Health inspection·May 21, 2025

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. (12) 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 § 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 § 72311. Nursing Service - General (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR § 72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. F609 42 CFR §483.12 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. (b) The facility must develop and implement written policies and procedures that: (5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. An unannounced visit was conducted by California Department of Public Health (CDPH) on 4/15/2025, at 7:30 AM, to investigate a Facility Reported Incident regarding an allegation of Resident 2 touching Resident 1’s buttocks and exposing his private area to Resident 1 on 4/12/2025, at 6:50 AM. The facility failed to: 1. Prevent a sexual abuse (when someone touches another person in a sexual manner, unwanted touching of a sexual nature, or makes that person take part in sexual activity with them without consent) for Resident 1 when Resident 2 touched Resident 1’s buttocks and exposed his private parts in front of Resident 1 on 4/12/2025, at around 6:50 AM. 2. Report the sexual abuse for Resident 1 to the State Survey Agency (SSA), the Ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement (Local PD) within two (2) hours from when Certified Nurse Assistant (CNA) 1 witnessed Resident 2 inappropriately touch Resident 1 buttocks and when Resident 2 exposed his private area to Resident 1 and CNA 1 on 4/12/2025 at 6:50 AM. These deficient practices resulted in violating Resident 1’s rights to be free from abuse and having the potential to have negative psychosocial (the combined influence of thoughts, feelings, behaviors, relationships and environment on a person’s wellbeing and how they function) outcomes to Resident 1. These deficient practices also resulted in placing Resident 1 and other residents at risk of further abuse. A review of Resident 1's Admission Record indicated Resident 1, a 46-year-old-female, was admitted to the facility on 4/08/2025, with diagnoses that included injury of unspecified body region (means that there is an injury, but the exact area of the body affected is not identified) open wound right knee, sequela (resulting from prior injury), anxiety disorder (a type of mental health condition that can cause excessive worry, restlessness, difficulty concentrating, sleep disturbances, and muscle tension), and effusion in the right ankle (the result of excess fluids gathering in the soft tissues surrounding the joint). A review of Resident 1’s History and Physical (H&P) dated 4/13/2025 indicated Resident 1 has the capacity to understand and make decisions. A review of Resident 1’s Progress Note dated 4/12/2025, at 12:01 PM, indicated that around 8:25 AM the Director of Nursing (DON) called asking about the sexual abuse by Resident 2 to Resident 1 that happened on 4/12/2025 at 6:50 AM. The progress notes indicated that according to the Case Manager (CM), Resident 1 emailed CM (did not specify when) and claimed that Resident 2 touched her inappropriately on the buttocks and showed his private parts in front of her. The progress notes indicated the night shift Charge Nurse (CN) stated Resident 1 was in station 1 waiting for her morning medication when male resident (Resident 2) passed by and inappropriately touched her and showed his private parts to her. The progress notes indicated that Certified Assistant Nurse (CNA) 1 was present at the time of the sexual abuse incident and told Resident 2 that what he did was not allowed. The progress notes also indicated that Resident 2 then turned around while in his wheelchair and pulled down his pants and underwear to show his private part to Resident 1 and CNA 1. The progress notes indicated, on 4/12/2025, at around 9:15 AM, Registered Nurse Supervisor (RN Sup) 1 left a voicemail at the local Police Department, at 9:17 AM, called the SSA and left message, and at 9:19 AM, called the Ombudsman and left a message. A review of Resident 1’s written statement undated, indicated that on 4/12/2025, at 6:50 AM, Resident 1 was standing and waiting for her pain medication at the nursing station at around 6:50 AM, and Resident 2 passed by Resident 1 while sitting in his wheelchair and “slapped her (Resident 1) buttocks twice quickly”. The written statement indicated that at around 6:53 AM, Resident 2 taunted Resident 1 by making a facial gesture of no regret and that CNA 1 was present and witnessed the incident. The written statement also indicated, Resident 2 then turned around while in his wheelchair and pulled down his pants and underwear showing/exposing his penis. A review of the facility Investigation Statement for CNA 1 dated 4/13/2025, indicated that CNA 1 stated that on 4/12/2025, at around 6:50 AM, Resident 1 was standing at the hallway near the Nursing Station and Resident 2 passed by and touched Resident 1’s buttocks. The investigative statement indicated CNA 1 reported it to the CN and it did not indicate if it was reported to SSA, Ombudsman and/ or local PD. A review of Resident 2’s Admission Record indicated that Resident 2, a 64-year-old-male, was admitted to the facility on 8/09/2024 with a diagnosis of dysphagia (difficulty swallowing), oral phase (problems with using the mouth, lips and tongue to control food or liquid), schizophrenia (a mental disorder with a range of symptoms that affect thoughts, behaviors, and perceptions of reality), acquired absence of left leg above the knee, and anxiety disorder. A review of Resident 2’s H&P dated 8/09/2025, indicated that Resident 2 has the mental capacity to understand and make medical decisions. A review of Resident 2’s Minimum Data Set (MDS- a resident assessment tool), dated 2/12/2025, indicated Resident 2 needed supervision (helper provides verbal cues and resident completes activity), assistance from staff for toileting hygiene, showers and lower body dressing and setup or clean-up assistance (helper sets up or cleans up; resident completes activity) for oral and personal hygiene and putting on/taking off footwear. During an interview with the DON on 4/15/2025 at 7:37 AM, the DON stated CM called her on 4/12/2025 regarding an incident that happened on 4/12/2025 at around 6:50 AM, between Resident 1 and Resident 2. The DON stated that CM told the DON that according to Resident 1, Resident 1 was standing in the hallway near the nurse’s station when Resident 2 passed by and touched Resident 1’s buttocks and then exposed his private area to both Resident 1 and CNA 1. During an interview with RN Sup 1 on 4/15/2025, at 8:10 AM, RN Sup 1 stated, “When I interviewed the night shift nurses (that worked on 4/12/2025), they said the incident (Resident 2 inappropriately touching Resident 1’s buttocks) happened at 6:50 AM, close to change of shift at 7 AM.” RN Sup 1 stated the time frame to call and report an abuse to SSA, Ombudsman and local PD is within 2 hours from when the allegation was made or when the abuse was witnessed which was on 4/12/2025 at 6:50 AM. RN Sup 1 stated that RN Sup 1 reported the abuse by Resident 2 to Resident 1 to SSA, Ombudsman and local PD on 4/12/2025 between 9:15 AM to 9:30 AM and the two-hour window to report had already passed. During a concurrent interview with RN Sup 1 on 4/15/2025, at 8:33 AM, RN Sup 1 stated that Resident 1 told RN Sup 1 that on 4/12/2025, at around 6:50 AM, Resident 2 pulled Resident 2’s pants down while in his wheelchair and showed his private part to Resident 1. RN Sup 1 stated, Resident 1 told RN Sup 1 that CNA 1 saw the sexual abuse by Resident 2 to Resident 1. RN Sup 1 stated Resident 2 showing his private area to Resident 1 was considered a sexual abuse and can cause Resident 1 psychosocial harm (harm to a person’s mental or emotional well-being, often caused by factors in their work or social environment). RN Sup 1 stated the abuse by Resident 2 to Resident 1 should have been reported to SSA within 2 hours from when it happened and if the facility did not report it, there’s a possibility that Resident 2 can do the inappropriate sexual behavior again to Resident 1 or to other residents in the facility. During an interview with CM on 4/15/2025, at 10:49 AM, CM stated she received an email from Resident 1 on 4/12/2025, in the morning indicating Resident 2 touched Resident 1 inappropriately and then exposed Resident 2’s private area to Resident 1 and CNA 1. During an interview with the administrator (Admin) on 4/15/2025, at 11:18 AM, the Admin stated he received a phone call from the DON on Saturday (4/12/2025) morning around 8:30 AM to 9:30 AM. Admin stated, “I am the abuse coordinator.” Admin stated that the facility has to report. But in cases of a serious allegation such as abuse, the facility needs to report to the SSA, Ombudsman and local PD within 2 hours from the incident of abuse or allegation. Admin stated the charge nurse during the period the abuse incident happened was the one responsible to start the process of the investigation and make the report to the SSA, Ombudsman and local PD from when the CNA 1 witnessed the sexual abuse by Resident 2 to Resident 1. The Admin stated that it is not acceptable that the abuse incident by Resident 2 to Resident 1 was not reported within 2 hours to the appropriate agencies to ensure the safety of all the residents regardless of any allegation. Admin stated, the sexual abuse by Resident 2 to Resident 1 happened on 4/12/2025 at around 6:50 AM and it was not reported to the appropriate agencies until 9:15 AM (2 hours and 30 minutes) which was more than the 2 hour timeframe. During an interview with the CN on 4/15/2025, at 12:17 AM, the CN stated, “When there is abuse reported, I must investigate and report to DON, Admin, local PD and Ombudsman within 2 hours. I did not endorse to RN Sup during the change of shift. It’s not acceptable for a resident to touch another resident’s butt, it’s inappropriate and it’s a type of abuse, especially if there’s no consent. It’s considered sexual abuse.” During an interview with CAN 1 on 4/17/2025, at 9:02 AM, CNA 1 stated the incident between Resident 1 and 2 happened right before change of shift on 4/12/2025, at around 6:50 AM. CNA 1 stated that CNA 1 witnessed Resident 2 passing by in the hallway near the nurse’s station and touching Resident 1’s buttocks. CNA 1 stated she approached Resident 2 and told him it was inappropriate to touch another resident’s buttocks and Resident 2 then proceeded to pull down his pants and exposed his penis to both Resident 1 and CNA 1. CNA 1 stated she let the CN know about the incident with Resident 1 and 2. CNA 1 stated that she was not aware the incident between Resident 1 and 2 was not reported by the CN to the Admin, SSA, local PD and to Ombudsman within 2 hours. A review of the facility's policy revised 8/2006, titled "Abuse Prevention Program" indicated, “Our residents have the right to be free from abuse”. The policy indicated the facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents…or any other individual. A review of the facility’s policy revised on 9/2022, titled, “Abuse, Neglect (failure to provide care), Exploitation (treating someone unfairly) or Misappropriation or Misappropriation (unauthorized use of someone else’s belongings)-Reporting and Investigation”, indicated, “All reports of resident abuse (including injuries of unknow origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.” 1. If resident abuse, neglect, exploitation….is suspected, the suspicion must be reported immediately to the administrator and to tother officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility (SSA) b. The local/state ombudsman e. Law enforcement 3. “Immediately” is defined as: