Health inspection·October 20, 2023

42 CFR § 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. (a) The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 22 CCR § 72527 Patient’s 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. (11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. 42 CFR § 483.12(b) The facility must develop and implement written policies and procedures that: (b) (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. 22 CCR § 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. 22 CCR § 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. On 8/24/2023, the Department received a facility reported incident (FRI) regarding an allegation of Resident 1 was touched under her clothing inappropriately by Resident 2. On 8/25/2023, an unannounced visit was conducted at the facility. On 8/23/2023 around 4:30 p.m., Resident 2 was found by Certified Nurse Assistant (CNA) 2, inside Resident 1's room, touching Resident 1 on her thighs and Resident 1 stated Resident 2 touched her (Resident 1) vagina.  The facility failed to: ensure Resident 1’s rights to be free from sexual abuse, implement policies and procedures (“Abuse Prohibition, Dignity, and Resident’s Rights”), and ensure Resident 1 was treated with dignity and respect. These failures resulted in Resident 2 going into Resident 1's room and touching Resident 1 on her thighs and vagina. Resident 1 felt scared, anxious, had trouble sleeping, difficulty relaxing, and does not feel safe at the facility.  a. During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was a 69-year-old female who was admitted to the facility on 5/19/2022 and last readmitted on 7/30/2022. Resident 1's diagnoses included epilepsy (a sudden alteration of behavior due to temporary changes in the electrical functioning in the brain), legal blindness (eyesight is diminished and not able to see), hemiplegia right side (paralysis that affects only one side of your body).  A review of Resident 1's History and Physical (H&P), dated 7/31/2023, indicated Resident 1 had the capacity to understand and make decisions.  During a review of Resident 1's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 8/2/2023, the MDS indicated Resident 1's cognitive (ability to learn, reason, remember, understand, and make decisions) skills was moderately impaired. The MDS indicated Resident 1 required extensive assistance for activities of daily living (ADL) including eating, personal hygiene, and dressing.  During an interview on 8/25/2023 at 9:15 a.m., Resident 1 stated Resident 2 came into her room about a week ago (unable to recall exact date and time) touched her feet and heard her (Resident 2) talking and mumbling words. Resident 1 stated there was another incident (on 8/23/2023) while Resident 1 was sleeping, Resident 1 stated "I felt her (Resident 2) finger in my vagina." Resident 1 stated, she was legally blind and can only see shadows but heard Resident 2's voice while she was touching her vagina, and it was the same voice of the person who touched her feet. Resident 1 stated, she was scared, shouted for help and someone (CNA 2) came and removed Resident 2 from her room. Resident 1 stated, she had trouble sleeping and it was hard to relax, since the lady (Resident 2) came into her room and inappropriately touched her.   During a concurrent interview and record review on 8/25/2023 at 10:50 a.m., with the Social Worker (SW), Resident 1's SW "Progress Notes," dated 8/23/2023 was reviewed. The SW "Progress Notes" indicated on 8/23/2023, the SW checked in with Resident 1 regarding a report of abuse. The SW progress note indicated Resident 1 verbalized feeling anxiety about the situation (Resident 2 touching Resident 1 inappropriately). The SW progress note indicated Resident 1 does not know if she feels safe at the facility. The SW stated, Resident 2 had severe dementia (the loss of thinking, remembering, and reasoning), known to be a wanderer (someone who often travels from place to place, especially without any clear aim or purpose), and goes into residents' rooms. The SW stated, Resident 2 required one to one supervision since Resident 2 touched Resident 1. The SW stated it was important to make sure residents who were wandering were kept safe, and ensure other residents were kept safe from resident who were wandering around.  During a concurrent interview and record review on 8/25/2023 at 2:00 p.m., with the Director of Nursing (DON), Resident 1's "Change of Condition ([COC] a clinical deviation from a resident's baseline)" dated 8/23/2023 was reviewed. The COC indicated on 8/23/2023, Resident 1 had a changed in condition and verbalize having anxiety related to a situation, Resident 2 touched Resident 1 on her thighs without consent. The DON stated, on 8/23/2023 Resident 2 entered Resident's 1 room and touched Resident 1 without her consent. The DON stated CNA 2 reported she found Resident 2 touching Resident 1 on top of the blanket over Resident 1's body. The DON stated Resident 1 was upset that Resident 2 was touching her without her consent. The DON stated Resident 2 was not being closely monitored and the facility needed to keep a closer watch on Resident 2 to prevent her from roaming into other residents' rooms and to prevent non-consensual touching of another resident. The DON stated, Resident 1 was scared after Resident 2 touched Resident 1 without consent.  During an interview on 8/25/2023 at 3:00 p.m., CNA 2 stated on 8/23/2023 around 4:30 p.m., she was in the hallway and heard screaming from Resident 1's room. CNA 2 stated she went inside Resident 1's room and saw Resident 2's hands on top of the blanket of Resident 1 and was touching Resident 1's thighs. CNA 2 stated Resident 1 called a family member (FM) and was very upset about what had occurred. CNA 2 stated Resident 1 had informed her that Resident 2 came into her room and touched her vagina. CNA 2 stated Resident 2 was a wanderer and there had been a huddle (meeting) on 8/19/2023 to keep a close watch on Resident 2 and ensure Resident 2 does not go into residents' rooms.   During an interview on 8/25/2023 at 3:30 p.m., the Administrator (ADM) stated, Resident 2 went into Resident 1's room on 8/23/2023 and touched Resident 1’s thighs on top of the blanket without permission. The ADM stated they failed to keep track of Resident 2 whereabouts to prevent Resident 2 from going into Resident 1's room and touching Resident 1 without consent.   During an interview on 8/30/2023 at 1:00 p.m., the FM stated that he received a call from Resident 1, and she was crying hysterically. The FM stated Resident 1 told him that a woman put her fingers in her vagina. The FM stated Resident 1 was in her right mind, and she would have no reason to lie about the events that occurred. The FM stated Resident 1 was blind but understands what was going on.  During a review of Resident 2's Admission Record (Face Sheet), the Face Sheet indicated Resident 2 was a 61 year old female and was admitted to the facility on 8/11/2023. Resident 2's diagnoses included dementia, anxiety (persistent worry and fear about everyday situations), metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction).  A review of Resident 2's H&P, dated 8/14/2023, indicated Resident 2 cannot make decisions but can make needs known.  A review of Resident 2's MDS, dated 8/18/2023, indicated Resident 2's cognition was severely impaired. The MDS indicated Resident 2 required supervision for ADL including bed mobility, walking in room, walking in corridors, and required limited assistance in locomotion on and off unit. The MDS indicated Resident 2 had wandering behavior that occurred daily, the wandering behavior placed Resident 2 at significant risk of getting to a potentially dangerous place, and the wandering significantly intruded on the privacy or activities of others. Resident 2's behavior status, care rejection (behavior that interrupts or interferes with the delivery or receipt of care) or wandering compared to prior assessment was worse.  A review of Huddle form (meeting minutes or agenda), dated 8/19/2023, indicated to monitor Resident 2 and prevent Resident 2 from going into another resident room.  A review of Huddle form dated 8/20/2023, indicated to monitor Resident 2 from going into another resident's room.  A review of Resident 2's Care Plan for wandering into another resident’s room, date initiated 8/19/2023, indicated a goal of staff supervision and redirecting Resident 2 to common areas. The Care Plan indicated to assist Resident 2 to common areas, redirect as much as possible, engage resident in activities of interest and consider 1:1 direct supervision if behavior repeats.  A review of Resident 2's COC evaluation, dated 8/23/2023 at 7:03 p.m., indicated on 8/23/2023 Resident 2 was alleged an aggressor towards Resident 1. The COC indicated Resident 2 was placed on one to one (1:1-when an individual staff member is assigned to directly supervise no more than one resident and the staff shall stay within very close proximity to ensure constant supervision and immediate intervention if needed for safety reasons) sitter/ nurse to ensure she was monitored after the incident. A review of Resident 2's "Follow-up Documentation (facility report to describe the results of the abuse investigation)," dated 8/23/2023, indicated CNA 2 saw Resident 2 going inside Resident 1's room, and shortly after, Resident 1 started screaming and CNA 2 found Resident 2 touching Resident 1. The document indicated CNA 2 assisted Resident 2 out of the room. There was no documentation indicating Resident 2 was on one-to-one supervision or was being monitored. A review of Resident 2's "Interdisciplinary Meeting (IDT)," dated 8/23/2023, the IDT indicated, Resident 2 touched another resident (Resident 1) without her consent and had tendency to wander around.   During an interview on 8/25/23 at 1:00 p.m., with Licensed Vocational Nurse (LVN) 1, stated, Resident 2 was a wanderer and would wander all day and night. LVN 1 stated, there was a huddle on 8/19/2023 and 8/20/2023 to keep a close watch on Resident 2 due to Resident 2 went into Resident 1's room. On 8/23/2023 at around 4:30 p.m., Resident 2 was found touching Resident 1 on thigh area.   A review of facility's policy and procedure (P&P) titled, "Abuse Prohibition," dated 2/23/2021, indicated, "Healthcare Centers prohibit abuse…Instances of abuse of all patients, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish…It includes sexual abuse…Sexual Abuse is a non-consensual sexual contact of any type with a resident…It includes but is not limited to sexual harassment, sexual coercion or sexual assault."  A review of the facility's P&P titled, “Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating,” dated 9/2022, indicated all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft 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's P&P titled, "Dignity," undated, P&P indicated, "Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem…Staff promote, maintain and protect resident privacy."  A review of facility's P&P titled, "Resident Rights," dated 12/2021, indicated, "Federal and state laws guarantee certain basic rights to all residents of this facility…a dignified existence…be treated with respect, kindness, and dignity…be free from abuse and neglect."  On 8/23/2023 around 4:30 p.m., Resident 2 was found by CNA 2, inside Resident 1's room, touching Resident 1 on her thighs and Resident 1 stated Resident 2 touched her (Resident 1) vagina. The facility failed to: ensure Resident 1’s rights to be free from sexual abuse, implement policies and procedures (Abuse Prohibition, Dignity, and Resident’s Rights), and ensure Resident 1 was treated with dignity and respect. These failures resulted in Resident 2 going into Resident 1's room and touching Resident 1 on her thighs and vagina. Resident 1 felt scared, anxious, had trouble sleeping, had difficulty relaxing, and does not feel safe at the facility.  These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.