Health inspection·May 24, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00893581. Representing the Department, HFEN # 43452. A Class B Citation was written. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations Freedom from Abuse, Neglect, and Exploitation §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. §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(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 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. On 4/9/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about resident's abuse. The facility failed to implement its policy regarding reporting of residents' allegation of sexual abuse and to submit a conclusion report of Investigation within five days or in accordance with state or federal law for Residents 2 and 3. As a result, there was a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further sexual abuse for Residents 2 and 3. A review of Resident 2's Admission Record indicated Resident 2 was admitted on 8/28/2023 with diagnoses including encephalopathy (a chemical imbalance in the blood affecting the brain), human immunodeficiency virus (HIV - a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases, It is spread by contact with certain bodily fluids of a person with HIV, most commonly during unprotected sex [sex without a condom or HIV medicine to prevent or treat HIV], or through sharing injection drug equipment), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and cellulitis of right lower limb (bacterial skin infection). A review of Resident 2's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 3/5/2024, indicated Resident 2's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was mildly impaired for daily decision-making and required supervision to set-up assistance from staff for activities of daily living (ADL- eating, oral hygiene, personally hygiene). A review of Resident 3's Admission Record indicated the resident was originally admitted on 3/15/2023 and readmitted on 9/17/2023 with diagnoses including cellulitis of right and left lower limb, altered mental status, and hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting right dominant side. A review of Resident 3's MDS dated 3/24/2024, indicated Resident 3's cognition was mildly impaired for daily decision-making and required moderate to maximal assistance from staff for ADL- eating, oral hygiene, toileting hygiene, and personal hygiene. During an interview with Resident 2 on 4/10/2024 at 10:53 a.m., Resident 2 stated, he has a partner and in a relationship with another resident, Resident 3. Resident 2 stated, Resident 3 is a black descent, and he is his "boyfriend". Resident 2 further stated the staffs are allowing them to have a relationship and they are aware of their situation before but lately; they are not letting them go to the same Activity Room and they separate them. Resident 2 stated, he is to go to the Activity Room 2 only (3rd floor) away from Resident 3. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 4/10/2024 at 11:06 a.m., LVN 1 stated, sometime last week, Restorative Nursing Assistant 1 (RNA 1) reported to her that Resident 2 was found sitting on the lap of Resident 3 inside Resident 2's room. LVN 1 stated, they reported it to the Director of Nursing (DON) and she was made aware of the incident. During an interview with RNA 1 on 4/10/2024 at 11:12 a.m., RNA 1 stated, she witnessed Resident 2 and Resident 3 in Resident 2's room, Resident 2 was on top of Resident 3's lap while sitting on the wheelchair. RNA 1 stated, she did not witness how it started but she reported it to LVN 1 RNA 1 stated, she separated and reoriented both residents. RNA 1 further stated, they both reported the incident to the DON. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 4/10/2024 at 11:19 p.m., LVN 2 stated, Licensed Vocational Nurse 3 (LVN 3) mentioned to him on 4/5/2024 that Resident 2 and Resident 3 was observed in the Activity Room 2 (AR 2) by the Activity Assistant 1 (AA 1) having intercourse. LVN 2 stated, DON and the Administrator (ADM) were aware of the incident and did not do any investigation. LVN 2 stated, DON and ADM did not report it to the State Agency and the Police because they want to hide the situation and the incident. LVN 2 stated, he talked to the DON about it and DON just shrugged it off. LVN 2 further stated, Resident 2 was diagnosed with HIV and the management did not try to do any testing for Resident 3. During an interview with Resident 3 on 4/10/2024 at 12:03 p.m., Resident 3 stated, he is friends with Resident 2. When asked if he (Resident 3) knows the current date and his location, Resident 3 was unable to answer correctly, Resident 3 answered, today was the "12th" and he is in "Angeles". During an interview with Activity Director (AD) on 4/10/2024 at 2:25 p.m., AD stated, AA 1 notified him that Resident 2 was found touching Resident 3 inappropriately sometime last week in the Activity Room 2 in 3rd floor. AD stated, he told the managements including DON, ADM, and Human Resources (HR) and they had a meeting about it. AD stated, they were told to keep an eye on both residents. AD stated all staffs are mandated reporter that is why he reported it to the managements. During an interview with DON on 4/10/2024 at 4:27 p.m., DON stated, she was not aware of the sexual abuse allegation incident for Resident 2 and Resident 3. DON stated, they did not do any investigation of the sexual allegation. A review of the facility's policy and procedures (P&P) titled, "Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating", reviewed 9/2023 indicated, "all reports of resident abuse (including injuries of unknown 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... The Administrator or 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 b. the local/state ombudsman c. The resident's representative d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury... Within five business days of the incident, the administrator will provide a follow-up investigation report. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified." The facility failed to implement its policy regarding reporting of residents' allegation of sexual abuse and to submit a conclusion report of investigation within five days or in accordance with state or federal law for Residents 2 and 3. As a result, there was a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further sexual abuse for Residents 2 and 3. The above violations had direct or immediate relationship to the health, safety, or security of Residents 2 and 3.