Health inspection·April 30, 2025

§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(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other 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. §72315 Nursing Service--Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. §72523 Patient Care Policies and Procedures (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. § 72527 Patients' Rights (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. On 3/18/2024, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) woke up to a man (Resident 2) inserting his hands in her genital area and on the same day (3/18/2025) the CDPH received a Facility Reported Incident (FRI) that Resident 1 reported Resident 2 entered her room, and she woke up when she felt something cold touching her private area. On 3/19/2024 the CDPH conducted an unannounced visit to the facility to investigate the complaint allegation and FRI. During the investigation the CDPH determined on 3/17/2024, at approximately 11 p.m., Resident 2 entered Resident 1's room unbeknownst to facility staff and without her (Resident 1's) consent. The facility failed to : 1. Ensure Resident 1 was free from sexual abuse by Resident 2, when Resident 2 entered Resident 1's room and touched her private area. 2. Conduct a thorough investigation when they did not interview other residents in the facility, following an allegation made by Resident 1 that Resident 2 came to her room, which was confirmed by the facility's video surveillance. 3. Follow their Policy and Procedure (P/P), titled, "Abuse Prevention, Screening and Training Program" revised 2018, that indicated the facility does not condone any form of resident abuse. 4. Follow their P/P titled, "Abuse Reporting and Investigations" revised 3/2018, that indicated the facility thoroughly investigates allegations of abuse. These failures resulted in Resident 2 entering Resident 1's room unbeknownst to staff on 3/17/2025 at approximately 11 p.m. Resident 2 unfastened Resident 1's incontinent brief and touched her private area, causing Resident 1 to feel scared and helpless, and an incomplete investigation into the allegation of sexual abuse. These deficient practices had the potential for Resident 1 to suffer emotional consequences and for other residents in the facility to be subjected to the same abuse. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was initially admitted to the facility on 3/30/2024 and readmitted on 3/7/2025 with diagnoses including muscle weakness. A review of Resident 1's History and Physical (H&P), dated 3/8/2025, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 3/14/2025, indicated Resident 1's cognitive (ability to think, understand, learn, and remember) skills for daily decision making were intact. A review of Resident 1's Change of Condition ([COC] a significant change in resident's status that requires intervention) dated 3/17/2025, indicated Resident 1 reported a sexual abuse encounter at approximately 11 p.m., on 3/17/2025. A review of Resident 2's Admission Record (Face Sheet) indicated Resident 2 was initially admitted to the facility on 1/23/2025 and readmitted on 3/3/2025 with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremors) and dementia (a progressive state of decline in mental abilities). A review of Resident 2's H/P, dated 3/4/2024, indicated Resident 2 did not have the capacity to make decisions. A review of Resident 2's MDS, dated 3/7/2025, indicated Resident 2 had moderate cognitive impairment (a brain condition that causes subtle changes in thinking and memory, resulting in more difficulty with these functions than is expected for someone's age). During an interview on 3/19/2025, at 11:45 a.m., Resident 1 stated on 3/17/2025 at night (approximately 11 p.m.) she was in her bed sleeping when she was awakened because she felt cold air on her private area and something cold on her left hip and groin area. Resident 1 stated her diaper was unfasted on the left side, her pubic area was exposed and when she looked up, she saw a man, who appeared to be a resident, wearing a knit cap with a pom-pom (round ball of yarn) on top of the cap, standing to the left side of her bed looking down on her. Resident 1 stated she screamed, and the resident opened the door and left her room leaving the door open. Resident 1 stated she called out for help and when Registered Nurse (RN) 1 came to her room, she told RN 1 that a man came into her room and unfastened her diaper and touched her private area. Resident 1 stated, RN 1 asked her, "are you sure you weren't dreaming? You were probably sleeping," and then she (RN 1) left the room, as if she (RN 1) didn't believe her. Resident 1 stated, a Certified Nursing Assistant (CNA) 1 came into her room, and she (Resident 1) told her what happened, and CNA 1 left the room. Resident 1 stated she saw Licensed Vocational Nurse (LVN) 1 in the hallway and called her, and LVN 1 came to her room and stayed with her. Resident 1 stated she told everyone who came in her room what happened, and she felt like they did not believe her and thought she was making it up. During an interview 3/19/2025 at 12:30 p.m., Resident 4 (Resident 2's Roommate) stated Resident 2 liked to walk around in the room and leave the room at night, but he was not sure where he went when he left the room. On 3/19/2025, at 1:30 p.m., the facility's video surveillance was viewed with the Administrator (ADM) present. The ADM stated the incident reported by Resident 1 occurred on 3/17/2025 at approximately 11 p.m., but the video's date and time indicated the incident occurred on 3/16/2025 from 7:58 p.m., through 8:30 p.m., which was not accurate. The ADM stated the identity of the man seen in the video was Resident 2. The video's footage and sequence of events were as follows: At 7:58 p.m., Resident 2 was seen, wearing a knitted cap with a pom-pom on the top of it, pushing a walker with a seat attached, entering Resident 1's room, closing the door behind him. At 8:07 p.m., Resident 2 exits Resident 1's room At 8:12 p.m., Resident 2 enters Resident 1's room and closes the door. At 8:14 p.m., Resident 2 exits Resident 1's room. At 8:15 p.m., RN 1 walks by Resident 1's room and turns her head to look into Resident 1's room, walks past the room toward the end of the hall. At 8:16 p.m., RN 1 was seen in the doorway of Resident 1's room (not fully in the room) and was observed standing in the doorway talking to someone in the room, gesturing with her hands and then leaves room. At 8:19 p.m., CNA 1 was seen standing in the doorway of Resident 1's room, talking to someone in the room, CNA 1 then leaves the room. At 8:30 p.m., LVN 1 enters Resident 1's room During a review of the facility's Investigative Report, dated 3/21/2025, the Investigative Report indicated, Resident 2 entered Resident 1's room, per Resident 1's witnessed account and confirmed via video footage. The facility took appropriate and immediate action and provided timely reporting to all agencies and interested parties, this appears to be an isolated, unavoidable, unanticipated and unexpected incident involving Resident 2. During an interview on 3/19/2025, at 3 p.m., RN 1 stated on 3/17/2025 she was walking down the hallway when she heard someone in Resident 1 and Resident 3's room asking for help. RN 1 stated, she thought Resident 3 was asking for her diaper to be changed and she (RN 1) left the room to call CNA 1 for assistance. RN 1 stated, she thought Resident 1 was asleep and didn't return to the room until CNA 1 and LVN 1 alerted her that Resident 1 reported to them that a man had been in her room and touched her private area. During an interview on 3/19/2025, at 3:28 p.m., LVN 1 stated on 3/17/2025 at approximately 11 pm., while she was passing medications, she heard Resident 1 calling out from her room. LVN 1 stated Resident 1 appeared very upset and reported that a man had been in her room and touched her private area. LVN 1 stated, she asked Resident 1, "are you sure you were not asleep?" You could have been sleeping." LVN 1 stated Resident 1 described the man who had been in her room as wearing a knitted hat with a pom-pom on top of it, who was using a walker with a seat attached. LVN 1 stated Resident 1 pointed to her (Resident 1's) left hip area and said, he touched her there. LVN 1 stated she called RN 1 into the room and reported the incident to her. During an interview on 3/20/2025, at 11:46 a.m., CNA 1 stated on 3/17/2025 while she conducted her rounds, she was directed by RN 1 to assist Resident 1's roommate (Resident 3), who needed a diaper change. CNA 1 stated, when she went to the room Resident 1 was very upset and scared, and she kept repeating that a man came into her room and touched her private area. CNA 1 stated, Resident 1 gave her a description of a man wearing a knit cap. CNA 1 stated, she immediately left Resident 1's room and reported the allegation of abuse to another staff member (LVN 1). During an interview on 3/20/2025 at 12:06 p.m., the Director of Nurses (DON) stated she was not at the facility when the alleged abuse occurred. it was reported to her. The DON stated when she arrived at the facility, she spoke to Resident 1 who told her she was not ok, and she (DON) assured her (Resident 1) that she was there for her. The DON stated she encouraged Resident 1 to go to the General Acute Care Hospital (GACH) to be evaluated. During an interview on 3/25/2025, at 9:45 a.m., the DON stated the completed their investigation and that she and the Administrator (ADM) had not interviewed all interviewable residents in the facility to inquire if Resident 2 or any other resident had entered their rooms without consent. The DON stated she and the ADM determined conducting interviews with staff, Resident 1, Resident 2 and their respective roommates was sufficient to determine that the incident on 3/17/2025 was an isolated event. The DON stated failure to interview other residents in the facility resulted in their investigation not being thorough, which could lead to unrecognized acts of abuse. The DON stated it was important to interview other residents to ensure no other allegation of abuse had occurred. A review of the facility's P/P titled, "Abuse Reporting and Investigations" revised 3/2018, indicated the facility thoroughly investigates allegations of abuse. A review of the facility's P/P titled, "Abuse Preventions, Screening and Training Program" revised 2018, indicated the facility does not condone any form of resident abuse. The administrator as abuse prevention coordinator is responsible for the coordination, and implementation of the facility's abuse prevention, screening and training program policies. Sexual abuse is defined as non-consensual sexual contact of any type, sexual harassment, sexual coercion or sexual assault. The P/P indicated the administrator, or designated representative will provide a safe environment for the resident as indicated for the situation. The facility failed to: 1. Ensure Resident 1 was free from sexual abuse by Resident 2, when Resident 2 entered Resident 1's room and touched her private area. 2. Conduct a thorough investigation when they did not interview other residents in the facility, following an allegation made by Resident 1 that Resident 2 came to her room, which was confirmed by the facility's video surveillance. 3. Follow their Policy and Procedure (P/P), titled, "Abuse Prevention, Screening and Training Program" revised 2018, that indicated the facility does not condone any form of resident abuse. 4. Follow their P/P titled, "Abuse Reporting and Investigations" revised 3/2018, that indicated the facility thoroughly investigates allegations of abuse. These failures resulted in Resident 2 entering Resident 1's room unbeknownst to staff on 3/17/2025 at approximately 11 p.m. Resident 2 unfastened Resident 1's incontinent brief and touched her private area, causing Resident 1 to feel scared and helpless, and an incomplete investigation into the allegation of sexual abuse. These deficient practices had the potential for Resident 1 to suffer emotional consequences and for other residents in the facility to be subjected to the same abuse. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 1.