Other·May 28, 2026

22 C.F.R. §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 § 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 § 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 § 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 4/15/2026, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) alleging Resident 2 and Resident 4 were found in bed unclothed. On 4/14/2026, the CDPH conducted an unannounced visit to the facility to investigate 4 unrelated FRIs at the facility. Upon investigation, it was determined there was an alleged incident on 11/16/2025 where Resident 2 and Resident 4 were found in bed unclothed. The facility failed to: 1. Follow its policy and procedure (P&P) titled "Abuse, Neglect, Exploitation and Misappropriation Prevention Program", revised 4/2024, which indicated all residents have the right to be free from any form of abuse including sexual abuse, and the facility was committed to ensure that residents were protected from sexual abuse. As a result, Resident 2 was sexually abused by Resident 4 and had the potential for Resident 2 to experience physical harm, emotional trauma, fear, humiliation, and psychological distress. Resident 2 was a 63-year-old female, originally admitted to the facility on 7/29/2024 and readmitted on 10/6/2025. Resident 2's diagnoses included dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 2's History and Physical (H&P), dated 10/8/2025, indicated Resident 2 had fluctuating capacity to understand and make decisions. A review of Resident 2's Minimum Data Set ([MDS] - a resident assessment tool), dated 11/25/2025, indicated Resident 2's cognition was moderately impaired. The MDS indicated Resident 2 required moderate assistance from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 2's progress note, dated 11/16/2025 at 11:02 a.m., indicated on 11/16/2026, Resident 2 and Resident 4 were observed unclothed in Resident 2's bed. During an interview on 4/15/2026 at 10:15 a.m., Resident 2 stated she did not want to engage in sexual activity and did not consent to sexual contact with Resident 4. Resident 4 was an 83-year-old male, originally admitted to the facility on 1/3/2025 and readmitted on 7/11/2025. Resident 4's diagnoses included dementia, schizoaffective disorder, and major depressive disorder. A review of Resident 4's MDS, dated 7/15/2025, the MDS indicated Resident 4's cognition was moderately impaired. The MDS indicated Resident 4 required moderate assistance from staff for ADLs. During an interview on 4/15/2026 at 11:40 p.m., Resident 4 stated he liked women and liked to socialize with women. Resident 4 could not recall whether or not he engaged in sexual activity with Resident 2. During a concurrent interview and record review on 4/15/2026 at 12:00 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 2's progress note, authored by LVN 1, dated 11/16/2025 at 11:02 a.m., was reviewed. The progress note indicated on 11/16/2025, Resident 2 was observed unclothed in her bed with Resident 4. LVN 1 stated she observed both residents unclothed in Resident 2's bed. LVN 1 stated at the time of the incident, both residents verbally consented to sexual activity. LVN 1 stated she was not aware if an assessment was performed to determine either resident's capacity to consent to sexual activity. During an interview on 4/15/2026 at 12:30 p.m., the Director of Nursing (DON) stated the incident involving Resident 2 and Resident 4 was considered sexual abuse. The DON stated it was not the facility's practice to allow residents to engage in sexual activity without appropriate assessment. The DON stated that, if residents expressed a desire to engage in sexual activity, the facility was required to assess the residents' capacity to consent and, if appropriate, provide privacy. The DON further stated the facility failed to ensure Resident 2 was protected from sexual abuse. A review of the facility's P&P titled "Abuse, Neglect, Exploitation and Misappropriation Prevention Program", revised 4/2024, indicated all residents had the right to be free from any form of abuse including sexual abuse. The P&P indicated the facility was committed to ensure residents were protected from sexual abuse. The facility failed to: 1. Follow its policy and procedure (P&P) titled "Abuse, Neglect, Exploitation and Misappropriation Prevention Program", revised 4/2024, which indicated all residents have the right to be free from any form of abuse including sexual abuse, and the facility was commitment to ensure that residents were protected from sexual abuse. As a result, this resulted in Resident 2 being sexually abused by Resident 4 and had the potential for Resident 2 to experience physical harm, emotional trauma, fear, humiliation, and psychological distress. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.