Health inspection·May 2, 2024

F689 Code of Federal Regulations, Title 42, Section 483.25 (d) Accidents. The facility must ensure that – §483.25(d)(1) The patient environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, Title 22, Section 72311. Nursing Service - General (a)Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. On 3/18/2024, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident regarding resident abuse. As a result of the investigation, the facility failed to provide supervision and monitoring for Residents 1, 2, and 4 as indicated in the facility's policies and procedures (P&P) titled, "Hallway Monitor" and "Rounds/Headcount." 1. Resident 1 reported to the Recreational Activities Assistant (RAA) that Resident 2 pulled down Resident 2's pants and asked Resident 1 to perform oral sex on Resident 2 in Resident 2's room. 2. Resident 4 reported to staff that Resident 2 came into Resident 4's room in the middle of the night, pulled down Resident 4's blanket, tried to grab Resident 4's genitals, and asked Resident 4 for oral sex. As a result of these failures, Resident 2 experienced feelings of mental and emotional distress and felt unsafe until Resident 1 was moved to another room. Resident 4 hit Resident 2 on the back of Resident 2's head due to feeling upset about the incident with Resident 2. 1. A review of Resident 1's Admission Record indicated the facility admitted Resident 1 to the facility on 8/6/2023 with diagnoses including but not limited to schizoaffective disorder, suicidal behavior, and insomnia. A review of Resident 1's Minimum Data Set (MDS) dated 2/8/2024 indicated Resident 1's cognitive ability was intact. The MDS indicated Resident 1 had feelings of being down, depressed, and hopeless for one day. A review of Resident 1's Nursing Note (NN) dated 2/14/2024, timed at 8:03 PM indicated three or four days ago, Resident 1 notified the RAA of Resident 2 allegedly pulling down his pants and asking Resident 1 for oral sex.. The NN indicated Resident 2 denied the allegations. The NN indicated Licensed Vocational Nurse 1 (LVN 1) notified the previous Director of Nursing through the phone and the Social Worker (SW) through voicemail. 2. A review of Resident 2's AR indicated the facility admitted Resident 2 to the facility on 3/22/2023 with diagnoses including but not limited to schizoaffective disorder. A review of Resident 2’s Psychiatric Evaluation (PE) dated 3/23/2023 indicated Resident 2 was alert and oriented to person, place, and time. A review of Resident 2's untitled CP, initiated on 9/5/2023 indicated Resident 2 had socially inappropriate behavior such as stealing items, going into other residents' rooms, being intrusive with others, removing clothing in front of others, and dressing inappropriate in situations. The CP interventions indicated for staff to ask Resident 2 to identify triggers one time weekly, discuss and evaluate the effectiveness and side effects of current medication treatment, and for Resident 2 to attend Anger Management, Coping Skills, and Dual Diagnosis group once weekly. A review of Resident 2's MDS, dated 12/29/2023 indicated Resident 2's cognitive ability was intact. 3. A review of Resident 4's AR indicated the facility admitted Resident 4 to the facility on 10/5/2023 with diagnoses including but not limited to schizophrenia, hyperlipidemia, and tobacco use. A review of Resident 4's History and Physical (H&P) dated 10/7/2023 at 2:25 PM indicated Resident 4 was alert and oriented to person. A review of Resident 4's MDS dated 1/11/2024 indicated Resident 4's cognitive ability was intact. A review of Resident 4's Nursing Notes (NN) dated 3/18/2024, timed at 8:50 AM indicated Resident 4 hit Resident 2 on the back of the head during medication pass in the hallway at around 8:45 AM on 3/18/2024. The NN indicated Resident 4 stated Resident 2 came into Resident 4’s room last night and wanted oral sex. The NN indicated Resident 4 denied physical contact. The NN indicated Resident 4 did not notify the staff when the incident occurred. A review of Resident 4's Social Services Noted (SSN) dated 3/18/2024, timed at 4:58 PM indicated Resident 4 stated on the previous night (3/17/2024) Resident 2 went to Resident 4's room, took Resident 4's blanket, and tried to grab Resident 4's genitals. The SSN indicated Resident 4 told Resident 2 to get out and Resident 2 did. The SSN indicated Resident 4 did not report the incident to anyone. The SSN indicated Resident 4 stated Resident 4 hit Resident 2 (on 3/18/2024) because Resident 4 was upset. During an interview on 3/19/2024 at 10:02 AM with Resident 4, Resident 4 stated Resident 2 came into his room in the middle of the night on 3/17/2024, pulled down Resident 4's blanket, and grabbed Resident 4's genitals. Resident 4 stated Resident 2 wore a red shirt when Resident 2 came into Resident 4's room at night and stated Resident 4 saw Resident 2 in the same red shirt in the morning of 3/18/2024. Resident 4 stated he wanted to punch Resident 2 on the teeth, so he tried to turn Resident 2 to face him and hit Resident 2 in the face. During an interview on 3/19/2024 at 12:02 PM with LVN 1, LVN 1 stated Resident 4 was upset and Resident 4 visually identified Resident 2 as the resident who went into Resident 4's room at night (on 3/17/2024) and asked to perform oral sex. LVN 1 stated Resident 2 was wearing a red crew neck on 3/18/2024. During an interview on 3/19/2024 at 1:52 PM with Resident 1, Resident 1 stated Resident 2's room shared a bathroom with Resident 1's room. Resident 1 stated Resident 2 came to the doorway of Resident 1's room through the shared bathroom and asked Resident 1 a question but was unsure of what Resident 2 wanted. Resident 1 stated he followed Resident 2 through the shared bathroom to Resident 2's room. Resident 1 stated Resident 2 then pulled down his pants and asked Resident 1 for oral sex. Resident 1 stated, "What are you doing? Stop!" Resident 1 stated he walked away and reported the incident to a staff member. Resident 1 stated it was stuck in his mind the whole day, and stated, "I felt so upset." Resident 1 stated after the incident, he did not feel safe with Resident 2 in the next room, until Resident 2 was moved to a different room on 2/17/2024. During an interview on 3/19/2024 at 3:06 PM with Resident 2, Resident 2 stated he asked Resident 1 to come to Resident 2's room then Resident 1 sat on Resident 2's bed. Resident 2 stated he sat next to Resident 1 on the bed. Resident 2 stated he pulled out his genitals out of his pants to show Resident 1. Resident 2 stated Resident 1 said, "No, what are you doing?" Resident 2 stated he thought Resident 1 wanted to "play with him" since Resident 1 followed him to his room. During an interview on 3/19/2024 at 3:52 PM with the RAA, the RAA stated Resident 1 reported to her that Resident 2 pulled down his pants and asked Resident 1 for oral sex. The RAA stated Resident 1 looked visibly upset and shaken up after the incident stating Resident 1 felt "uncomfortable." The RAA stated Resident 1 said that Resident 1 could not get it off his mind, and stated Resident 1 followed up with RAA at the end of the day to ask if she reported the incident. The RAA stated it was not typical behavior for Resident 1 to follow up with the RAA and stated, "it really bothered him (Resident 1)”. During an interview on 3/20/2024 at 8:55 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated she saw Resident 4 hit Resident 2 on the right side of the face during medication pass. CNA 1 stated Resident 4 said Resident 2 came into his room in the night and asked him for oral sex. CNA 1 stated residents were not allowed to engage in sexual activities or have physical contact. CNA 1 stated staff encouraged residents to not go into other resident's rooms. CNA 1 stated she had never seen Resident 2 with sexually inappropriate behavior. CNA 1 stated Resident 2 would pace on and off a lot in the hallway but most of the time stayed in Resident 2's room. During an interview on 3/20/2024 at 10:39 AM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated staff needed to monitor the residents every 15 minutes and do a headcount. LVN 2 stated staff needed to monitor residents with inappropriate behaviors closer and ensure residents were not going into other residents' rooms and not acting inappropriately with others. LVN 2 stated if those interventions did not work, staff needed to place the resident with inappropriate behavior within the line of sight. During an interview on 3/20/2024 at 11:00 AM with the Director of Nursing (DON), the DON stated residents with inappropriate sexual behavior required closer monitoring. The DON stated in addition to the 15-minute rounds/headcount, staff will provide additional visual checks/monitoring every 30 minutes or hour. A review of the facility's undated P&P titled, "Rounds/Headcount,” indicated rounds/headcount duty was where assigned staff members made visual contact of every resident at the very least every 15 minutes to insure resident's whereabouts and safety. The P&P indicated rounds/headcount was done continuously. The P&P indicated all residents shall be placed on 15-minute rounds unless resident “is on 1:1”. The P&P indicated nursing staff observed each resident at 15-minute interval. The P&P indicated rounds were continuous; the staff assigned to rounds/headcount should not be sitting nor doing any other duty. A review of the facility's undated P&P titled, "Hallway Monitor," indicated to provide guidelines for staff regarding appropriate method to conduct hallway monitoring and to help provide a safe and secure environment for residents. The P&P indicated staff were to make rounds, observe the residents' rooms continuously and record at 10-minute intervals. The P&P indicated check room and room hallways and check bathrooms. The P&P indicated residents were to be entering their own rooms only. The facility failed to provide supervision and monitoring for Residents 1, 2, and 4 as indicated in the facility's P&P titled, "Hallway Monitor" and "Rounds/Headcount." 1. Resident 1 reported to the RAA that Resident 2 pulled down Resident 2's pants and asked Resident 1 to perform oral sex on Resident 2 in Resident 2's room. 2. Resident 4 reported to staff that Resident 2 came into Resident 4's room in the middle of the night, pulled down Resident 4's blanket, tried to grab Resident 4's genitals, and asked Resident 4 for oral sex. As a result of these failures, Resident 2 experienced feelings of mental and emotional distress and felt unsafe until Resident 1 was moved to another room. Resident 4 hit Resident 2 on the back of Resident 2's head due to feeling upset about the incident with Resident 2. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Residents 1, 2 and 4.