Health inspection·October 22, 2025

On 9/8/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident regarding resident sexual abuse.      On 9/6/2025 at approximately 3:55 AM to 4 AM, Certified Nursing Assistant (CNA) 1 heard grunting (mumbling)/moaning from Resident 1’s room (who was nonverbal). CNA1 observed Resident 2 naked from the waist down on top of Resident 1, who was in a supine (lying face up) position on Resident 1’s bed. Licensed Vocational Nurse (LVN1 who came into Resident 1’s room after CNA1 screamed for help) noticed Resident 2 pulling his pants up walking away from Resident 1. Resident 1 was unable to verbalize the incident. The facility called 911 (emergency phone number) and sent Resident 1 to the General Acute Care Hospital (GACH) 2 9/9/for a trauma evaluation (assessing the immediate physical injuries). GACH2 admitted Resident 1 for an evaluation on sexual assault (nonconsensual sexual act). The facility failed to:    1.Ensure Resident 1 was free from sexual abuse (non-consensual sexual contact of any type or sexual harassment) from Resident 2 who had a history of inappropriate sexual behavior of walking around the facility with his genitals (sexual organs) out and masturbating (stimulate own genitals for sexual pleasure) excessively during his residence at the facility.    2.Ensure Resident 2, who had a history of inappropriate sexual behavior of walking around the facility with his genitals out and masturbating excessively while residing in the facility, was closely monitored to mitigate risk and ensure prompt intervention for the safety of other residents.    3.Conduct an interdisciplinary team meeting (IDT, a collaborative group of diverse health care professionals from different fields who work together) to address Resident 2’s inappropriate sexual behavior of walking around with his genitals out and masturbating.    4.Implement its policies and procedures titled “Abuse, Neglect, Exploitation (means taking advantage of a resident for personal gain through the use of manipulation, intimidation, or threats), and Misappropriation Prevention Program” and “Residents Rights,” indicating residents have the right to be free from abuse.     As a result of these failures, Resident 1 experienced sexual abuse from Resident 2 while under the care of the facility and resulted in Resident 1 being admitted to the GACH2 for an evaluation on sexual assault.       During a review of Resident 1’s Admission Record, the Admission record indicated the facility admitted a forty-five-year-old-male on 5/27/2025  with diagnoses including generalized muscle weakness (a widespread loss of muscle strength that affects multiple muscle groups throughout the body),  anxiety (excessive worry, fear, and nervousness), and developmental disorders of speech and language (difficulties in learning, understanding, and using spoken words).      During a review of Resident 1’s History and Physical (H&P) dated 6/9/2025, the H&P indicated Resident 1 did not have capacity to understand and make decisions.     During a review of Resident 1’s Minimum Data Set (MDS, a resident assessment tool), dated 8/29/2025, the MDS indicated Resident 1’s cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired (reduced). The MDS indicated Resident 1 had unclear speech (slurred or mumbled words) and was rarely/never understood. Resident 1 was dependent (helper does all the effort) with eating, personal hygiene (practices and habits that maintain cleanliness and health of the body) oral (mouth) hygiene, showering/bathing, dressing, and toilet use. Resident 1 was dependent on staff to go from sitting to lying position and from lying position to a sitting position on the side of the bed.        During a review of Resident 1’s Progress Notes dated 9/6/2025 at 3:55 to 4AM, indicated the CNA (CNA1) heard grunting/moaning from Resident 1’s room. The Progress Notes indicated Resident 1 was nonverbal. The Progress Notes indicated the CNA (CNA1) went to Resident 1’s room and the CNA (CNA1) observed Resident 2 on top of Resident 1 who was in a supine position naked from the waist down, and the resident’s hospital gown pulled up. The Progress Notes indicated the CNA (CNA1) yelled for help and the Charge Nurse (LVN1) noticed Resident 2 pulling his pants up walking away from Resident 1. The Progress Notes indicated Resident 1 was unable to verbalize the incident. The Progress Notes indicated the facility called 911 at 4:13AM. The Progress Notes indicated Resident 1’s medical doctor ordered at 5:41AM to transfer Resident 1 to the hospital for trauma evaluation.   During a review of Resident 1’s GACH2 Emergency Department (ED) record dated 9/6/2025 at 11:32 AM, the ED record indicated Resident 1 arrived from the facility to GACH2 for complaints of sexual assault at 3:55AM that was witnessed by a CNA (unidentified). The GACH2 record indicated the Emergency Medical Services (EMS, emergency medical personnel who respond to emergency situations) reported that another resident (unidentified) was apparently on top of Resident 1 with no pants on. The GACH record indicated the GACH admitted Resident 1 for further evaluation.      During a review of Resident 2’s GACH1 Progress Notes dated 7/23/2025 (prior to admission), the GACH1 record indicated Resident 2 had a history of psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and hypersexuality (compulsive [incontrollable] sexual behavior).     During a review of Resident 2’s GACH1 Consultation Notes dated 8/19/2025, the GACH1 record indicated Resident 2 was positive (showed action) for masturbating and disrobing (removing clothes) at Resident 2’s nursing home facility (different facility) with sexual aggression towards his roommate.     During a review of Resident 2’s Admission Record, the Admission Record indicated the facility admitted a sixty-six-year-old-male on 8/22/2025 with diagnoses including other psychotic disorder (severe mental illness where the individual’s thoughts and perceptions are so out of sync with those around them that they have trouble functioning in daily life) not due to a substance or known physiological condition (how the body functions at any given moment) unspecified severity, with other behavioral disturbance (a consistent pattern of problematic, disruptive, or unhealthy behaviors that interfere with a person’s ability to function normally in daily life, affecting their self-control and respect for rules and the rights of others).      During a review of Resident 2’s H&P dated 8/23/2025, the H&P indicated Resident 2 had hypersexual behavior.      During a review of Resident 2's Order Summary Report dated 8/25/2025, the Order Summary Report indicated Resident 2 had an order for Haloperidol (medication used for behavioral issues) manifested(shown) by inappropriate sexual behavior, walking around with his genitals out and masturbating excessively.       During a review of Resident 2’s MDS, dated 8/29/2025, the MDS indicated Resident 2 was able to walk without assistance.      During a review of Resident 2’s Progress Notes dated 8/25/2025 at 11:17 AM, the Progress Notes indicated Resident 2 had inappropriate sexual behavior and was walking around the facility with his genitals out and masturbating excessively.     During a review of Resident 2’s Care Plan Report dated 8/25/2025, the Care Plan Report indicated Resident 2 had a potential for behavior disturbance related to psychosis manifested by inappropriate sexual behavior, walking around with his genitals out and masturbating excessively. The Care Plan Report indicated the nursing intervention was to intervene as needed to protect the rights and safety of others.        During a review of Resident 2’s Medication Administration Record (MAR) dated September 2025, the MAR indicated Resident 2 had inappropriate sexual behavior, walking around with his genitals out and masturbating excessively on the following dates:   -On 9/2/2025 during the 11PM to 7AM shift.   -On 9/3/2025 during the 11PM to 7AM shift.   -On 9/4/2025 during the 7AM-3PM shift and the 3-11PM shift.   -On 9/5/2025 during the 11PM-7AM shift.   -On 9/6/2025 during the 7AM-3PM shift, and the 11PM-7AM shift.   -On 9/7/2025 7during the 7AM-3PM shift and on 3PM-11PM shift.   -On 9/8/2025 during the 7AM-3PM shift.     During a review of Resident 2’s Nursing Progress Notes dated 9/6/2025 at 8:20AM, the Nursing Progress Note indicated at 3:55 AM to 4AM the CNA (CNA1) heard grunting/moaning from Resident 1’s room. The CNA (CNA1) went to Resident 1’s room and CNA1 observed Resident 2 on top of Resident 1 naked. The Nursing Progress Notes indicated CNA (CNA1) yelled for help. The Charge Nurse (LVN1) noticed Resident 2 pulling his pants up walking away from Resident 1.    During a review of Resident 2’s Application for up to 72-hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (5150 form) dated 9/7/2025, the 5150-form indicated Resident 2 was a danger to others and at risk for hurting someone (unidentified) sexually and required further evaluation.      During an interview on 9/8/2025 at 2:02 PM, with CNA1, CNA1 stated that on 9/6/2025 between 3:55AM to 4AM she (CNA1) heard commotion coming out of Resident 1’s room. CNA1 stated she (CNA1) saw Resident 2 naked on top of Resident 1’s bed in between Resident 1’s legs. CNA1 stated Resident 1 was naked from the waist down and Resident 1’s legs were open.          During a concurrent interview and record review on 9/9/2025 at 8:18 AM, with Registered Nurse Supervisor (RNS), Resident 2’s Care Plan Report initiated on 8/25/2025 was reviewed. RNS stated the Care Plan Report indicated Resident 2 had a behavior of inappropriate sexual behavior, walking around with his genitals out and masturbating excessively. The interventions were to intervene as needed to protect the rights and safety of others. The RNS stated the facility did not follow the care plan. The incident between Resident 1 and Resident 2 could have been prevented. Resident 2 should have been closely monitored.     During a concurrent interview and record review on 9/9/2025, at 8:42 AM with LVN3, Resident 2’s MAR dated September 2025 was reviewed. LVN3 stated the MAR indicated Resident 2 had inappropriate sexual behavior of walking around with genitals out and masturbating on the following dates: on 9/2/2025 during the 11PM-7AM shift, on 9/3/2025 11PM to 7AM shift, on 9/4/2025 during the 7AM-3PM and the 3PM-11PM shifts, on 9/5/2025 during the 11PM-7AM, and on 9/6/2025 during the 11PM-7AM shift.  During an interview on 9/9/2025 at 9:44 AM, with LVN2, LVN2 stated she (LVN2) saw Resident 2 masturbating inside his room in his bed on 9/4/2025 (time unidentified) during the 7-3 pm shift with the privacy curtains open.       During a concurrent interview and a record review of Resident 2’s medical chart (in general) on 9/9/2025 at 10:07AM, with the Social Services Director (SSD), the SSD stated the facility did not conduct an interdisciplinary team meeting (IDT, a collaborative group of diverse health care professionals from different fields who work together) to address Resident 2’s inappropriate sexual behavior of walking around with his genitals out and masturbating. The SSD stated the facility should have conducted an IDT to discuss Resident 2’s inappropriate sexual behaviors to have better interventions.        During an interview on 9/9/2025 at 12:45 PM with the DON, the DON stated she (DON) reviewed Resident 2’s preadmission GACH1 record and that she (DON) was aware Resident 2 had a behavior of masturbation, and the facility would be able to care for Resident 2. The DON stated there was no IDT conducted. There should have been an IDT to have interventions. The DON stated the Medical Director was notified on 9/9/2025 of Resident 1 and Resident 2’s sexual abuse incident.     During an interview with the Medical Director on 9/9/2025 at 1:15PM, the Medical Director stated the DON notified him of Resident 1 and Resident 2 allegation of sexual abuse on 9/9/2025. The Medical Director stated the facility needed to conduct an IDT regarding Resident 2’s behavior of inappropriate sexual behavior to have better interventions.     During an interview with the ADM on 9/9/2025 at 1:38PM, the ADM stated the facility was responsible for knowing what type of residents (in general) would be admitted to the facility. He (ADM) was aware of Resident 2’s behavior of masturbating and not of any other behaviors of Resident 2 such as sexual behavior, that was inappropriate.       During a review of the facility’s Abuse, Neglect, Exploitation (means taking advantage of a resident for personal gain through the use of manipulation, intimidation, or threats), and Misappropriation Prevention Program, policy and procedure (P&P) dated April 2021 and reviewed 1/16/2025, the P&P indicated the residents have the right to be free from abuse including sexual abuse. The P&P indicated the facility would protect residents from abuse, neglect...by anyone including, but not necessarily limited to... other residents.        During a review of policy titled, “Residents Rights” dated 1/16/2025 indicated, “Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident’s right to be free from abuse...”    The facility failed to:    1.Ensure Resident 1 was free from sexual abuse from Resident 2 who had a history of inappropriate sexual behavior of walking around the facility with his genitals out and masturbating excessively during his residence at the facility.    2.Ensure Resident 2, who had a history of inappropriate sexual behavior of walking around the facility with his genitals out and masturbating excessively while residing in the facility, was closely monitored to mitigate risk and ensure prompt intervention for the safety of other residents.    3.Conduct an IDT meeting to address Resident 2’s inappropriate sexual behavior of walking around with his genitals out and masturbating.    4.Implement its policies and procedures titled “Abuse, Neglect, Exploitation, and Misappropriation Prevention Program” and “Residents Rights,” indicating residents have the right to be free from abuse.     As a result of these failures, Resident 1 experienced sexual abuse from Resident 2 while under the care of the facility and resulted in Resident 1 being admitted to the GACH2 for an evaluation on sexual assault.           These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.