Health inspection·July 22, 2025

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by anyone. 22CCR §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. 22CCR §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 6/11/2025, the California Department of Public Health (CDPH) received a complaint indicating an allegation of sexual abuse occurred on 6/9/2025 at 11 p.m. On 6/12/2025 at 8:30 am, the CPDH conducted an unannounced onsite visit to investigate the allegations. The facility failed to protect Resident 1 from a non-consensual sexual contact (any sexual touching or contact that occurs without the explicit [clear] and voluntary agreement with individuals involved), with Resident 2, by failing to ensure: 1). Resident 2's whereabouts (location) were monitored on 6/10/2025 around 1:05 a.m. 2). Resident 2 did not go into Resident 1's room and sexually assaulted (when someone either touches another person in a sexual manner without consent or makes another person touch them in a sexual manner without consent) the resident. These failures resulted in Resident 1 being sexually assaulted by Resident 2 and had the potential to cause psychological trauma (a lasting negative effects on a person's thoughts, feelings, and behaviors as a result from various experiences, including accidents, violence, abuse) to Resident 1. a). Resident 1 was a 76-year-old female, was admitted to the facility on 12/12/2024, with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (mental illness characterized by persistent sadness, loss of interest in activities, and significant impairment in daily life), and anxiety disorder (feelings of worry, nervousness, or unease). A review of Resident 1's History and Physical (H&P) dated 12/30/2024, indicated Resident 1 could not make medical decisions but could make needs known. A review of residents 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/15/2025, indicated Resident 1 had no cognitive impairment. The MDS indicated Resident 1 required partial/ moderate assistance (Helper does less than half the effort) with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene The MDS indicated Resident 1 required supervision or touching assistance with transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side.) During an interview on 6/12/2025 at 9:30 a.m. with Resident 1, Resident 1 could not recall what happened on 6/10/2025. Resident 1 was confused, talking about her neighbor's apartment and stated a lot of people touched her when she moved around or when they said hi to her. During an interview on 6/12/2025 at 10:37 a.m. with the Certified Nursing Assistance (CNA) 3, CNA 3 stated Resident 1 was alert, could follow simple commands, but was confused. CNA 3 stated Resident 1 liked to walk around her room and in the hallways. CNA 3 stated male residents were not allowed by the facility to go inside female resident's rooms. CNA 3 stated Resident 1 was just seen (time not specified) sitting in the front lobby, talking with another residents on 6/9/2025. b). Resident 2 was a 75-year-old male, admitted to the facility on 6/9/2025, with diagnoses including bipolar disorder (mood swings ranging from depressive lows to manic highs) other psychoactive substance (substance abuse substances include alcohol, caffeine, nicotine, marijuana, and certain pain medicines), and tobacco use (Nicotine dependence). Resident 2 was transferred to a general acute care hospital on 6/10/2025 for evaluation. A review of Residents 2's clinical admission record, dated 6/9/2025, indicated Resident 2 was alert, able to make self-understood and could understand others. The clinical admission record indicated Resident 2 could move all extremities and had no impairment. A review of the Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) meeting notes dated 6/11/2025 at 10:00 a.m., indicated on 6/10/2025 at approximately 1:05 a.m., during a routine room check by Registered Nurse (RN) 1 Supervisor, observed Resident 2 on top of Resident 1's body, in Resident 1's room. RN 1 stated Resident 1 had her pants down, and Resident 2's face was near her genital area. The IDT indicated RN 1 intervened immediately and separated both residents. During an interview on 6/12/2025 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 2 was admitted to the facility on 6/9/2025, alert and oriented and was observed in his room, in bed around 11 p.m. LVN 3 stated, the facility's protocol when with a newly admitted resident was to check on the resident's behavior for safety. LVN 3 stated we (facility staff) also need to check where the residents are because some residents are unable to sleep and could be walking anywhere. During an interview on 6/12/2025 at 12:20 p.m. with the RN 1, RN 1 stated Resident 1 was only oriented to name and was redirectable. RN 1 stated, on 6/10/2025 around 1 a.m., during her (RN 1) routine rounds; Resident 2 was not in his room. RN 1 stated when she got to Resident 1's room, the door was closed. RN 1 stated she opened the door and saw both Residents 1 and 2 were in Resident 1's bed. RN 1 stated Resident 1 was lying flat on her back with her pants down and Resident 2's face was down in Resident 1's genital area (private part of the body). RN 1 stated she separated both residents and took Resident 2 back to his room. RN 1 stated Resident 1 was assessed and had no signs of emotional trauma or injuries. RN 1 stated one-to-one supervision (continuous, focused attention provided by a staff member) was provided to each of the residents. During an interview on 6/12/2025 at 2:51 p.m. with the Director of Nursing (DON), the DON stated at 1:00 a.m., on 6/10/2025, she was notified regarding the incident (Resident 1 seen lying flat on her back with her pants down and Resident 2's face was down in Resident 1's genital area) between Resident 1 and Resident 2. The DON stated male and female rooms were kept apart, and the male residents should not go inside female rooms. The DON stated CNAs had been informed to always check on residents and stay close to their assigned areas. The DON stated the facility had no policy for consensual sexual relationship because it was not something that happened all the time. The DON stated the facility had no consent or IDT meeting related to the consensual sexual relationship between Resident 1 and Resident 2. During an interview on 6/18/2025 at 2:48 p.m. with the ADM, the ADM stated when residents express their desire to have sexual relationship, first we the staff need to assess the mental capacity of the residents. The ADM stated an IDT meeting should be conducted and consents obtained prior to the residents able to have consensual sexual relationship. The ADM stated the facility had not conducted an IDT meeting nor obtained consents for Resident 1 and Resident 2 to have a consensual sexual relationship. The ADM stated the facility had no policy about consensual sexual relations between residents. The facility failed to protect Resident 1 from non-consensual sexual contact, with Resident 2, by failing to ensure: 1). Resident 2's whereabouts were monitored on 6/10/2025 around 1:05 a.m. 2). Resident 2 did not go into Resident 1's room and sexually the resident. These failures resulted in Resident 1 being sexually assaulted by Resident 2 and had the potential to cause psychological trauma to Resident 1. These violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to the resident.