Health inspection·October 15, 2024

F600 -Freedom from Abuse, Neglect, and Exploitation §483.12 Freedom from Abuse, Neglect, and Exploitation The Patient has the right to be free from abuse, neglect, misappropriation of Patient 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 Patient’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.

F607 §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 patients and misappropriation of patient 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 §483.75. §483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. §483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act. §483.12(b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. On 8/26/2024, at 9:10AM, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident regarding sexual abuse. The facility failed to ensure Patients 2, 3, and 4 residing at the facility were free from sexual abuse (non- consensual [something is not agreed to by one or more of the people involved] sexual contact) from Patient 1, who had a diagnosis of Alzheimer’s disease (a brain condition that causes a progressive decline in memory, thinking, learning and organizing skills), by failing to: 1. Protect Patient 3 from nonconsensual sexual contact (any physical contact with another person of a sexual nature without effective consent) when Patient 1 grabbed Patient 3’s left arm and pulled down Patient 3’s sleeve on 3/10/2024. 2. Protect Patient 4 from nonconsensual sexual contact, in accordance with the facility’s policy and procedures (P&P) on “Abuse Prevention Program,” when Patient 1 swiped his open palms across Patient 4’s breasts on 3/26/2024, as witnessed by an unknown group of Patients in the facility’s Activity Room. 3. Protect Patient 2 from nonconsensual sexual contact when Patient 1 “grabbed/cupped” Patient 2’s left arm tightly and left breast with both hands, as witnessed by Housekeeper (HK) 1, on 8/25/2024. Patient 2 complained of pain when Patient 1 grabbed her left breast with both hands. 4. Protect and prevent further nonconsensual sexual contact of Patient 1 to other Patients when the facility failed to develop a comprehensive, Patient specific care plan on 5/24/2024, in accordance with the physician order dated 5/24/2024, to monitor Patient 1’s behavior episodes of mood disorder (a mental health condition that affects a person’s emotional state of long periods of extreme feelings) of inappropriately touching females (Patients and staff) in a sexual manner. 5. Ensure the Interdisciplinary Team (IDT - of professionals plan, coordinate and deliver you personalized health care) implement safeguards to prevent further potential sexual abuse, in accordance with the facility’s policy and procedure on “Abuse Prevention Program,” when female facility staff reported having knowledge of Patient 1’s sexually inappropriate behaviors (for an unknown period of time) among female Patients and staff such as grabbing arms, breasts, kissing, and asking for oral sex. 6. Ensure to have a system in place to implement care plan interventions that are relevant to Patient 1’s behavioral needs, diagnosis and sufficient staff assigned to manage behaviors and effectively monitor/supervise the Patient’s whereabouts throughout the shifts to protect other female Patients from non-consensual sexual contact, in accordance with the facility’s P&P titled “Behavioral Health Services.” As a result, Patient 4 verbalized being in a state of "shock" after Patient 1 "swiped his open palms across her breast" on 3/26/2024, and Patient 2 reported pain to the left arm and breast after Patient 1 grabbed her left breast with both hands on 8/25/2024. Patient 2 expressed feeling of sadness, embarrassed, upset, worried, and afraid that the incident of Patient 1 grabbing her by the arm and breast may happen again. Patient 3 verbalized being upset when Patient 1 grabbed her left arm and pulled her (gown) sleeve down. These deficient practices placed other female Patients at risk for sexual abuse or non-consensual sexual contact from Patient 1 and cause psychosocial (covers a person's mental, emotional, social, and spiritual health) distress, physical injuries, hospitalization, and death. Findings: 1. A review of Patient 1’s Admission Record [AR] indicated the facility admitted the 90 year old male on 9/16/2023, with a diagnosis of Alzheimer’s Disease. A review of Patient 1’s Change of Condition [COC] evaluation dated 11/13/2023, indicated Patient 1 was having episodes of “Inappropriate sexual behavior towards the staff.” A review of Patient 1’s Care Plan dated 11/13/2023, indicated a care plan was developed on Patient 1’s episodes of inappropriate sexual behavior (did not indicate specific sexual behavior) toward staff. The care plan interventions included was to assign a male CNA to reduce behavior episodes, monitor for episodes of inappropriate sexual behavior towards staff. A review of Patient 1’s Order Summary Report dated 11/30/2023, indicated to monitor behavior episodes of “grabbing random things and staff” every shift. A review of Patient 1’s History and Physical [H&P - a comprehensive physician’s note regarding the assessment of the patient’s health status) dated 8/24/2024, indicated the Patient did not have the capacity to understand and make decisions. A review of Patient 1’s Minimum Data Set (MDS; a care assessment screening tool) dated 6/7/2024, indicated the Patient had severely impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated the Patient required supervision or touching assistance providing verbal cues while assisting Patient to complete activities of daily living (eating, oral hygiene, toileting hygiene, showering and bathing). A review of Patient 1’s COC evaluation dated 3/10/2024, indicated Patient 1 had an altercation and became verbally and physically aggressive pulling at the sleeves of a female Patient [Patient 3]. A review of Patient 1’s care plans dated 3/10/2024, the care plan indicated the Patient’s physical behavior and poor impulse control (difficulty controlling actions or reactions) as evidenced by Patient 1 grabbing sweater sleeve of female Patient and pulling it down. The care plan interventions included to intervene prior to agitation escalating (increasing rapidly) and to walk calmly away. A review of Patient 1’s COC evaluation dated 3/26/2024, the COC evaluation indicated “Patient [1] brushed his arm against another Patient’s chest.” The COC evaluation indicated the physician recommended for the Patient to be followed by social service, Psychologist and Psychiatrist. A review of Patient 1’s care plan dated 3/26/2024, the care plan indicated Patient 1 “brushing his arm against another Patient’s chest,” with interventions included, for staff to closely monitor Patient 1 for inappropriate behaviors such as inappropriate grabbing, touching, brushing, kissing, hugging and other behaviors that may be deemed inappropriate. A review of Patient 1’s Psychiatric Follow up note dated 4/9/2024, the Psychiatric Follow up note indicated Patient 1 had an adjustment disorder [a recognized short-term health condition that occurs when one goes through a change in life and has difficulty adjusting to it], with disturbance of conduct – inappropriate sexual advances towards women. A review of Patient 1’s Order Summary Report for May 2024, indicated a physician order dated 5/24/2024, to monitor Patient 1’s behavior episodes of mood disorder (a mental health condition that affects a person’s emotional state of long periods of extreme feelings) which indicated touching females sexually inappropriately and count/document every shift for Trileptal (mood stabilizer medication) usage. A review of Patient 1’s COC evaluation dated 8/25/2024, the COC evaluation indicated Patient 1 had episodes of inappropriate behavior of touching another Patient's hand and breast. The COC Evaluation findings suggested that the Patient had the ability to understand and follow simple instructions but due to Alzheimer’s disease shows unpredictable behavior. A review of Patient 1’s care plan dated 8/25/2024, the care plan indicated Patient 1 had episodes of inappropriate physical behavior of touching left hand and breast of another Patient. The care plan interventions included to inform the responsible party of Patient 1’s behavior, monitor behavior every shift, and report to the physician, if persistent. A review of Patient 1’s Order Summary Report for August 2024, indicated a physician order dated 8/27/2024, to monitor behavior episodes of mood disorder which included touching females sexually inappropriately, every shift. 2. A review of Patient 4’s AR indicated the facility admitted the 58 year old female on 3/12/2024, with diagnoses that included radiculopathy (pinched nerves which cause pain, weakness and numbness). A review of Patient 4’s H&P dated 3/13/2024, the H&P indicated the Patient had the capacity to understand and make decisions. A review of Patient 4’s MDS dated 3/8/2024, the MDS indicated the Patient was cognitively intact. A review of Patient 4’s Police Report dated 3/26/2024, the Police Report indicated the police officer’s interview with Patient 4 while in the facility, on 3/26/2024. The Police Report indicated that according to Patient 4, Patient 1 was known to be “touchy-feely (touching and holding people more than usual, often in a way that makes other people uncomfortable),” explaining that Patient 1 grabs female Patients by the hand, including herself (Patient 4), and tells them he loves them. The Police Report indicated Patient 4 verbalized Patient 1 has Alzheimer’s disease but has periods of reality. The Police Report indicated Patient 4 stated that on 3/26/2024, while she was in the Activity group, Patient 1 “swiped his open palm across her breasts.” The Police Report indicated Patient 4 verbalized being “in shock,” including the other Patients who were present in the Activity group and witnessed Patient 1 swiping his open palm across Patient 4’s breasts. The Police Report further indicated, Patient 4 stated she was in the facility for her “Physical disability [any physical limitations or disabilities that inhibit the physical function] and is in complete control and awareness of her mental faculty [the abilities or capacities of the mind, including the ability to think clearly, reason, and understand].” 3. A review of Patient 2’s AR indicated the facility admitted the 64 year old female on 8/16/2023, with diagnoses that included cerebral infarction (blood flow to brain is blocked causing tissue death). A review of Patient 2’s H&P dated 1/31/2024, indicated the Patient had the capacity to understand and make decisions. A review of Patients 2’s MDS, dated 8/14/202024, indicated the Patient was cognitively intact (has sufficient judgment, planning, organization, self control and able to manage the normal demands of environment). A review of Patient 2’s Social Service [SS] Note dated 8/25/2024, timed at 6:58 PM, the SS note indicated the Patient appeared to still be upset regarding the incident with Patient 1. The SS Note indicated while Patient 2 was on her way to a smoke break, Patient 1 followed her in his wheelchair, took her by the arm and “grabbed/cupped her left breast.” The SS Note indicated Patient 2 stated “he should not have done that” and that she told him “Please don't do that.” A review of the facility’s written Final Investigation Report regarding Patient 1 and Patient 2’s sexual abuse allegation, (undated), signed by the facility’s ADM. The Report indicated that on 8/25/2024, HK 1 witnessed Patient 1 “touched [Patient 2’s] left breast” while in the facility’s hallway. The Report indicated HK 1 told Patient 1 to stop. The Report indicated HK 1 reported the incident to the charge nurse. The Report indicated Patient 1 denied Patient 2’s allegations and instead stated that Patient 2 was the one who put Patient 1’s hand on Patient 2’s breast. The Report indicated a one-to-one sitter was assigned to Patient 1 on 8/27/2024 (two days after Patient 2’s allegation of inappropriate touching was made against Patient 1). The Report indicated the facility “would continue to monitor Patient 1’s behaviors.” A review of Patient 2’s SS Note dated 8/26/2024 timed at 10:32 AM, the SS Note indicated a “Follow up wellness visit [a visit from a professional to detect potential concerns early]” to Patient 2 indicated the Patient was doing well but “the incident left her feeling embarrassed.” 4. A review of Patient 3’s AR, the AR indicated the facility admitted the 68 year old female on 12/12/2023, with diagnoses that included history of ischemic attack (mini stroke) and cerebral infarction (a stroke that results in death of brain tissue). A review of Patient 3’s Health Status Note dated 3/10/202024, the Note indicated that at around 11:50 AM, Patient 1 was witnessed roaming around the facility in his wheelchair in the Activity Room, then engaged in a verbal and physical altercation with Patient 3 and suddenly grabbed the left arm and pulled Patient 3’s sleeve down. A review of Patient 3’s COC evaluation dated 3/10/2024, the COC evaluation indicated Patient 1 was witnessed grabbing Patients 6’s arm and pulling her (gown) sleeve down. Patient 3 was encouraged to verbalize feelings at that time. The COC evaluation indicated Patient 3 stated she was upset at this time. A review of a facility document titled “Incident Summary” dated 3/10/2024, the incident summary indicated Patient 1 admitted to pulling down the sleeve of Patient 3 and acknowledged the inappropriateness of his actions. A review of Patient 3’s MDS dated 8/1/2024, the MDS indicated the Patient had moderate cognitive impairment (a condition where a person’s intellectual functioning is significantly below average, along with significant deficits in behavior) requiring moderate assistance with transfers from chair to bed, shower to chair. During an interview with Patient 2 on 8/26/2024 at 11:30 AM, Patient 2 stated than on 8/25/2024 while she was rolling her wheelchair down the facility hallway going to the Smoking Area, Patient 1 came out of his room and started rolling in his chair towards her. Patient 1 stated that when Patient 1 was closer to her, Patient 1 grabbed her left arm "tightly” and said, “I love you.” Patient 2 stated she had told Patient 1 “No! Please let go of me!” Patient 2 stated after that Patient 1 grabbed her left breast with both hands. Patient 2 stated “It