Health inspection·September 5, 2024

42 CFR §483.12Freedom from Abuse, Neglect, and Exploitation 42 CFR §483.12(a) The facility must: 42 CFR §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 22 CFR § 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 CFR § 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 CFR § 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: (10) To be free from mental and physical abuse. On 7/22/2024, the California Department of Public Health (CDPH) received a FRI indicating Resident 1touched Resident 2 on her back inappropriately. On 8/5/2024, the CDPH conducted an unannounced visit to the facility of sexual abuse from Resident 1, who had a known history of hypersexual behaviors (an intense focus on sexual fantasies, urges, or behaviors that can't be controlled), to Resident 2 that occurred two weeks prior. The facility failed to: 1. Intervene and provide a safe distance between Resident 1 and Resident 2 when Resident 1 began masturbating (to pleasure oneself sexually) in public. 2. Ensure the Social Services designee (SSD) notified the licensed nurses when Resident 1 first exhibited hypersexual behaviors on 2/17/2024. These violations resulted in Resident 1 feeling angry, and uncomfortable. During a concurrent observation and interview, on 8/5/2024, at 2:14 p.m., with the Director of Nursing (DON), the camera footage, dated 7/20/2024, timed at approximately 8:00 a.m. to 9:00 a.m., was reviewed. The camera footage showed Resident 1 stood less than an arm’s distance away from Resident 2, for approximately ten to fifteen minutes, while Resident 2 talked on the phone in the hallway. The camera footage showed two staff members (Registered Nurse [RN] 1 and Certified Nursing Assistant [CNA] 1) walk past both residents, RN 1 stopped, and exchanged words with Resident 1, then proceeded to walk away from both residents. The camera footage showed CNA 1 looked in the direction of both residents and proceeded to walk past the two residents. Resident 1 lowered his shorts and inserted his left hand into his shorts and moved his arm in a back-and-forth jerking motion. The DON stated Resident 1 stood too close to Resident 2, which was an inappropriate and unsafe distance. The DON stated she would have expected the facility staff to immediately, separate the residents to ensure safety for both residents. The DON stated because staff did not intervene to maintain a safe distance between the two residents, and there was an increased risk for Resident 1 to exhibit inappropriate sexual behavior in a public setting, in front of Resident 2. The DON stated any display of inappropriate touching, or sexual behavior directed at a specific individual, in a public setting, was classified as sexual abuse. 1. A review of Resident 1’s Admission Record, indicated Resident 1 was initially admitted to the facility on 8/29/2022 and readmitted on 6/5/2023. Resident 1’s diagnoses included schizophrenia (a serious mental health condition that affects how people think, feel, and behave) and chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 1’s Minimum Data Set ([MDS]- a comprehensive resident assessment and care-screening tool), dated 6/14/2024, indicated Resident 1’s cognition (ability to think and reason) was moderately impaired. The MDS indicated Resident 1 was independent with activities of daily living (ADLs, daily self-care activities such as grooming, dressing, toileting, and personal hygiene). A review of Resident 1’s care plan titled, "Physical Aggression" dated 3/27/2023, indicated Resident 1 was to be placed on one-to-one monitoring for safety if necessary. A review of Resident 1’s care plan (CP) titled "Hypersexual Behavior," dated, 2/17/2024, indicated staff will encourage Resident 1 to attend healthy relationship, symptom management, and impulse control group. The interventions also indicated staff will model and role play appropriate behaviors for Resident 1, notify Resident 1's Medical Doctor, Psychiatrist (a doctor who specializes in mental health), Psychologist (a person who specializes in the study of mind and behavior or in the treatment of mental, emotional, and behavioral disorders), and Therapist for additional support and interventions. A review of Resident 1’s Behavior plan, dated 2/17/2024, indicated Resident 1 masturbated in the doorway of his room on 2/17/2024. The behavior plan indicated the plan was placed into effect so that Resident 1 would not have another similar incident while in the facility. The plan indicated staff would intervene immediately and reassess interventions if Resident 1 deviated from the plan. A review of the facility’s Incident Follow-Up Report, dated 7/25/2024, indicated on 7/22/2024, Resident 2 reported she sat by the phone in the hallway when Resident 1 approached her and touched her on the back. The report indicated Resident 1 saw Resident 2’s left hand inside his shorts when she turned around. 2. A review of Resident 2’s Admission Record indicated Resident 2 was admitted to the facility on 4/30/2024 with diagnoses that included schizoaffective disorder (mental health problem where you experience psychosis as well as mood symptoms) and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). A review of Resident 2’s MDS, dated 5/13/2024, indicated Resident 2’s cognition was intact and not impaired. The MDS indicated Resident 2 was independent with ADLs. During a concurrent observation and interview, on 8/5/2024, at 9:50 a.m., with Resident 2, Resident 2 stated on 7/19/2024, Resident 1 touched himself inappropriately in front of her while she used the phone. Resident 2 stated it happened again on 7/20/2024, and staff had knowledge of the incident. Resident 2 stated she was told to just “ignore” the resident. Resident 2 stated that it made her feel angry and upset. Resident 2 was observed with fast breathing as she stated the incident made her feel “uncomfortable” for the duration that she was in the same unit as Resident 1. Resident 2 stated she felt angry when staff did not do anything to prevent Resident 1 from inappropriately touching himself. Resident 2 stated she knew Resident 1 touched himself inappropriately (in public). 3. A review of Resident 3’s Admission Record indicated Resident 3 was admitted to the facility on 12/7/2023 with diagnoses that included schizoaffective disorder (mental health problem where you experience psychosis as well as mood symptoms). A review of Resident 3’s MDS, dated 6/21/2024, indicated Resident 3’s cognition was intact. The MDS indicated Resident 3 was independent with ADLs. During an interview, on 8/5/2024, at 10:14 a.m., with Resident 3, Resident 3 stated she witnessed Resident 1 stand by Resident 2 and “jack off” (the stimulation of private body parts for sexual pleasure) in front of Resident 2 while she used the phone. Resident 3 stated she tried to get Resident 2 to stop what he was doing but he did not listen. Resident 3 stated staff had knowledge of the incident but did not do anything to stop or prevent Resident 1's action. Resident 3 stated Resident 1 was known to have similar incidents and display inappropriate sexual behaviors in public. During a concurrent observation and interview, on 8/6/2024, at 1:00 p.m., with the Program Manager (PM), the camera footage, dated 7/20/2024, timed at approximately 8:00 a.m. to 9:00 a.m., was reviewed. The PM stated he would have separated the two residents immediately. The PM stated staff, based on the camera footage staff did not intervene immediately to ensure Resident 2’s safety, and due to the lack of intervention and supervision, this led Resident 2 to be subjected to Resident 1’s inappropriate sexual behavior. During an interview on 8/6/2024, at 2:59 p.m., with Registered Nurse (RN) 1, RN 1 stated on 7/20/2024 she recalled that Resident 1 stood at an unsafe distance form Resident 2. RN 1 stated that she should have delegated another staff member to supervise the two residents before she proceeded to walk away. RN 1 stated “anything could have happened” during the times that both residents were left unattended because the two residents were unsupervised. During a concurrent interview and record review on 8/6/2024, at 3:16 p.m., with RN 2, Resident 1’s Behavior Plan, dated 2/17/2024, and Resident 1’s Change of Condition Notes, dated 2/2024, were reviewed. RN 2 stated the Behavior Plan indicated on 2/17/2024, Resident 1 masturbated in the doorway of his room. RN 2 stated the Change of Condition notes did not indicate Resident 1’s physician, psychiatrist, or the psychologist were notified of Resident 1’s inappropriate sexual behavior on 2/17/2024. RN 2 stated, the normal process was to complete a change of condition note, and notify the physician, and conservator or responsible party. RN 2 stated a change of condition note should have been completed on 2/17/2024 so the doctors could place proper orders and interventions for Resident 1. RN 2 stated there was a possibility Resident 1’s condition worsened or continued over time if the doctors were not made aware of his behaviors. During an interview on 8/6/2024, at 3:50 p.m., with the Director of Nursing (DON), the DON stated a change of condition note should have been made for Resident 1’s display of inappropriate sexual behavior on 2/17/2024. The DON stated the SSD did not relay that information to the licensed nursing staff so that the licensed nurses could complete the change of condition note and notify the physician. The DON stated, the SSD was expected to communicate any medical or behavioral changes to the nursing staff, and there was a delay in care for the medical treatment and interventions for Resident 1’s hypersexual behaviors. The DON stated if the doctors were not made aware of changes of condition, then it was considered “negligence”. A review of the facility’s Social Services Designee Job Description (undated) indicated the SSD was to ensure that all charted progress notes were completed accurately, informative, descriptive, and timely of the services provided and of the resident's response to the service. The job description indicated the SSD was to communicate with the medical staff, nursing service, and other department directors. A review of the facility’s Policy and Procedure (P&P) titled, “Abuse”, dated 2023, indicated every resident had the right to be free from abuse, the basic responsibility of every employee was to ensure the safety and well-being of the resident, and staff shall promote dignity and assist residents as needed. A review of the facility’s P&P titled, “Preventing Resident Abuse”, dated 2023, indicated the facility was to assess residents with signs and symptoms of behavior problems and implementing care plans to address behavioral issues. The P&P indicated the facility was to identify areas within the facility that may make abuse and neglect more likely to occur and monitoring these areas regularly. The facility failed to: 1. Intervene and provide a safe distance between Resident 1 and Resident 2 when Resident 1 began masturbating (to pleasure oneself sexually) in public. 2. Ensure the Social Services designee (SSD) notified the licensed nurses when Resident 1 first exhibited hypersexual behaviors on 2/17/2024. These violations had a direct or immediate relationship to the health, safety, or security of patients or residents.