Health inspection·August 13, 2025

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. §483.12(a) The facility must— §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. §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[.] 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 § 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. 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. 22 CCR §72543. Patients’ Health Records. (f) Patients' health records shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each patient. 22 CCR § 72547 (a)?A facility shall maintain for each patient a health record which shall include: (5)?Nurses' notes which shall be signed and dated. Nurses' notes shall include: (B)?Meaningful and informative nurses' progress notes written by licensed nurses as often as the patient's condition warrants. On 6/20/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint and a facility-reported incident regarding sexual abuse (any sexual activity that occurs without consent). The facility failed to ensure Resident 1, who had moderate impaired cognition (noticeable and significant difficulties in functions like memory, language, and problem-solving), was free from sexual abuse by Resident 2 (Resident 1’s roommate) on 6/20/2025. The facility failed to:?? 1. Protect Resident 1 from Resident 2 when Certified Nursing Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1 witnessed Resident 2, topless with uncovered breasts, was at the head of Resident 1’s bed leaning on top of Resident 1 who was lying on her (Resident 1) bed. Resident 2 was rubbing her (Resident 2) exposed breasts against Resident 1’s chest while Resident 2 was sucking Resident 1’s chin causing it (Resident 1’s chin) to be red.?? 2. Identify?the potential risks of Resident 2’s sexually inappropriate behavior to other residents (in general).?? 3. Prevent sexual abuse by ensuring facility licensed staff monitored?and documented Resident 2’s sexually inappropriate behavior, develop appropriate interventions and implement interventions to protect other residents from potential abuse. ?4.?Identify?and evaluate whether Resident 1 had the capacity to consent to perform sexual activity with Resident 2 or other residents to prevent sexual abuse.? 5. Assess Resident 1 for possible injuries, and document assessment findings for 72 hours following the sexual abuse incident that occurred on 6/20/2025 at approximately 4:50 a.m. in accordance with the facility’s policy and procedure (P&P) titled, “Abuse Prevention and Prohibition Program,” last reviewed on 4/28/2025, indicating, “A Licensed Nurse assesses the resident (alleged victim) for possible injuries.”? 6. Implement its P&P titled, “Abuse Prevention and Prohibition Program,” last reviewed on 4/28/2025,?indicating, “Each resident has the right to be free from abuse…. The Facility has zero-tolerance for abuse…. Staff must not?permit?anyone to engage in … sexual … abuse….”? As a result, Resident 1 was subjected to sexual abuse by Resident 2 while under the care of the facility. CNA 1 stated that on 6/20/2025 Resident 1 appeared panicked and in shock during the incident. After the sexual abuse incident, CNA 3 approached Resident 1 to offer assistance with changing, but Resident 1 refused. CNA 3 stated that Resident 1 became agitated (feeling or appearing troubled), began shaking and appeared visibly nervous. On 6/20/2025 at 10:24 a.m., the facility sent Resident 2 to General Acute Care Hospital 1 (GACH 1) for psychological evaluation due to the sexual abuse incident. A review of Resident 1’s Admission Record indicated the facility admitted Resident 1, an 80-year-old female, on 4/18/2023 with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris (clogged heart arteries without chest pain), hypertension (high blood pressure), and dementia (decline in mental abilities, like memory and thinking, that is severe enough to interfere with daily life). A review of Resident 1’s Initial History and Physical (H&P – a comprehensive assessment of a resident’s medical condition), dated 4/11/2025, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 6/1/2025, indicated Resident 1 was moderately impaired with thought process and required substantial assistance from staff to complete activities of daily living (ADLs – activities such as bathing, dressing, and toileting a person performs daily). A review of Resident 1’s Progress Notes, dated 6/20/2025 at 10:22 a.m., indicated that on 6/20/2025 at 4:50 a.m., CNA 1 reported to LVN 1 that Resident 2 was found on top of Resident 1 with Resident 2’s breasts exposed and rubbing against Resident 1, and Resident 2 was sucking Resident 1’s chin. The note indicated LVN 1 noted a red mark on Resident 1’s chin attributed to Resident 2 sucking on Resident 1’s chin. A review of Resident 2’s Admission Record indicated the facility originally admitted Resident 2, an 89-year-old female, on 11/22/2021 and readmitted on 1/26/2023 with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris and hypertension. A review of Resident 2’s Initial H&P, dated 1/30/2025, indicated Resident 2 had fluctuating capacity to understand and make decisions due to dementia. A review of Resident 2’s MDS, dated 5/25/2025, indicated Resident 2 was moderately impaired with thought process and required substantial to partial assistance from staff to complete ADLs. A review of Resident 2’s Care Plan Report, dated 9/17/2024, indicated Resident 2 exhibited masturbatory behavior. A review of Resident 2’s Progress Notes, dated 6/20/2025 at 4:50 a.m., indicated that on 6/20/2025 at 4:50 a.m., CNA 1 reported to LVN 1 that Resident 2 was found on top of Resident 1 with Resident 2 breasts exposed and rubbing against Resident 1 and Resident 2 was sucking Resident 1’s chin. The note indicated LVN 1 noted a red mark on Resident 1’s chin attributed to Resident 2 sucking on Resident 1’s chin. The note indicated RN 1 notified Resident 2’s Physician. The note further indicated that on 6/20/2025 at 10:24 a.m., Resident 2’s Physician gave an order to transfer Resident 2 to GACH 1 for further evaluation. During an interview on 6/23/2025 at 11:13 a.m., with LVN 1, LVN 1 stated that while LVN 1 was in the nurse’s station on 6/20/2025 at “around 4:50 a.m.,” CNA 1 was standing at the doorway of Residents 1 and Resident 2’s room (near the nurse’s station) and reported to LVN 1 that Resident 2 was on top of Resident 1. CNA 1 stated Resident 2’s blouse was down to her (Resident 2’s) waist, and Resident 2 rubbed her (Resident 2) uncovered breasts against Resident 1’s chest. LVN 1 stated CNA 1 reported Resident 2 was sucking Resident 1’s chin. She (LVN 1) immediately went to Resident 1 and 2’s room and observed that Resident 2 was still on top of Resident 1. She (LVN 1) instructed Resident 2 to move away from Resident 1 and to return to Resident 2’s bed. Resident 2 became slightly agitated and made a hand gesture indicating for LVN 1 to go away. Resident 1’s chin was red from Resident 2’s sucking. She (LVN 1) notified RN 1 right away. LVN 1 stated that since being hired in 2/2025, she (LVN 1) had been aware of and had observed Resident 2’s behavior of patting and touching her (Resident 2) own private area and her (Resident 2) own breasts. Staff in the unit were aware of Resident 2’s behavior. LVN 1 stated this was considered as sexual abuse due to Resident 2’s inappropriate behavior towards Resident 1 by rubbing her (Resident 2) breasts to Resident 1’s chest. During an interview on 6/23/2025 at 11:38 a.m. with CNA 1, CNA 1 stated that she (CNA 1) found Resident 2 on top of Resident 1 with Resident 2’s blouse down to her (Resident 2) waist, rubbing her (Resident 2) breasts against Resident 1, sucking Resident 1’s chin. She (CNA 1) reported the incident to LVN 1 right away. CNA 1 stated that the incident was considered sexual abuse because Resident 1 did not give any consent to Resident 2 as Resident 1 was confused. During an interview on 6/23/2025 at 12:29 p.m. with CNA 4, CNA 4 stated Resident 2 usually touches herself and CNA 4 provides privacy to Resident 2. During an interview on 6/24/2025 at 6:29 a.m. with CNA 1, in Resident 1 and Resident 2’s room, CNA 1 stated that she (CNA 1) was in another resident’s (name not indicated) room (room across Residents 1 and 2’s room) when she (CNA 1) heard a bed-squishing noise prompting her (CNA 1) to check and proceed to the doorway of Residents 1 and Resident 2’s room. CNA 1 then demonstrated that Resident 2 was standing on the right side, near the head of Resident 1’s bed. CNA 1 stated Resident 2 was observed rubbing her (Resident 2) exposed breasts to Resident 1’s chest and sucking Resident 1’s chin. CNA 1 stated that, at the time, Resident 1 appeared panicked and shocked. During an interview on 6/24/2025 at 6:39 a.m. with CNA 3, CNA 3 stated she (CNA 3) was assigned to care for Resident 1 after the sexual abuse incident on 6/20/2025 at around 4:50 a.m. CNA 3 stated that she (CNA 3) offered to assist Resident 1 with changing, but observed that Resident 1 was agitated – holding her hands close to her chest, appearing very nervous, shaking, and refusing to be changed. During a concurrent interview and record review on 6/24/2025 at 9:56 a.m. with Risk Manager Nurse (RMN), Resident 1’s Progress Notes dated 6/20/2025 to 6/24/2025 and vital signs (measurements of the body’s most basic functions) dated 6/20/2025, were reviewed. Resident 2’s Progress Notes dated 6/20/2025 and vital signs dated 6/20/2025, were also reviewed. The RMN stated that there was no documented evidence that assessment was done, and vital signs were taken after the sexual abuse incident on 6/20/2025 at “around 4:50 a.m.” for Resident 1 and Resident 2. RMN stated Resident 1’s condition must be monitored after the sexual abuse incident for 72 hours every shift, but it was not done. During a telephone interview on 6/25/2025 at 10:11 a.m. with FM 1, FM 1 stated Resident 1 was a conservative person, and that this sexual abuse incident that occurred on 6/20/2025 at around 4:50 a.m. will “destroy, traumatize, and mentally damage” Resident 1. Resident 1 will lose a lot of sleep, will not know what to do, feel victimized (a feeling of being subject to harmful or unjust treatment), and will feel her life will be ruined just like other sexual victims. FM 1 stated that the family members (FM 1, FM 2, and FM 3) were shocked and traumatized. FM 1, FM 2, and FM 3 cried, felt angry and felt guilty by choosing the facility. FM 1, FM 2 and FM 3 lost sleep, felt anxious, and uneasy when they found out about Resident 1’s sexual abuse incident on 6/20/2025 at around 4:50 a.m. During a concurrent interview and record review on 6/25/2025 at 11:13 a.m. with Registered Nurse 2 (RN 2), Resident 2’s Care Plan titled, “Exhibiting Masturbatory Behavior,” dated 9/17/2024, and all other current care plans since re-admission, Medication Administration Record (MAR – a document that serves as a legal record of all medications administered to a resident), and Progress Notes from 5/8/2024 to 6/20/2025 were reviewed. RN 2 stated that there were no documented interventions in Resident 2’s care plan to address or monitor Resident 2’s masturbatory behavior. RN 2 further stated there was no documented evidence of behavioral monitoring related to Resident 2’s behavior in Resident 2’s MAR or Progress Notes. The care plan had not been assessed or updated to reflect how Resident 2’s masturbatory behavior might potentially impact other residents. RN 2 stated that had the facility developed a care plan addressing how Resident 2’s masturbatory behavior could potentially impact other residents, the sexual abuse incident may have been prevented. There was no assessment or documentation regarding Resident 2’s masturbatory behavior during a review of Resident 2’s progress notes from 5/8/2024 to 6/20/2025. RN 2 stated that as a result Resident 2’s behavior was not monitored, and Resident 2 sexually abused her roommate (Resident 1). During a concurrent interview and record review with RN 2, Resident 1’s Progress Notes, dated 6/20/2025 to 6/24/2025 and vital signs dated 6/20/2025 were reviewed. Resident 2’s Progress Notes dated 6/20/2025 and vital signs dated 6/20/2025, were also reviewed. RN 2 stated that there was no head-to-toe assessment (a systematic and comprehensive physical examination that evaluates all major body systems, from the head to the feet, to determine a resident’s overall health status) conducted and no vital signs were taken for Resident 1 and Resident 2 after the sexual abuse incident on 6/20/2025 at 4:50 a.m. RN 2 stated that staff should have conducted a head-to-toe assessment, checked vital signs and monitored both Resident 1 and Resident 2 (was discharged to GACH 1 on 6/20/2025 at 10:24 a.m.) every shift for 72 hours to assess the potential impact of the incident .It was important to closely monitor Resident 1 following the sexual abuse incident. RN 2 stated there was no documented evidence the facility identified and evaluated whether Resident 1 had the capacity to consent to perform sexual activity with Resident 2 or other residents to prevent sexual abuse.? During a concurrent interview and record review on 6/25/2025 at 1:05 p.m. with Resident Care Planner (RCP) 1, Resident 2’s Care Plan titled, “Exhibiting Masturbatory Behavior,” dated 9/17/2024, was reviewed. RCP 1 stated she (RCP) was the author of the care plan, and a nurse (RCP 1 could not remember who the nurse was) reported that Resident 2 had an episode of masturbatory behavior (RCP 1 did not remember the date). Monitoring Resident 2’s behavior was not included in Resident 2’s care plan interventions. Behavioral monitoring is necessary to evaluate the effectiveness of interventions. RCP 1 stated that Resident 2’s care plan did not include any interventions to identify or address the potential risk Resident 2’s behavior posed to other residents. It is important to include how Resident 2’s behavior may affect other residents in the care plan, and that the sexual abuse incident could have been prevented if appropriate interventions had been implemented for Resident 2. During an interview on 6/25/2025 at 2:26 p.m. with CNA 6, CNA 6 stated that she (CNA 6) was the regular morning shift CNA assigned to Resident 2 and had been providing care for her (Resident 2) since Resident 2’s admission. Resident 2 would call her into Resident 2’