Health inspection·July 10, 2025

42 CFR §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. 22 CFR § 72311 Nursing Service- General (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient. 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 5/28/2025, the California Department of Public Health (CDPH) received a facility reported incident (FRI) regarding a resident-to-resident abuse allegation. On 5/29/2025, the CDPH conducted an unannounced visit at the facility to investigate the FRI. The facility failed to ensure Resident 2, who had a known history of wandering into Resident 1’s room, was provided with the appropriate intervention and adequate supervision. The facility failed to: 1. Implement its policy and procedure (P&P) titled “Abuse and Neglect Prohibition Policy,” to ensure Resident 1 was free from sexual abuse. 2. Implement its P&P titled “Wandering Behavior Management,” to prevent Resident 2 from wandering into Resident 1’s room. 3. Address Resident 2’s refusals of quetiapine furnarate (medication used to manage schizophrenic symptoms) and donezepril (medication used to treat dementia [a progressive state of decline in mental abilities]) which had the potential to increase his wandering behaviors. As a result, on 5/28/2025, Resident 2 wandered into Resident 1’s room and touched Resident 1’s left breast, which subjected Resident 1 to preventable sexual abuse while under the care of the facility. Resident 1 was an 82-year-old female, admitted to the facility on 7/30/2021 and readmitted on 10/28/2023 with diagnoses which included cataracts (a common age-related eye condition that could affect vision in older adults) and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 1’s Minimum Data Set (MDS, a resident assessment tool), dated 4/25/2025, indicated Resident 1 had severely impaired cognitive skills for daily decision making (ability to think and reason). Resident 1 had impaired vision. Resident 1 required assistance with eating. The MDS indicated Resident 1 required supervision with oral hygiene and Resident 1 required moderate assistance (helper did less than half the effort) with personal hygiene. Resident 1 was dependent (helper did all the effort) with toileting hygiene, showering/bathing, and tub/shower transfer. A review of Resident 1’s Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there was a change of condition among the residents) form, dated 5/28/2025 at 3:04 p.m., indicated on 5/28/2025, Resident 2 was seen moving his hand away from Resident 1’s breast. Resident 2 was a 72-year-old male, admitted to the facility on 2/7/2017 and readmitted on 7/13/2024. Resident 2’s diagnoses included severe dementia (a progressive state of decline in mental abilities) with behavioral disturbance (any pattern of behavior that was persistently disruptive, inappropriate, or causes problems for the individual or those around them), schizophrenia (a mental illness that was characterized by disturbances in thought), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that ranged from the lows of depression to elevated periods of emotional highs). A review of Resident 2’s History and Physical (H&P), dated 3/6/2025, indicated Resident 2 had fluctuating capacity to understand and make decisions. A review of Resident 2’s MDS, dated 3/28/2025, indicated Resident 2 had severely impaired cognitive skills for daily decision making. Resident 2 had a behavior of rejecting care that was necessary to achieve his goals for health and well-being daily. Resident 2 required setup assistance with eating. The MDS indicated Resident 2 required supervision with bed-to-chair transfer and walking. Resident 2 required maximal assistance (helper did more than half the effort) with oral hygiene and Resident 2 was dependent with toileting hygiene and showering/ bathing. The MDS indicated Resident 2 had impairment to the lower extremities and used a wheelchair for mobility. A review of Resident 2’s care plan titled “Has a behavior problem and desires r/t (related to) schizophrenia, constant walking in the hallway for no apparent reason,” initiated 8/4/2021, the care plan indicated staff were to administer medication as ordered, monitor/ document for side effects and effectiveness, and intervene as necessary to protect the rights and safety of others. A review of Resident 2’s Physician’s Order dated 6/12/2023, indicated to administer Donezepril HCL (medication used to treat dementia) 10 milligrams (mg) by mouth at bedtime for dementia. A review of Resident 2’s Physician’s Order dated 2/3/2025, indicated to administer Quetiapine Furnarate (medication used to manage schizophrenic symptoms) 400 mg by mouth two times a day for schizophrenia manifested by constantly roaming around the facility in circles. A review of Resident 2’s Medication Administration Record (MAR) for 5/2025, indicated Resident 2 refused 16 out of the 28 doses of donezepril. Resident 2 refused 17 of 57 doses of quetiapine furnarate. Resident 2 had increased behavior episodes from 5 episodes to 15 episodes of constantly roaming around the facility from 5/24/2025 to 5/28/2025. A review of Resident 2’s SBAR, dated 5/28/2025 at 2:40 p.m., indicated on 5/28/2025, Payroll Director (PD) 1 observed Resident 2 in Resident 1's room. The SBAR indicated PD 1 observed Resident 2 touching Resident 1’s breast. During an interview on 5/29/2025 at 10:20 a.m. with Certified Nursing Assistant (CNA) 1, stated on 5/28/2025 around 2:15 p.m., Resident 2 was observed by PD 1 in Resident 1’s room touching Resident 1’s breast. CNA 1 stated on 5/28/2025 around 2:16 p.m., she observed Resident 2 coming out of Resident 1’s room pushing his wheelchair with one hand and pulling up his pants with the other hand. It was not Resident 2’s first time entering Resident 1’s room. Resident 2 wandered around the facility and liked to go to Resident 1’s room. She (CNA 1) was instructed by an unidentified nurse to remove Resident 2 from Resident 1’s room, and to provide frequent redirection to Resident 2 because the resident kept passing by Resident 1’s room. CNA 1 stated Resident 2 was very non-compliant with care and needed frequent redirection. During an interview on 5/29/2025 at 10:37 a.m. PD 1 stated on 5/28/2025 around 2:15 p.m., she observed Resident 2’s hand on Resident 1’s left breast in Resident 1’s room. PD 1 stated Resident 2 immediately removed his hand and PD 1 instructed Resident 2 to leave the room. During a concurrent interview and record review on 5/29/2025 at 11:29 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 2’s MAR for 5/2025 was reviewed. The MAR indicated Resident 2 refused donezepril and quetiapine furnarate on multiple shifts that month (5/2025). LVN 1 stated the MAR indicated Resident 2 refused donezepril for six consecutive days from 5/19/2025 to 5/24/2025 at 8 p.m. LVN 1 stated Resident 2 had dementia, and it was important for Resident 2 to take his donezepril to prevent inappropriate sexual behavior. The donezepril was to manage Resident 2’s wandering behavior. The nurse should have notified the physician when Resident 2 continued to refuse his medications. During a concurrent interview and record review on 5/29/2025 at 11:52 a.m. with Registered Nurse (RN) 1, Resident 2’s Nursing Progress Notes for 5/2025 were reviewed. The notes did not indicate documentation regarding Resident 2’s refusals of donezepril and quetiapine in 5/2025. RN 1 stated the nurse should have documented and notified Resident 2’s physician of Resident 2’s medication refusals. The purpose of notifying the physician was to provide updates of Resident 2’s condition and possibly receive an alternative medication order. RN 1 stated the physician might have ordered to transfer Resident 2 to the hospital for further evaluation due to medication refusal. There was a risk for Resident 2’s wandering and dementia behavior to worsen. RN 1 stated it was possible for Resident 2 to wander into the female residents’ room and cause unwanted sexual interactions. It was inappropriate for Resident 2 to touch Resident 1’s breast because it violated Resident 1’s rights to be free from abuse. Resident 2 touching Resident 1’s breast was considered sexual abuse. Staff should have provided constant monitoring of Resident 2’s movement and redirected the resident to prevent any sexual abuse. Resident 3 was 77-year-old female, admitted to the facility on 10/16/2024 and readmitted on 3/17/2025 with diagnoses which included DM and generalized muscle weakness. A review of Resident 3’s H&P, dated 10/17/2024, indicated Resident 3 had the capacity to understand and make decisions. A review of Resident 3’s MDS, dated 4/25/2025, indicated Resident 3 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 3 had adequate vision and was able to understand others. During an interview on 5/29/2025 at 10:03 a.m. with Resident 3 (Resident 1’s roommate), Resident 3 stated on 5/28/2025 (unable to recall time), she called staff to assist when Resident 2 entered the room for the second time that day. Resident 3 stated she was unable to see what was happening between Resident 1 and Resident 2 because Resident 1’s privacy curtain was closed. Resident 2 had been coming inside Resident 1’s room since 10/2024. Staff would come into the room and take Resident 2 away. During an interview on 5/29/2025 at 11:52 a.m., RN 1 stated Resident 3 was alert. RN 1 stated nurses should report to the charge nurse when a male resident was observed going into a female resident’s room to avoid sexual abuse. During an interview on 5/29/2025 at 1:16 p.m., the Assistant Director of Nursing (ADON), stated Resident 2 propelled around the facility in his wheelchair. Staff should have monitored the behaviors and medication compliance for the dementia residents. The dementia residents were forgetful and had wandering behaviors. The residents could be aggressive at the late stage of dementia. The risks of not taking medication for the dementia residents were worsening wandering behavior and aggressive behavior toward self, residents, and staff. When residents refused medications, the nurses needed to inform the resident’s physician, complete a change of condition, and update the care plan. The purpose of notifying the physician was for an alternative medication regimen and care interventions. It also kept the physicians updated on the residents’ conditions so staff could provide the appropriate care. The ADON stated it was a delay of necessary care because it was important for Resident 2 to take his medications. Staff should have closely monitored Resident 2 to ensure his whereabouts. There was potential for sexual interaction when Resident 2 wandered into the other residents’ rooms. Resident 2 refusing his medications contributed to Resident 2’s thinking Resident 1 was his wife. The ADON stated Resident 2 touching Resident 1’s breast violated Resident 1’s rights and was considered sexual abuse. During a telephone interview on 5/29/2025 at 4:09 p.m., Resident 2’s Nurse Practitioner (NP 1), stated he expected the nurse to notify him or the primary physician when Resident 2 refused his medications. It was important for Resident 2 to take donezepril and quetiapine furnarate as ordered to prevent unwanted behavior. NP 1 stated one of the side effects (an effect of a drug or other type of treatment that was in addition to or beyond its desired effect) of refusing donezepril and quetiapine furnarate was the increased risk of wandering into other residents’ rooms and increased hypersexual activities for Resident 2. Resident 2 was “disorganized,” which manifested wandering and confusion. NP 1 stated if he was aware Resident 2 touched Resident 1’s breasts on 5/28/2025, he would have increased Resident 2’s medication for safety. Resident 2’s behavior would been more manageable. A review of the facility’s P&P titled “Wandering Behavior Management,” dated 12/2016, indicated to ensure that each resident who was a wandering risk was provided the appropriate intervention and adequate supervision. The P&P indicated the facility was to modify the plan of care as needed to address the wandering risk behaviors by monitoring for any type of medical causes that increases wandering. A review of the facility’s P&P titled “Abuse and Neglect Prohibition Policy,” dated 6/2022, indicated to ensure that facility staff were doing all that was within their control to prevent occurrences of abuse for all the residents. The facility should be identifying, correcting, and intervening in situations in which abuse was more likely to occur, and it included analysis of the supervision of staff to identify inappropriate behaviors. The P&P indicated that the facility should analyze the assessment, care planning, and monitoring of the residents with needs and behaviors which might lead to conflict, such as the residents who have behaviors such as entering other residents' rooms. The P&P further indicated that sexual abuse was non-consensual sexual contact of any type with a resident. The facility failed to ensure Resident 2, who had a known history of wandering into Resident 1’s room, was provided with the appropriate intervention and adequate supervision. The facility failed to: 1. Implement its policy and procedure (P&P) titled “Abuse and Neglect Prohibition Policy,” to ensure Resident 1 was free from sexual abuse. 2. Implement its P&P titled “Wandering Behavior Management,” to prevent Resident 2 from wandering into Resident 1’s room. 3. Address Resident 2’s refusals of quetiapine furnarate and donezepril which had the potential to increase his wandering behaviors. As a result, on 5/28/2025, Resident 2 wandered into Resident 1’s room and touched Resident 1’s left breast, which subjected Resident 1 to preventable sexual abuse while under the care of the facility. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.