Health inspection·April 11, 2025

California Code of Regulations, Title 22, § 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. § 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: 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. § 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. Code of Federal Regulations, Title 42 F600 §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; (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. On 2/25/2025 at 7:36 AM, the California Department of Public Health [CDPH] conducted an unannounced visit at the facility to investigate a facility reported incident (FRI) regarding resident sexual abuse. Based on observation, record reviews, and interviews, CDPH determined that the facility failed to follow policies and procedures, provide dignity and respect, and protect the resident’s right to be free from sexual abuse from Certified Nurse Assistant (CNA) 1 on 2/21/2025 when CNA 1 “pull[ed] his penis out” and used Resident 1’s hand to “stroke his (CNA 1) penis.” CNA 1 stated he “stroked” Resident 1’s penis until he (Resident 1) ejaculated (the release of semen through the penis during orgasm [the height or peak of sexual arousal])” then used Resident 1’s blanket to clean the resident. As a result of these failings, Resident 1 was sexually abused by CNA 1 on 2/21/2025. The sexual abuse incident against Resident 1 on 2/21/2025 had a negative psychosocial (refers to the combined influence of psychological factors and the surrounding social environment on physical, emotional, and/or mental wellness) impact on Resident 1, as verbalized by Licensed Vocational Nurse (LVN) 2 that Resident 1 had been having a hard time sleeping after the sexual abuse incident. The Social Services Director (SSD) documented in Resident 1’s records Resident 1’s facial expression of “disgust (a strong sense of dislike)” was “clearly defined (evident),” as a result of the sexual abuse incident by CNA 1, during an SSD visit in Resident 1’s room on 2/25/2025. Psychologist 1 wrote on his progress note dated 2/26/2025, Resident 1 displayed hopelessness, frustration, inconsistent sleep patterns, along with a noticeable lack of energy and difficulty concentrating, which have persisted for more than two weeks… which represented a clear departure from Resident 1’s baseline (starting point) functioning. A review of Resident 1’s Admission Record (AR) printed on 2/21/2025, the AR indicated a 57-year-old, male resident, admitted to the facility on 10/29/2024, with diagnoses including cerebral infarction (stroke - a stroke happens when there is a loss of blood flow to part of the brain) encephalopathy (a disease, disorder, or damage that affects the brain’s structure or function), adult failure to thrive (a decline caused by chronic diseases and functional impairments which could cause weight loss, decreased appetite, poor nutrition, and inactivity), and gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). The AR indicated Resident 1 had two family members named as the responsible party (RP) as (RP 1) and emergency contact (EC) as (EC 1). A review of Resident 1’s History and Physical (H&P) dated 11/21/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 2/4/2025, the MDS indicated the resident had severe cognitive impairment (problems with a person’s ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the resident was dependent on facility staff for all self-care and mobility. A review of Resident 1’s Communication Difficulties due to Neurological Impairments Care Plan (CP) dated 2/21/2025, the CP indicated a goal to improve the resident’s ability to convey needs and understand instructions to promote safety and engagement in activities of daily living (ADLs). A review of Resident 1’s Nursing Progress Note dated 2/21/2025 timed at 9:25 AM, the Progress Note indicated that on 2/21/2025 at around 1:30 AM the resident’s EC (EC 1) called the facility and asked who the nurse for Resident 1 was. The Progress Note indicated the Registered Nurse Supervisor (RNS 1) responded to EC 1’s phone call and informed EC 1 that CNA 1 was assigned to Resident 1 during the 11 PM to 7 AM shift dated 2/21/25 timed at 1:30 AM. The Progress Note indicated that around 2 AM, six (6) police officers entered the facility looking for CNA 1 and questioned CNA 1. The Progress Note indicated the DON was notified, and the resident was assigned a new CNA. The Progress Note further indicated that at 3:30 AM, EC 1 arrived at the facility and stayed at Resident 1’s bedside. The Progress Note indicated at 3:35 AM, the police officers left the facility with CNA 1. The Progress Note further indicated that at 4:15 AM, more police officers gathered Resident 1’s personal belongings. The Progress Note indicated the ADM was notified at this time. The Progress Note indicated on the same day, 2/21/2025 at 6:30 AM, the ADM arrived at the facility and met with EC 1. The Progress Note indicated the ADM conducted an in-service (training that take place while someone was employed) regarding abuse and proper care with the residents to the staff in the facility and Resident 1’s physician was notified. At 7:30 AM, the police forensics team continued their investigation. A review of the Video Footage date-stamped dated 2/21/2025, from the hidden camera installed by family members in Resident 1’s room on 2/25/2025 at 1:15 PM, the video footage showed Resident 1 in bed with CNA 1 wearing black scrub suit (a loose-fitting, usually two-piece garment clothing worn by healthcare personnel) holding a mobile phone on his right hand with the phone facing towards Resident 1’s body. The video footage showed CNA 1 used his left hand to lift up his (CNA 1) shirt and pull down his (CNA 1) pants. The video footage showed CNA 1’s penis was quickly displayed. The video footage showed CNA 1 took Resident 1’s hand to stroke his (CNA 1) penis. The video footage showed after 11 seconds, CNA 1 used his left hand and typed on his phone and then pulled his (CNA 1) pants up. The video footage showed CNA 1 held Resident 1’s hand and pushed Resident 1's hand and then placed a bed sheet and a personal blanket over Resident 1. The video footage showed the CNA 1 opened the bedside curtain and walked away. A review of the local Police Department’s (PD) Initial Report dated 2/21/2025 documented and timed at “12:20 AM,” the Initial Report indicated on 2/21/2025 at “Approximately 0200 (2 AM) hours, I (PD) responded to a radio call regarding a suspicious circumstance” at the facility. The Initial Report indicated “Officers arrived on scene, spoke to (EC 1), observed video footage (a section of recorded video or film, usually captured by a camera) of the crime as it (crime) occurred, and took the suspect (a person thought to be guilty of a crime) (CNA 1) into custody (a person was under arrest or being held by the police in a secure location).” The Initial Report indicated the offense information included “sexual battery (a crime that involves unwanted sexual contact with another person) on a medically institutionalized person (someone placed in a specialized institution for long-term care) and sexual battery involving unconscious person (someone who was not aware of their surroundings and could not respond to stimuli).” A review of the same PD Initial Report dated 2/21/2025 documented and timed at “12:20 AM,” the Initial Report indicated EC 1 noted Resident 1 “seemed to shut off and not his usual self” which caused EC 1 to install a hidden camera (in Resident 1’s room) to capture “any abuse or reason that caused the change in his (Resident 1) behavior.” The Report indicated EC 1 stated at approximately 2 AM (2/21/2025), the video footage from the hidden camera showed a male nurse (CNA 1) sexually abusing Resident 1. The suspect was dressed in black scrubs with a ring to the left hand and a tattoo to the right wrist and showed CNA 1 “pull his penis out” and use Resident 1’s hand to “stroke his penis.” The Initial Report indicated the video footage then showed Resident 1 move his hand away from CNA 1’s “penis” then purposely reaching for Resident 1’s hand and “putting it around his penis once again to stroke himself.” The video then showed CNA 1 grab Resident 1’s “penis and begin to stroke him (Resident 1).” A review of the same PD Initial Report dated 2/21/2025 documented and timed at “12:20 AM,” the Initial Report indicated Officer 1 and Officer 2 observed the suspect (CNA 1) walking out of the facility lobby to the door and based on CNA 1’s behavior and matching description, the police officers detained CNA 1. Officer 1 told CNA 1 they were conducting an investigation and to be honest and CNA 1 stated Resident 1 “grabbed his (CNA 1) penis.” CNA 1 stated he initially approached Resident 1 to check on him and noticed he had an “erect penis (when a person’s penis becomes hard and enlarged from an increase in blood flow)” and felt sorry for Resident 1’s physical condition and wanted to “manipulate his penis sexually.” The PD Initial Report indicated CNA 1 at first grabbed Resident 1’s hand and used his hand to “stroke his penis” and when CNA 1 noted Resident 1 moved his hand away, CNA 1 grabbed Resident 1’s hand and placed his hand back on his “penis.” The PD Initial Report indicated Officer 1 asked CNA 1 if he understood that Resident 1 was physically unable to move, fight back, or give consent and CNA 1 stated he was aware of the resident’s condition and knew what he was doing was wrong but kept going. CNA 1 stated he “stroked” Resident 1’s “penis until he (Resident 1) ejaculated (the release of semen through the penis during orgasm [the height or peak of sexual arousal])” and then used Resident 1’s blanket to clean the resident. A review of the same PD Initial Report dated 2/21/2025 documented and timed at “12:20 AM,” the Initial Report indicated evidence collected from Resident 1’s room included: digital clock hidden camera with charging cable, a hot spot [from a wireless network operator] with charging cable, keys belonging to suspect’s (CNA 1) vehicle, medical gown, blanket, wedge pillow case from the right side of Resident 1’s body, bed sheet (over Resident 1), bed sheet (under Resident 1), soiled diaper, small blanket, a black back brace, cloth from trash, paper towel from trash, plastic gloves, two possible “DNA” swabs from left and right hands of CNA 1, two reference swabs from CNA 1, black jacket from CNA 1, blue scrub shirt from CNA 1, blue scrub pants from CNA 1, left and right shoe from CNA 1, two reference swabs from Resident 1, and two possible DNA from left and right hands of Resident 1. A review of the same PD Initial Report dated 2/21/2025 documented and timed at “12:20 AM,” the Initial Report indicated based on the video footage and statements from CNA 1, Officer 1 arrested CNA 1 for sexual battery on a medically institutionalized person and sexual battery involving an unconscious person. The PD Initial Report indicated CNA 1’s mobile phone was given to assault detectives (officers who oversee crime scenes) for further investigation. A review of Resident 1’s Change of Condition (COC) dated 2/21/2025 at 2:17 AM, the COC indicated the resident had an alleged abuse. The COC indicated at 2 AM, a police officer interviewed LVN 1 regarding Resident 1’s cognitive and physical abilities. The COC indicated at 3:30 AM the police officers took all of Resident 1’s linen. The COC indicated at 7:30 AM a forensics team interviewed LVN 1 and swabbed the resident’s skin. A review of Resident 1’s IDT Meeting Notes dated 2/21/2025 at 7:13 PM, the IDT Note indicated the meeting consisted of EC 1, the DON, the MDS Coordinator, a CNA (CNA 2), and the Social Services Director (SSD). The IDT Note indicated EC 1 stated she lost faith in everything after the incident between CNA 1 and Resident 1. The IDT Note indicated CNA 1 admitted to the police that the “incident in question (sexual abuse)” had happened more than once. The IDT Note indicated EC 1 stated the resident was “acting strange” on “Tuesday (2/18/25)” and was requesting to transfer the resident to another facility closer to family. A review of Resident 1’s Nursing Progress Note (PN) dated 2/21/2025 at 11:16 PM, the PN indicated the resident was on monitoring for alleged sexual abuse and was provided a one-to-one sitter (a person who takes care of someone side by side). The PN indicated the resident was noted to be having a hard time sleeping and the facility staff member (LVN 2) ensured Resident 1 was safe and provided a calm environment. A review of Resident 1’s Risk for Safety Concerns related to Alleged Physical/Sexual Abuse CP dated 2/21/2025, the CP indicated a goal for the resident to remain safe. The CP interventions included assigning two (2) CNA’s when providing care, monitor for any changes of condition, and to provide privacy to the resident when doing perineal care (cleaning the area between the genitals and anus). A review of Resident 1’s Physician’s Order (PO) dated 2/24/2025 at 10:02 AM, the PO indicated a Psychiatric (a mental health assessment that could help diagnose and treat emotional, behavioral, or developmental disorders) and Psychology Evaluation (a process that assess a person’s mental health and behavior). A review of Resident 1’s Social Service (SS) Note dated 2/25/2025 at 5:44 PM, the SS Note indicated the SSD conducted a psychosocial intervention visit. The SS Note indicated as the resident was nonverbal and SSD wanted to capture the resident’s vocal tone, facial expressions, and bodily movements as communication regarding the events on the evening of 2/21/2025. The SS Note indicated the resident’s facial expression for “disgust” was clearly defined. The SS Note further indicated “Perhaps as a feeling of revulsion (a strong feeling of dislike) and disapproval around something unpleasant or offensive. The muscles of his face contracted, indicating the need to remove thoughts of the experience. The expression was in the form of a raised upper and lower lip, wrinkled nose, and lowered eyebrows, representing the emotional state of disgust of his experience.” The SS Note indicated the resident closed his eyes and was still, as if the resident was sleeping. A review of Resident 1’s Psychological Evaluation (PE) dated 2/27/2025 at 12:20 PM, authored by a Psychologist (Psychologist 1), the PE indicated Resident 1’s cognitive functioning was severely impaired. The PE indicated Resident 1’s behavior was guarded/irritable, was bed bound (confined to bed), and affect (a general term for feelings or emotions) observed was sad/agitated. The