Health inspection·June 20, 2025

Willful Material Falsification HSC§1424 (f) (2) (f) (1) Any willful material falsification or willful material omission in the health record of a patient of a long-term health care facility is a violation. (2)“Willful material falsification,” as used in this section, means any entry in the patient health care record pertaining to the administration of medication, or treatments ordered for the patient, or pertaining to services for the prevention or treatment of decubitus ulcers or contractures, or pertaining to tests and measurements of vital signs, or notations of input and output of fluids, that was made with the knowledge that the records falsely reflect the condition of the Patient or the care or services provided. On 5/8/2025 at 10:30 AM, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint allegation regarding sexual abuse (non-consensual [without the person's permission] touching of one person for the sexual gratification of another). As a result of the investigation, CDPH determined that the facility willfully falsified Patient 2’s medical records as indicated below: 1. Charge Nurse 1 (CN 1) willfully falsified Resident 2’s SBAR (Situation, Background, Assessment, Recommendation - a structured communication tool used to improve clean and efficient communication, especially in critical situations or when transferring information between health-care professionals) by documenting that Resident 2 “inappropriately touched” a staff (unknown) rather documenting Resident 2 inappropriately touching Resident 1. 2. Minimum Data Set (MDS - a resident assessment tool ) Nurse (MDSN) willfully falsified Resident 2’s care plan (a document that outlines the facility’s plan to provide personalized care to a resident that includes measurable objectives and time frames to meet a resident’s medical, nursing, and mental and psychosocial needs) by developing a care plan that indicated Resident 2 had “inappropriate behavior” of touching female staff/Certified Nurse Assistant (CNA) rather than addressing inappropriately touching Resident 1 . These deficient practices resulted in failure in the delivery of necessary services and care for Resident 1 and Resident 2 such as monitoring of behavior, psychosocial support, separating Resident 1 from Resident 2, and had the potential to place other residents in the facility at risk for experiencing sexual abuse by Resident 2 due to Resident 2’s unaddressed inappropriate behavior of touching other resident/s without the other resident’s consent (permission for something to happen or agreement to do something). On 5/8/2025, Resident 1 expressed feeling scared and did not feel safe in the facility since the incident occurred with Resident 2. A review of Resident 1’s Admission Record, the Admission Record indicated Resident 1, a 62-year-old-female, was admitted to the facility on 4/26/2023 with diagnoses that included other recurrent depressive disorder (persistent sadness and loss of interest in activities, affecting thoughts, behaviors, feelings, and well-being), schizophrenia (a mental illness that can affect thoughts, moods, and behavior), and unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). A review of Resident 1’s MDS, dated 5/3/2025, the MDS indicated Resident 1 was assessed as having moderately impaired (decisions poor; cues/supervision required) cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 1 required partial/moderate assistance (helper does more than half the effort) with upper body dressing, personal hygiene, sit to stand, and chair/bed-to-chair transfer. Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, and lower body dressing. A review of Resident 2’s Admission Record, the Admission Record indicated Resident 2, a 76-year-old-male, was admitted to the facility on 5/19/2023 with diagnosis that included unspecified dementia (a progressive state of decline in mental abilities), recurrent depressive disorder, and specified anxiety disorder (fear characterized by behavioral disturbances). A review of Resident 2’s MDS, dated 2/21/2025, the MDS indicated Resident 2 was assessed having moderately impaired cognitive skills for daily decision making. Resident 2 required supervision or touching assistance with oral hygiene, upper body dressing, sit to stand, chair/bed-to-chair transfer, and toilet transfer. Resident 2 was independent with wheeling his manual wheelchair at least 50 feet (ft- unit of measurement) and make two turns and 150 ft in a corridor or similar space. During an interview on 5/8/2025, at 10:59 AM, with Charge Nurse 1 (CN 1) and the Director of Nursing ( DON) , CN 1 stated, on 5/6/2025, at around 1 PM, Resident 1 and Resident 2 were sitting on their wheelchairs and were placed next to each other in the hallway in front of Room A. CN 1 stated Resident 1 and Resident 2 were waiting to be taken to the Activity Room. CN 1 stated she was sitting in the nurse’s station and when she stood up, observed Resident 2 touch Resident 1 on her inner thigh. CN 1 stated she called Resident 2’s name and observed Housekeeping Staff (HKS) pull Resident 2’s wheelchair away from Resident 1 and parked it on the opposite side of the hallway. CN 1 stated Resident 2 wheeled his wheelchair to Resident 1 and rubbed her back from behind. CN 1 stated she walked towards Resident 1 and Resident 2 and wheeled Resident 2 to the nurse’s station. CN 1 stated Resident 1 stated she did not feel comfortable being touched by Resident 2 after the incident happened. During a concurrent observation and interview on 5/8/2025, at 11:32 AM, with Resident 1, Resident 1 was sitting on her wheelchair outside of her room. Resident 1 was alone and rocked back and forth during the interview. Resident 1 stated that a couple of days ago Resident 2 touched her and pointed to her scapular (the flat triangular bone located on the back of the upper body) area when asked where she was touched. Resident 1 stated the incident occurred in the hallway close to the nurse’s station while waiting to go to the activity room. Resident 1 stated she told Resident 2 to stop touching her and to leave her alone. Resident 1 stated she did not feel safe in the facility because she was raped (a type of sexual assault involving sexual intercourse, or other forms of sexual penetration, carried out against a person without their consent) before when she was living in the streets. Resident 1 stated only CN 1 talked to her about the incident since it happened. During an interview on 5/9/2025, at 1:55 PM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated facility staff who witnessed the sexual abuse was responsible for initiating an SBAR and the care plan for the resident. LVN 1 stated it was important that the information on the SBAR and care plan was accurate. During a concurrent interview with CN 1 and record review, on 5/9/2025, at 2:25 PM, Resident 2’s SBAR, dated 5/6/2025 was reviewed. CN 1 stated on 5/6/2025, before 3 PM, CN 1 was called to the DON’s office for a meeting by the Administrator (ADM). CN 1 stated when she arrived at the DON’s office the ADM, MDSN, Social Services Director (SSD), and Director of Staffing Development (DSD) were there. CN 1 stated the ADM told CN 1 to initiate an SBAR and indicate that Resident 2 had inappropriate behavior with staff since the ADM did not plan on reporting the incident between Resident 1 and 2 to CDPH. CN 1 stated she disagreed with the ADM and told the ADM that was not what happened. CN 1 stated she reminded the ADM that Resident 1 was inappropriately touched by Resident 2 and not the staff. CN 1 stated the ADM wanted CN 1 to document Resident 2’s behavior problems towards staff to justify Resident 2’s needs to get evaluated by a psychiatrist (psych- medical director who specializes in diagnosis, treatment, and prevention of mental, emotional, and behavioral disorder) and transferred out of the facility without getting Resident 1 involved. CN 1 stated, on 5/7/2025, she initiated Resident 2’s SBAR and documented that Resident 2 had inappropriate behavior towards female staff and was trying to touch CNAs inappropriately. During a concurrent interview and record review on 5/9/2025, at 2:54 PM, with MDSN, Resident 2’s care plan for inappropriate behavior was reviewed. MDSN stated on 5/6/2025, Resident 2 touched Resident 1’s inner thigh and upper back in the hallway. MDSN stated the ADM called a meeting in his office to discuss what to do with Resident 2. MDSN stated the ADM wanted to get a psych consult for Resident 2 but needed a reason why a consultation was necessary. MDSN stated the ADM met with MDSN and CN 1 in the DON’s office. MDSN stated that during the meeting, the ADM stated he wanted CN 1 to document that Resident 2’s inappropriate behavior was towards female staff and not Resident 1. MDSN stated CN 1 did not want to follow what the ADM was asking CN 1 to do. MDSN stated she could not understand why the ADM wanted MDSN to indicate that female staff was inappropriately touched and not Resident 1. MDSN 1 stated CN 1 documented on the SBAR that Resident 2 inappropriately touched female staff on 5/7/2025. MDSN stated she wrote Resident 2’s care plan that indicated Resident 2 had inappropriate behavior and was touching female staff on 5/7/2025 after CN 1 asked for her help. MDSN stated that what she documented on Resident 2’s care plan did not match what actually happened. MDSN stated she did not indicate in the care plan that it was Resident 1 who was touched inappropriately. MDSN stated CN 1 was “guided” by the ADM to write in the SBAR that Resident 2 inappropriately touched a female staff instead of inappropriately touched Resident 1. MDSN stated all facility staff are responsible for documenting what actually happened. During an interview on 5/9/2025, at 4:47 PM, with SSD, SSD stated she was in the DON’s office when the ADM met with CN 1 and MDSN. SSD stated the ADM asked CN 1 to document on the SBAR that Resident 2 inappropriately touched staff and not Resident 1. SSD stated that because of CN 1’s inaccurate documentation, she was not able to assess Resident 1 after the incident that occurred between Resident 1 and 2. SSD stated that if SSD documented the incident between Resident 1 and 2 then CN 1’s documentation on the SBAR will not match with SSD’s documentation. SSD stated it was not right that what happened to Resident 1 was not documented because it was not advocating for Resident 1. During an interview, on 5/9/2025, at 7:29 PM, with the DON, the DON stated it was important for facility staff to accurately document what occurred to the residents in the facility. The DON stated facility staff were not allowed to falsify any documentation. During a review of the facility’s policy and procedure (P&P) titled, “Charting and Documentation,” revised on 3/2024, the P&P indicated, “Documentation in the medical record will be objective (not opinionate or speculative), complete, and accurate. During a review of the facility’s P&P titled, “Administrator,” revised on 3/2024, the P&P indicated, “The Administrator is responsible for, but not limited to implementing established Resident care policies, personnel policies, safety and security policies, and other operational policies and procedures necessary to remain in compliance with current laws, regulations, and guidelines governing long-term care facilities.” As a result of the investigation, CDPH determined that the facility willfully falsified Patient 2’s medical records as indicated below: 1. CN 1 willfully falsified Resident 2’s SBAR by documenting that Resident 2 “inappropriately touched” a staff (unknown) rather documenting Resident 2 inappropriately touching Resident 1. 2. MDSN willfully falsified Resident 2’s care plan by developing a care plan that indicated Resident 2 had “inappropriate behavior” of touching female staff/CNA rather than addressing inappropriately touching Resident 1. The above facts indicate that there was a willful material falsification in Resident 2’s medical record.