2]." The interventions included: perform a body check, provide one-on-one reassurance, monitor for changes in mood, behavior, socialization, sleep, or appetite, and Social Services Director to provide supportive one-to-one visits. During a review of Resident 1's "Physician Progress Note" (PPN), dated 4/8/24 at 12:57 p.m., the PPN indicated, "LATE ENTRY FOR 04/01/2024 08:30 [8:30 a.m.]: Patient [Resident 1] was involved in an incident with another resident [Resident 2] recently [3/30/24] but does not recall any of the details. She [Resident 1] continues to demonstrate cognitive [mental] decline/dementia. She continues to be unable to make her own medical decisions. She does have varying degrees of clarity and can carry on conversations and express her needs. Overall has poor safety awareness. When asked about these incidents she does not seem to recall any details of specifics." During a review of the facility's "Initial and Final Report (IFR)," dated 4/1/24, the IFR indicated, "On 3/30/2024 at about 0900 [9 a.m.] hours [Resident 1] was found by the C.N.A. [Certified Nursing Assistant- CNA 2] lying on her bed with her adult brief down and [Resident 2] was standing on the right side of her bed." During a review of Resident 2's ROA, the ROA indicates Resident 2 was admitted on 6/20/23. The MDS assessment dated 12/25/23 indicated Resident 2's BIMS score was 13, which indicates Resident 1 is cognitively intact. Resident 2 is independent with mobility and can walk 150 feet independently. During a review of the "Behavior Management Note (BMN)," dated 2/22/24 at 6:50 p.m., the BMN indicated, "Resident [Resident 2] provided comfort by touching resident [Resident 6] arm. Resident [6] later explained to writer that she does not prefer to be touched on the shoulder or arm when resident [Resident 1] comes to visit her." During a review of Resident 2's "Nurses Notes (NN)," dated 2/26/24 at 4:20 p.m., the NN indicated, "Informed SS [Social Services] to work on setting healthy boundaries with him [Resident 2], in regard to friendship with another resident [Resident 1] telling her to move to Trona with him." During a review Resident 2's "Behavioral Management Note, Alert Charting Note (BMNACN - when staff monitor and document a resident's change in condition every shift for 72 hours)," dated 2/26/24 at 11:21 p.m., the BMNACN indicated, "Resident [2] is on alert charting for behaviors relating to [Resident 1] and inappropriate sexual comments towards staff. Resident [2] was heard stating to CNA [Certified Nursing Assistant - unidentified] 'I would like to see more of your chest tattoo that is covered' and 'are there any tattoos you have tattoos are covered that I could see if you were naked' [sic]. Resident [2] also said to another CNA [unidentified] 'Your freckles look good all over your body'. CNA [unidentified] staff has reported many inappropriate comments from resident today." During a review of Resident 2's Plan of Care titled "CONFLICT," Effective Date 2/27/24, the Plan of Care indicates, "Resident [2] has been identified as having a high potential for conflict with staff/other residents/family. Resident is at risk for conflict due to crossing professional boundaries with staff AEB [As evidence by]: asking to see staff tattoos and freckles under clothing. Potential for crossing platonic boundaries with other residents AEB: discussing moving with another resident." The interventions include if resident is assigned one-on-one staff assignments will be rotated regularly to avoid burnout, staff will regularly document notes on behavior and refer to social services, Social Services will review resident chart documentation 1x monthly to identify any trends/issues. During a review of Resident 2's Plan of Care titled "SS-SEXUAL-BEHAVIORAL SYMPTOMS: PUBLIC SEXUAL ACTS," Effective Date 3/30/24, the Plan of Care indicates, "Resident [2] has engaged in sexual behaviors [with Resident 1] such as: Needs continual reminders of acceptable public behavior and of resident's rights. May be unable to comprehend or remember appropriate behavior related to a diagnosis of dementia" The interventions include to schedule and coordinate a care conference with resident and family, provide secured privacy, explain acceptable behavior and expressions of sexuality based on cognitive evaluation, evaluate resident's cognitive status for memory and social reasoning, remind resident in a private setting of the need to observe specific limits, protect other residents by close monitoring, educate staff on behavior approaches designed to effectively manage unacceptable sexual advances, and psychiatric evaluation. During a review of Resident 2's Plan of Care titled "SS-SEXUAL-BEHAVIORAL SYMPTOMS: PUBLIC SEXUAL ACTS," with an original date of 3/30/24 and an effective date of 4/9/24, the Plan of Care indicated, "Resident has engaged in sexual behaviors such as... .touches/fondles other resident, Makes verbally explicit comments and suggestions Needs continual reminders of acceptable public behavior and of resident's rights. . .03/30/24: Resident [2] found in a female resident's room with door closed. . .Resident [2] initially reports he did not touch female resident [1]. Resident [2] later reported to staff that he touched female resident's [1's] breasts and he reported to state surveyor that he 'tickled' the same female resident's [1's] vagina." The goals include Resident will not engage in sexual behavior in public by re-evaluation date [6/28/24], resident will not squeeze/slap/touch/fondle staff, resident will not make sexual advances to other non-consenting residents, and resident will respond to redirection and staff monitoring. The interventions include to protect other residents by close monitoring - every 15-minute checks x 3 days, every 30 minutes checks x 3 days and hourly checks x 14 days and re-evaluate for continued monitoring need, checks to include monitoring for activity and location and change room to near nursing station. During an interview on 4/8/24 at 11:24 a.m. with Resident 2, Resident 2 stated, "I did pull her [Resident 1] clothes down. I wanted to see what she looked like. I wanted to tickle her. I did tickle her down there [in her private area]. I find her to be attractive and I was interested." During an observation and interview on 4/8/24 at 11:46 a.m. with Resident 1, in Resident 1's room, Resident 1 was sitting in her wheelchair. Resident 1 stated, "I do not remember that this [sexual abuse] happened. What did he [Resident 2] do to me? I do not know who this resident [2] is." Resident 1 was unable to recall the 3/30/24 incident where Resident 2 admitted to touching Resident 1's breasts and perineal area. During an interview on 4/8/24 at 12:06 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 touched staff members in their private parts. LVN 1 stated Resident 1 has been displaying these behaviors for almost a month. LVN 1 stated he would inform Resident 1 the behavior was not appropriate, but LVN 1 did not report the behavior to anyone. During an interview on 4/8/24 at 12:16 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 2 was in Resident 1's room prior to the incident on 3/30/24. CNA 1 stated she "keeps an eye" on Resident 2 because she has noticed Resident 2 watches staff to see when they are busy and not at the nurses' station. CNA 1 stated Resident 2 is alert and oriented, and Resident 1 is confused. CNA 1 stated Resident 1 and Resident 2 would sit in the dining room holding hands. CNA 1 stated he seemed more interested in her [Resident 1] two weeks prior to the incident. During an interview on 4/8/24 at 2:15 p.m. with Director of Nursing (DON), DON stated she is aware Resident 2 has said inappropriate words to staff but was not aware of any other inappropriate behavior with other residents. During a concurrent interview and record review on 4/8/24 at 2:47 p.m., with Social Services Director (SSD) Resident 2's Plan of Care titled "SS-SEXUAL-BEHAVIORAL SYMPTOMS: PUBLIC SEXUAL ACTS," with an original date of 3/30/24 was reviewed. The Plan of Care indicated, "Resident has engaged in sexual behaviors such as. . .touches/fondles other resident, Makes verbally explicit comments and suggestions Needs continual reminders of acceptable public behavior and of resident's rights. . .03/30/24: Resident [2] found in a female resident's room with door closed. . .Resident [2] initially reports he did not touch female resident [1]. Resident [2] later reported to staff that he touched female resident's [1's] breasts and he reported to state surveyor tht [that] he 'tickeld [tickled]' the same female resident's [1's] vagina." The goals include Resident will not engage in sexual behavior in public by re-evaluation date [6/28/24], resident will not squeeze/slap/touch/fondle staff, resident will not make sexual advances to other non-consenting residents, and resident will respond to redirection and staff monitoring. The interventions include to protect other residents by close monitoring - every 15-minute checks x 3 days, every 30 minutes checks x 3 days and hourly checks x 14 days and re-evaluate for continued monitoring need, checks to include monitoring for activity and location and change room to near nursing station (not added until 4/9/24). SSD stated "close monitoring" means "just checking on him [Resident 2] when we are on the floor. I am not sure if it is specific enough." SSD stated to make sure close monitoring is occurring for Resident 2, he would review alert chartings (when staff monitor and document a resident's change in condition every shift for 72 hours). During a subsequent interview on 4/29/24 at 8:30 a.m., with SSD, SSD stated looking back now at the prior alert charting for Resident 2, shows the interventions were not effective. During an interview on 4/11/23 at 3:06 p.m. with CNA 2, CNA 2 stated Resident 1's room door was always open. On 3/30/24 after coming out of another resident's room, she noticed Resident 1's room door was closed and when she went in, she noticed Resident 2 was standing on Resident 1's right side and Resident 1's brief was all the way down to her ankles. CNA 2 stated Resident 1 and Resident 2 looked surprised. CNA 2 stated the time of the incident was right after breakfast during morning rounds approximately 9:30 a.m. CNA 2 stated this was the first time she noticed Resident 1 had her brief all the way down. CNA 2 stated she heard when the police [during the sexual assault incident that occurred on 3/30/24] asked Resident 1 if Resident 2 touched her breast, Resident 1 said yes. During an interview on 4/11/23 at 3:24 p.m. with LVN 3, LVN 3 stated she was notified of what CNA 2 witnessed [Resident 2 on the right side of Resident 1's bed and Resident 1 having her briefs down to her ankle] during med pass on 3/30/24. LVN 3 stated Resident 1 does not have the capacity to understand. LVN 3 stated she heard Resident 1 tell the police that Resident 2 touched her breast. During an interview on 4/29/24 at 9:46 a.m. with LVN 3, LVN 3 stated a few months ago Resident 2 had gone into Resident 1's room. LVN 3 stated Resident 2 had gone into Resident 1's room multiple times. LVN 3 stated during those incidents, she was made aware, and she informed staff to "keep any eye on them [Resident 1 and Resident 2]." During a review of the Policy and Procedure (P&P) titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," dated April 2021, the P&P indicated, "Residents have the right to be free from abuse. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse...by anyone including, but not necessarily limited to: b. other residents. . .8. Identify and investigate all possible incidents of abuse. 10. Protect residents from any further harm during investigations." In violation of the above cited, the facility failed to protect one of two sampled residents from abuse (Resident 1) when Resident 2, who had a history of inappropriate behavior, was not adequately supervised. This failure resulted in abuse when Resident 2 touched Resident 1's breasts and perineal area. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents and constitutes a class "B" citation.