Health inspection·March 6, 2025

California Code, Welfare and Institutions Code WIC 15630 (b)(1)(A)(i) (b) (1) A mandated reporter who, in their professional capacity, or within the scope of their employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that they have experienced behavior, including an act or omission, constituting physical abuse, as defined in Section 15610.63, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall report the known, suspected, or alleged instance of abuse by telephone or through a confidential internet reporting tool, as authorized by Section 15658, immediately or as soon as practicably possible. If reported by telephone, a written report shall be sent, or an internet report shall be made through the confidential internet reporting tool established in Section 15658, within two working days. (A) If the known, suspected, or alleged abuse occurred in a long-term care facility, except a state mental health hospital or a state developmental center, the following shall occur: (i) If the abuse was allegedly caused by another resident of the facility with dementia diagnosed by a licensed physician and there was no serious bodily injury, the reporter shall submit a written report of the known, suspected, or alleged instance of abuse to both of the following agencies within 24 hours. Code of Federal Regulations, Title 42  §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. On 1/22/2025 at 9:30 AM, an unannounced visit was conducted at the facility to investigate one Facility Report Incident (FRI) alleged sexual abuse that involved Resident 1 and Resident 2. The facility failed to report an alleged sexual abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for Resident 1 to the long-term care (LTC) ombudsman (advocates for patients of nursing homes), Law Enforcement, and California State of Department of Public Health (CDPH) within 24 hours after Resident 1 reported the allegation of sexual abuse to the facility’s Program Manager (PM) on 1/17/2025 at 7:15 PM. The facility reported the sexual abuse allegation of Resident 2 against Resident 1 to CDPH on 1/20/2025 at 6:40 PM, approximately 48 hours after the allegation of sexual abuse was reported by Resident 1 to the facility’s PM. This deficient practice had the potential to place Resident 1 and other residents residing in facility at risk for further sexual abuse. A review of Resident 1’s Admission Record, indicated the facility originally admitted Resident 1, a 40-year-old male, on 10/2/2024 and readmitted him on 10/25/2024 with diagnoses that included schizoaffective disorder (a chronic mental illness that affects a person's thoughts, feelings, and behaviors) and post-traumatic stress disorder (a mental health condition that can develop after experiencing or witnessing a traumatic event). During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/9/2025, indicated Resident 1 had severely impaired memory and cognition (ability to think and reason). The MDS indicated Resident 1 was independent with oral hygiene, toileting hygiene, and chair/bed-to-chair transfer, and required supervision or touching assistance with eating, shower/bathe self, and personal hygiene. During a review of Resident 1 ' s Progress Notes, dated 1/17/2025 timed at 7:15 PM, authored by LVN 2 indicated Resident 1 was "verbally counseled regarding receiving lewd comment even if it ' s a joke from his roommate." During a review of Resident 2's Admission Record, indicated the facility admitted Resident 2, a 27-year-old male, on 11/3/2021 with diagnoses that included schizoaffective disorder and depressive disorder (a mental illness that can cause a persistent low mood and loss of interest in activities). During a review of Resident 2 ' s MDS, dated 11/10/2024, indicated Resident 2 had intact memory and cognition. The MDS indicated Resident 2 was independent with oral hygiene, toileting hygiene, and chair/bed-to-chair transfer, and required supervision or touching assistance with eating, shower/bathe self, and personal hygiene. During a review of Resident 2 ' s Progress Notes, dated 1/17/2025, indicated a peer reported an incident that Resident 2 "displayed sexual inappropriate behavior towards roommate." During a review of undated written statement of the Program Manager (PM), the written statement indicated on 1/17/2025 approximately 7:15 PM, Resident 1 reported that the roommate, Resident 2, stated, “I' m going to rape (is a type of sexual assault involving sexual intercourse, or other forms of sexual penetration, carried out against a person without their consent.) you", as Resident 2 was making sexual gesture at Resident 1. During an interview on 1/23/2025 at 1 PM with the PM, the PM stated on 1/17/2025 around 7:15 PM, Resident 1 reported that he was having an issue with the roommate, Resident 2. The PM stated Resident 1 stated Resident 2 told Resident 1 that Resident 2 was going to rape Resident 1. The PM stated Resident 1 stated Resident 2 was standing next to his bed and doing humping gesture (an act or instance of sexual intercourse.) in front of Resident 1, then, Resident 1 ran out the room and reported to a staff member right away. The PM stated Resident 1 was crying when he was telling her about the situation. The PM stated the situation was considered as an alleged sexual abuse, so she immediately reported to the Program Director and the charge nurse was supposed to report the alleged abuse to the police, the ombudsman and the State of Department of Public Health. The PM stated she did not know if the charge nurse reported the incident to the police, the ombudsman and the State of Department of Public Health on 1/17/2025. During an interview on 1/23/2025 at 2:36 PM, with the Administrator (ADM), the ADM stated she was responsible to report any alleged abuse to the police, the ombudsman and CDPH within two hours after the alleged sexual abuse occurred. The ADM stated on the night of 1/17/2025, she received a text message informing her about the alleged sexual abuse of Resident 1 which occurred on 1/17/2025 and she started to provide the instructions to the staff on what to do to protect the residents, but she forgot to report the incident to the police, the ombudsman and CDPH until 1/20/2025. The ADM stated it was important to report any alleged abuse within two hours to protect residents immediately and prevent reoccurrence of abuse. During a review of the undated facility ' s Policy and Procedure (P&P) titled, "Policy on Abuse Prevention and Mandated Reporting," indicated "All alleged violations involving abuse, neglect, exploitation, or mistreatment, ...will be reported by the facility administrator, or his/her designee, to the following persons or agencies: a. The State Licensing/certification agency responsible for surveying/licensing the facility; b. The local/State ombudsman; c. Law enforcement officials ..."The P&P also indicated "Suspected abuse, ...will be reported within two hours." The facility failed to report an alleged sexual abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for Resident 1 to the long-term care (LTC) ombudsman (advocates for patients of nursing homes), Law Enforcement, and California State of Department of Public Health (CDPH) within 24 hours after Resident 1 reported the allegation of sexual abuse to the facility’s Program Manager (PM) on 1/17/2025 at 7:15 PM. The facility reported the sexual abuse allegation of Resident 2 against Resident 1 to CDPH on 1/20/2025 at 6:40 PM, approximately 48 hours after the allegation of sexual abuse was reported by Resident 1 to the facility’s PM. This deficient practice had the potential to place Resident 1 and other residents residing in facility at risk for further sexual abuse. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.