Health inspection·May 21, 2025

F600 42 CFR §483.12: Freedom from Abuse, Neglect, and Exploitation §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. 42 CFR §483.12(b): Freedom from Abuse, Neglect, and Exploitation §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, §483.12(b)(4) Establish coordination with the QAPI program required under 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 4/10/25, The California Department of Public Health (CDPH) conducted an onsite investigation at the facility regarding an employee to resident sexual abuse allegation. The facility failed to implement its policy titled "Abuse Prevention Program" reviewed by the facility on 8/2024, when on 4/8/2025 at 11:55 AM Resident 1 accused Certified Nursing Assistant 1 (CNA1) of sexual abuse (non-consensual sexual contact/touching of any type or sexual harassment), CNA1 was not immediately removed from providing direct care (including incontinent care) to residents and continued to have access to Resident 1. As a result of this deficiency, Resident 1 was not protected from the potential of further harm or retaliation from CNA1, and other residents were at risk of harm after CNA 1 was identified as a perpetrator. A review of Resident 1's Admission Record indicated the facility admitted the 85-year-old female on 11/21/2022 and re-admitted on 8/29/2024 with diagnoses that included functional quadriplegia (someone who has developed paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury but has regained some level of independence or functionality in daily activities), schizophrenia (a mental illness that is characterized by disturbances in thought) and muscle wasting (weakening, shrinking, and loss of muscle). A review of Resident 1's Quarterly Minimum Data Set (MDS- a resident assessment tool) dated 2/12/2025, indicated the resident had adequate hearing, could usually make themselves understood, and could usually understand others. The MDS indicated Resident 1 had severe cognitive (ability to acquire and understand knowledge) impairment. The MDS indicated Resident 1 was always incontinent with urine and was dependent upon staff for toileting hygiene. A review of Resident 1's Change in Condition (COC - a written communication tool that helps provide important information) Evaluation Communication Form, dated 4/8/2025 at 11:55 AM, indicated Resident 1 accused a staff member (CNA1) of touching the resident's body inappropriately. The COC indicated staff interviewed the resident regarding the allegation and notified the primary physician and the resident's psychiatrist. A review of the facility's assignment sheet, dated 4/8/2025," indicated that on 4/8/2025 from7AM to 3 PM CNA 1 was on duty. The assignment sheet indicated CNA1 signed in at 7:03 AM and signed out at 4 PM. A review of the facility's assignment sheet dated 4/9/2025 indicated that on 4/9/2025 from 7AM to 3 PM CNA 1 was on duty. The assignment sheet indicated CNA1 signed in at 7:05 AM. A review of the facility's Timecard Report for CNA 1 for 4/1/2025 thru 4/15/2025, indicated on 4/8/2025, CNA 1 signed in at 7:08 AM and signed out 3:40 PM (more than four hours after the abuse was alleged). The Timecard Report indicated on 4/9/2025 CNA1 signed in at 7:04 AM and signed out at 3:34 PM (the day after the abuse was alleged). A review of Resident 1's care plan for the alleged accusation of being touched, initiated 4/9/2025, indicated the resident was at risk for emotional distress. The care plan indicated the goal was to minimize the residents' emotional distress. The interventions included suspending CNA 1 until further notice, to protect the resident during the abuse investigation and the Social Services Director would monitor the residents for three days. A review of Resident 1's Social Services Note, dated 4/9/2025, indicated law enforcement spoke with Resident 1 regarding the abuse allegation. During a concurrent observation in Resident 1's room and interview on 4/10/2025 at 9:56 AM at Resident 1's bedside, Resident 1 was observed lying in bed. Resident 1 stated the week prior CNA1 touched the resident's private area inappropriately and made verbal sexually suggestive comments to Resident 1. Resident 1 stated she notified a nurse (did not recall exact time and date) and staff interviewed the resident. Resident 1 stated a staff member (unidentified) stated CNA 1 would not work with the resident again. During an interview on 4/10/2025 at 11:10 AM, the Director of Rehabilitation (DOR) stated on 4/8/2025 approximately between 12 and 2 PM, Certified Occupational Therapy Assistant 1 (COTA 1) notified the DOR about Resident 1's allegation of CNA 1 touching the resident in an unwelcome manner. The DOR on 4/8/2025 then notified the Social Services Director (SSD) and Director of Nursing (DON). The DOR stated the SSD, and the DON then went to speak with the resident. The DOR confirmed by stating CNA 1 continued to work after Resident 1 made the abuse allegation. During an interview on 4/10/2025 at 11:40 AM, COTA 1 stated that on 4/8/25 after lunch but before 3 PM, COTA1 attempted to give Resident 1 therapy when Resident 1 reported not wanting CNA1 to change the resident's incontinence brief. COTA 1 stated Resident 1 did not like the way CNA1 touched the resident. COTA 1 stated after Resident 1 made the abuse allegation, CNA1 was moved from Resident 1's side of the facility and started working on the opposite side of the facility. During an interview on 4/10/2025 at 1:08 PM, Licensed Vocational Nurse 1 (LVN 1) stated on 4/8/2025 upon returning from lunch around 11:30 AM, LVN 1 was notified of Resident 1's abuse allegation toward CNA 1 and at that time LVN 1 wrote a COC regarding Resident 1's abuse allegation. LVN 1 stated Resident 1 reported CNA 1 touched the resident inappropriately. During a concurrent review of the facility assignment sheet dated 4/8/2025, LVN 1 stated per the assignment sheet, CNA 1 signed out of work at 4 PM. LVN 1 stated generally after being accused of abuse, staff were to be suspended immediately, because the facility had to take the word of the resident to protect them from further harm. During a phone interview on 4/10/2025 at 2:03 PM, CNA1 stated the last time CNA1 worked with Resident 1 was a week ago. CNA1 stated they first heard of Resident 1's abuse allegation on 4/9/2025. CNA1 confirmed by stating that CNA1 worked the full shift on 4/8/2025 (the day of the abuse allegation) and came into work the next day as well (4/9/2025). CNA 1 stated the facility suspended CNA1 from work on 4/9/2025 at 12:30 PM. During a concurrent interview and record review on 4/10/2025 at 2:18 PM with Registered Nurse Supervisor 1 (RN 1), RN 1 reported Resident 1's abuse allegations to the mandated entities. RN 1 stated on 4/9/2025 around 12 noon RN 1 and the DSD suspended CNA1. RN 1 stated employees accused of abuse had to be suspended immediately to protect the residents from harm or retaliation. During a phone interview on 4/10/2025 at 3:39 PM, the DSD stated, with RN 1 the DSD suspended CNA 1 on 4/9/2025. The DSD stated staff are to be suspended right away and remain on suspension while the abuse investigation is underway. During an interview on 4/10/2025 at 4:02 PM, the Director of Nursing (DON) stated staff accused of abuse had to be suspended immediately to protect the residents' safety. A review of a facility P&P titled "Abuse Prevention" with a review date of 8/2024, indicated "Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms." The policy indicated "As part of the resident abuse prevention, the administration will... 8. Protect residents during abuse investigations." A review of the facility's P&P titled, " Abuse Investigation and Reporting," reviewed 8/2024, indicated the administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation and the administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. The facility failed to implement its policy titled "Abuse Prevention Program" reviewed by the facility on 8/2024, when on 4/8/2025 at 11:55 AM Resident 1 accused CNA1 of sexual abuse CNA1 was not immediately removed from providing direct care (including incontinent care) to residents and continued to have access to Resident 1. The facility failed to timely remove CNA 1 from the facility, thereby endangering both Resident 1 and other residents at risk of sexual abuse. As a result of this deficiency, Resident 1 and other residents were not protected from the potential of further harm or retaliation from CNA1 after being identified as a perpetrator. This violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious harm to residents would result.