Health inspection·January 10, 2025

F600 Freedom from Abuse, Neglect, and Exploitation 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. §483.12(a) The facility must— §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; 22 CCR §72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 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 11/26/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate one complaint and two facility-reported-incidents regarding sexual abuse (any sexual activity that occurs without consent [permission]). The facility failed to protect Resident 1’s right to be free from sexual abuse, when on 11/23/2024 at approximately 8 p.m., Certified Nursing Assistant (CNA) 1 inserted his (CNA 1) fingers inside Resident 1's vagina (female genitalia [reproductive organ of a female involved in producing children]). CNA 1 then grabbed Resident 1's right hand and coerced (to persuade [cause] someone forcefully to do something that they are unwilling to do) Resident 1 to touch CNA 1's penis (male genitalia [reproductive organ of a male]). As a result, Resident 1 was subjected to a nonconsensual (when a resident does not agree or cannot agree to participate in an act) sexual assault (the act in which one intentionally sexually touches another resident without the resident's consent) by CNA 1 while under the care of the facility. On 11/23/2024 at 8 p.m., 11/24/2024 at 10:40 a.m., and 11/24/2024 at 10:55 a.m., Resident 1 was observed agitated (feeling or appearing troubled or bothered), fearful (feeling a strong, immediate reaction to a perceived present danger), anxious (experiencing worry, unease, or nervousness), and crying. On 11/24/2024 at 4:38 p.m., Resident 1 was sent to the General Acute Care Hospital (GACH) for further evaluation due to the incident. A review of Resident 1's Admission Record indicated the facility admitted a 60-year-old female resident on 10/24/2024 with diagnoses including neurosyphilis (a bacterial infection of the brain), human immunodeficiency disease (a virus that attacks the body's immune system), suicide attempt (an act in which an individual tries to kill themselves), and muscle weakness. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/31/2024, indicated Resident 1 had moderate cognitive (relating to the mental process involved in knowing, learning, and understanding things) impairment. The MDS indicated Resident 1 required maximum assistance from staff with toileting hygiene and was dependent on staff for activities of daily living (ADLs) including sit to stand (the action of moving from a seated position to a standing position), toilet transferring (the process of safely moving a person to and from a toilet or bedside commode), and showering. A review of Resident 2's Admission Record indicated the facility admitted a 54-year-old female resident on 12/6/2023 with diagnoses including dysphagia (difficulty swallowing), essential (primary) hypertension (high blood pressure), and muscle weakness. A review of Resident 2's MDS, dated 2/29/2024, indicated Resident 2 had moderate cognitive impairment. Resident 2 was dependent on staff for ADLs including toileting hygiene and needed substantial/maximal assistance (helper does more than half the effort) for showering or bathing self and personal hygiene (including combing hair, shaving, applying makeup, washing/drying face, and hands). A review of the Change in Condition (COC - when there is a sudden and significant change from a resident's health) Evaluation Form, dated 11/24/2024, timed at 11 a.m., indicated that on 11/24/2024, during rounds at 10:55 a.m., Resident 1 reported that her (Resident 1's) CNA (referring to CNA 1) last night (on 11/23/2024) placed a finger inside her (Resident 1) vagina then grabbed her (Resident 1) hand and made her touch the CNA's (CNA 1) penis. The COC form further indicated Resident 1's physician was notified on 11/24/2024 at 12 p.m. and ordered to transfer Resident 1 to GACH 1 for further health evaluation. During an interview on 11/26/2024 at 10:20 a.m., Resident 2 stated on Saturday, 11/23/2024, at approximately 8 p.m., her roommate (Resident 1) was crying and told Resident 2 that she (Resident 1) did not want CNA 1 in her room again because he (CNA 1) inserted his (CNA 1's) fingers inside her (Resident 1's) private part (vagina). During an interview on 11/26/2024 at 11 a.m., Registered Nurse (RN) 1 stated on 11/24/2024 at around 10:55 a.m., Certified Nurse Assistant 2 (CNA 2) notified her (RN 1) that Resident 1 wanted to speak with her. RN 1 stated Resident 1 told her (RN 1) that last night (11/23/2024) CNA 1 placed a finger inside her vagina and stated CNA 1 grabbed her (Resident 1) hand and placed it on his (CNA 1) genitals. RN 1 stated Resident 1 was observed agitated and fearful. RN 1 stated she (RN 1) then called the MD and the MD ordered to transfer Resident 1 to the GACH for further evaluation. During an interview on 11/26/2024 at 11:19 a.m., the Manager on Duty (MOD) stated she was working Sunday morning, on 11/24/2024, when RN 1 came to tell her and asked her to assist with Resident 1 because she (Resident 1) had been abused. The MOD went to Resident 1's room and Resident 1 told her (MOD) that last night (11/23/2024) CNA 1 was changing Resident 1's incontinent brief (products that help manage the leakage of urine or stool that occurs with incontinence) wiped her and then placed his fingers inside her (Resident 1) private part. The MOD stated Resident 1 told her that CNA 1 grabbed her (Resident 1) other hand, placed Resident 1's hand on his (CNA 1) genitals, and was rubbing his (CNA 1) genitals with her (Resident 1's) hand. The MOD stated Resident 1 said "no", pushed her hand back away from CNA 1's genitals, and CNA 1 stopped. The MOD stated Resident 1 was scared with tears in her eyes. The MOD stated Resident 1 said, "I don't want to see" CNA 1. The MOD stated she (MOD) told Resident 1 to not worry because she (Resident 1) did nothing wrong and that CNA 1 was not coming back to her room. During an interview on 11/26/2024 at 12 p.m., the Director of Staff Development (DSD)stated the incident happened on Saturday, 11/23/2024 during the 3 p.m. to 11 p.m. shift. The DSD stated she was notified on Sunday (11/24/2024) at 10: 48 a.m. that CNA 1 had sexually assaulted Resident 1. The DSD stated she called CNA 1 immediately and he (CNA 1) told her that he was cleaning Resident 1 and that his finger slipped and touched Resident 1's genitalia. The DSD stated she suspended CNA 1. The DSD stated Resident 1 experienced sexual abuse in the facility. During an interview on 11/26/2024 at 12:05 pm, the SSD stated the Administrator (ADM) called him (SSD) to come in on Sunday (11/24/2024) to interview Resident 1. The SSD stated he (SSD) entered the room and told Resident 1 that he (SSD) was checking up on her (Resident 1). The SSD stated Resident 1 was visibly upset, fidgety, and stated she (Resident 1) was nervous because she (Resident 1) will be sent to the hospital for further evaluation. During a telephone interview on 11/26/2024 at 1: 30 p.m., CNA 2 stated that when she was working on Sunday, 11/24/2024, at 10:40 a.m., while she (CNA 2) was changing Resident 1, Resident 1 told her (CNA 2) that she (Resident 1) would like to speak with RN 1. CNA 2 stated Resident 1 appeared agitated and anxious. CNA 2 stated Resident 1 then told her (CNA 2) that last night (11/23/2024) CNA 1 was cleaning her (Resident 1) and he (CNA 1) touched her inappropriately. During an interview on 11/26/2024 at 1:35 p.m., the ADMIN stated RN 1 called her (ADMIN) on 11/24/2024 reporting that CNA 1 was changing Resident 1, and he (CNA 1) inserted his fingers inside Resident 1's private area (vagina). The ADMIN stated she (ADM) called CNA 1 and he (CNA 1) stated he (CNA 1) did slip his fingers inside Resident 1's private area. The ADMIN stated she suspended CNA 1 immediately, pending termination. During an interview on 11/26/2024 at 3:15 p.m., the Director of Nursing (DON) stated he (DON) was notified on 11/24/2024 at around 12 pm of an allegation of sexual abuse. The DON stated he came to the facility on Sunday (11/24/2024) at 1 p.m. to investigate the allegation. The DON stated Resident 1 told him that the day before (11/23/2024), CNA 1 came in her (Resident 1) room to change her incontinence pad and put his (CNA 1) fingers inside her (Resident 1) genitalia. The DON stated Resident 1 then told him that CNA 1 grabbed her (Resident 1) right hand and placed it on his (CNA 1) private area. The DON stated Resident 1 was upset. The DON stated Resident 1 did not tell any staff right away because she did not want anyone to get in trouble. The DON stated Resident 1 experienced sexual abuse while under the care of the facility. A review of Resident 1's GACH Emergency Documentation, dated 11/24/2024, indicated a chief complaint of sexual assault. The GACH Emergency Documentation report indicated Resident 1 complained of sexual assault by an employee of the facility she resides in. Resident 1 stated that CNA 1 was bathing her and changing her when CNA 1 inserted his fingers into her vagina. Resident 1 told CNA 1 to stop, and CNA 1 left the room. The report indicated Resident 1 told her roommate (Resident 2) of what CNA 1 did to her (Resident 1). A review of CNA 1's Corrective Action Memo, dated 11/24/2024, indicated CNA 1's type of violation is allegation of sexual abuse. The memo indicated CNA 1 stated he was assigned to Resident 1 and Resident 2 (11/23/2024). The memo indicated CNA 1 stated his fingers slipped into Resident 1's private area while cleaning Resident 1. The memo indicated the facility placed CNA 1 on suspension on 11/24/2024. A review of CNA 1's Corrective Action Memo, dated 11/25/2024, indicated the type of violation is an allegation of sexual abuse. The memo indicated CNA 1 was interviewed a second time on Monday morning of 11/25/2024 with CNA 1 admitting his fingers slipping into Resident 1's private area and he (CNA 1) also stated Resident 1 touched his private part. The memo indicated the facility terminated CNA 1. A review of the facility-provided policy and procedure titled, "Abuse-Prevention, Screening & Training Program, dated 6/12/2024, indicated the facility does not condone any form of resident abuse, neglect, misappropriation (unauthorized, improper, or unlawful use) of resident property, exploitation, and or mistreatment and develops facility policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. Sexual abuse is defined as a non-consensual sexual contact of any type, sexual harassment, sexual coercion, or sexual assault. The facility failed to protect Resident 1’s right to be free from sexual abuse, when on 11/23/2024 at approximately 8 p.m., CNA 1 inserted his (CNA 1) fingers inside Resident 1's vagina. CNA 1 then grabbed Resident 1's right hand and coerced Resident 1 to touch CNA 1's penis. As a result, Resident 1 was subjected to a nonconsensual sexual assault by CNA 1 while under the care of the facility. On 11/23/2024 at 8 p.m., 11/24/2024 at 10:40 a.m., and 11/24/2024 at 10:55 a.m., Resident 1 was observed agitated, fearful, anxious, and crying. On 11/24/2024 at 4:38 p.m., Resident 1 was sent to the GACH for further evaluation due to the incident. The above 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 to Resident 1.