Health inspection·February 28, 2025

F600 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 22 CCR § 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. 22 CCR §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. 22 CCR § 72527. Patient Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. On 1/15/2025 the California Department of Public Health conducted an unannounced visit to the facility to investigate a facility reported incident regarding an allegation of abuse. As a result of the investigation, the Department determined that the facility failed to: 1. Prevent Resident 2 from being sexually abused by Resident 1 on 1/12/25 in accordance with the facility's policy and procedure titled "Abuse Prevention Program-Abuse Prohibition," revised May 2024, which indicated the facility shall uphold resident's right to be free from sexual and physical abuse. 2. Conduct a psychosocial visit for 72 hours after Resident 1 displayed new aggressive behavior when Resident 1 punched a staff member on 1/7/25 per facility policy. 3. Implement the facility's policy and procedure titled, "Behavior Assessment, Intervention, and Monitoring," revised May 2024, to ensure the interdisciplinary team (IDT), a team of professionals from various fields who work together toward the goals of the resident) would thoroughly evaluate Resident 1's new or changing behavioral symptoms, which occurred on 1/7/2025, in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition. As a result, on 1/12/2025 at about 9 PM, Resident 1 sexually abused Resident 2 (the roommate) when Resident 2's incontinent brief was removed by Resident 1. Resident 1 used her left hand signaling to Resident 2 to stop crying and Resident 1 used the right hand to touch Resident 2's vagina. Resident 2, a 91-year-old female, cried loudly and was angry with distress (a state of emotional suffering). Resident 2 was subjected to physical and sexual abuse by Resident 1 while under the care of the facility. A review of Resident 1's Admission Record indicated the facility admitted the resident on 6/17/2024 with diagnoses including schizoaffective disorder, depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and mild cognitive impairment of uncertain or unknown etiology (problems with a person's ability to think, remember, use judgement). A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/24/2024, indicated the resident's problems with ability to think, remember and use judgement had declined and now had moderate cognitive impairment for daily decision making. The MDS indicated the resident did not have any behaviors of hallucinations (seems to see, hear, feel, or smell something that does not exist) or delusions (false belief that someone holds onto, even when there was evidence that it was not true), physical behavioral symptoms directed towards others (hitting, kicking, grabbing, abusing others sexually) or verbal behavioral symptoms towards others (threating others, screaming at others, cursing at others). A review of the Change of Condition (COC) Evaluation dated 1/7/2025, indicated Resident 1 had physical aggression towards an employee and Resident 1 punched the employee's left upper arm. The note indicated Resident 1's family and physician were notified. A review of Resident 1's Behavior Problem care plan dated 1/7/2025 with a focus on physical aggression (patient punched nurse) indicated the goal was for Resident 1 to verbalize understanding of need to control physical / verbal / social / sexual inappropriate behavior for three months. The care plan interventions indicated to share with the resident other options for dealing with feelings, and when resident becomes agitated: intervene before agitation escalates; guide away source of distress; engage calmly in conversation; if response was aggressive -walk calmly away, and approach later. According to a review of Resident 1's COC Evaluation dated 1/12/2025 (five days later), there was an allegation of sexual abuse as Resident 1 inappropriately touched (any physical contact that was unwanted) Resident 2's (the roommate) pelvic area, which was witnessed by the assigned certified nursing assistant (CNA) 1. A review of the COC findings indicated at approximately 9 PM on 1/12/2025, CNA 1 heard a noise inside Room 2's room, immediately went to the room, and witnessed Resident 1 touching the pelvic area of Resident 2. CNA 1 removed Resident 1 and took the resident to the nurse's station. Resident 1 was transferred to another room for increased visual monitoring. A review of Resident 2's Admission Record indicated the facility admitted the resident on 7/22/2015 with diagnoses including hemiparesis (condition that causes weakness or an inability to move on one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain) affecting left non-dominant side and unspecified dementia (a progressive state of decline in mental abilities). The Admission Record indicated the facility's Bioethics Committee (a group of people who ensure that human rights are respected) was Resident 2's responsible party. A review of Resident 2's MDS dated 10/20/2024, indicated the resident had severe cognitive impairment for daily decision making and did not have any behaviors of hallucinations or delusions, physical behavioral symptoms directed towards others or verbal behavioral symptoms towards others. The MDS indicated the resident required supervision or touching assistance with toileting and had impairment on both sides of the upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot). A review of Resident 2's COC Evaluation dated 1/12/2025, indicated Resident 2 was a victim of abuse (sexual) and a skin and psychosocial evaluation were done. The COC indicated Resident 2's skin was intact and showed no signs of emotional distress or psychosocial decline. During an interview with the Director of Nursing (DON) on 1/15/2025 at 10:11 AM, the DON stated Resident 1's behavior of punching the staff member on 1/7/2025 was a new behavior. During a concurrent review of the facility's policy titled, "Behavioral Assessment, Intervention, and Monitoring," the DON stated per policy, the IDT should have thoroughly evaluated Resident 1's new or changing behavioral symptoms. The DON stated there was no documentation indicating the IDT met after Resident 1's physical aggression incident on 1/7/2025. The DON stated it was important to have the IDT meet and develop individualized interventions to address Resident 1's specific behavior. The DON stated there was a potential for physical or verbal altercation since Resident 1's new behavior was not addressed. The DON stated Resident 1 also should have been visited by Social Work for a psychosocial evaluation and emotional support for 72 hours. The DON stated and confirmed based on documentation, Resident 1 was not visited by the Social Work Department after the incident on 1/7/2025. During an interview on 1/15/2025 at 12:57 PM, the Social Service Director (SSD) stated she was not aware of Residents 1's aggressive behavior from 1/7/2025 and did not conduct a psychosocial visit for Resident 1. The SSD stated it was important a psychosocial visit for 72 hours was conducted to check on Resident 1 to see if there was any emotional distress or any other changes in behavior. The SSD stated when a resident displayed a new behavior like aggression, there should be an IDT meeting to discuss the behavior. During an interview on 1/15/2025 at 1:41 PM, the Quality Assurance Nurse (QA), stated it was important the IDT met to identify causes and come up with interventions on how to manage and monitor Resident 1's new behavior. The QA stated it was important to have new interventions to ensure safety of Resident 1, staff, and other residents. The QA stated Resident 2 was a vulnerable resident because she was bedbound and could not speak for herself and could answer mostly yes or no questions. The QA stated if IDT would have met, IDT would have considered doing a room change for Resident 1 with a resident that was alert and oriented, could speak for themselves, and verbalize any concerns. On 1/15/2025 at 2:26 PM during an interview, the DON stated the allegation of Resident 1 touching Resident 2 inappropriately was a concern for sexual abuse. The DON stated Resident 2 was a vulnerable resident because she was bedbound and had dementia. The DON stated using a reasonable person concept she would have been emotionally distressed, uncomfortable, and felt unsafe if she was touched inappropriately. The DON stated it was important that all residents were free from abuse because it was the resident's right. During an interview on 1/15/2025 at 3:02 PM CNA 1 stated between 8:30 to 9 PM on 1/12/2025 she was charting at the front desk near Resident 2's room when she heard Resident 2 screaming and crying. CNA 1 stated she rushed to Resident 2's room and saw Resident 2's privacy curtain closed. CNA 1 stated when she walked to the foot of Resident 2's bed and saw Resident 1 using her left hand to make a motion with one finger over her mouth telling Resident 2 to stop crying and Resident 1's right hand touching Resident 2's vagina. CNA 1 stated Resident 2's diaper was off, and the blankets were open (not covering Resident 2). CNA 1 stated Resident 2's expression was angry because she was crying very loud. CNA 1 stated she immediately removed Resident 1 from the room and informed the charge nurse (Licensed Vocational Nurse, LVN) 1 what she observed. CNA 1 stated she observed the charge nurse (LVN 1) ask Resident 1 if it was true what she (CNA 1) had said CNA 1 heard Resident 1 respond "yes, she (Resident 2) likes to be touched." During a phone interview on 1/15/2025 at 3:22 PM, LVN 1 stated on 1/7/2025 at about 9:10 PM, she asked Resident 1 why she had removed Resident 2's diaper and touched Resident 2's private area. LVN 1 reported Resident 1 responded, "Because she (Resident 2) wanted her (Resident 1) to." During an interview on 1/16/2025 at 9:22 AM, the Administrator (ADM) stated he learned about the allegation of Resident 1 inappropriately touching Resident 2 on 1/12/2025. The ADM stated there was a concern for sexual abuse and based on his investigation Resident 1 was the perpetrator and Resident 2 was the victim. The ADM stated based on the reasonable person concept, he would feel terrible if someone touched him inappropriately because it was demeaning. The ADM stated all residents and staff have a right to be free from abuse because it was part of resident dignity and respect. A review of the facility's policy and procedure titled, "Abuse Prevention Program-Abuse Prohibition," revised May 2024, indicated the facility shall uphold resident's right to be free from sexual, physical, and mental abuse, and involuntary seclusion. A review of the facility's policy and procedure titled, "Behavior Assessment, Intervention, and Monitoring," revised May 2024, indicated the interdisciplinary team would thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition. The policy indicated the interdisciplinary team would evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. The policy indicated under Management - interventions and approaches would be based on a detailed assessment of physical, psychological, and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. It indicated the care plan would include, as a minimum: a description of the behavioral symptoms, including frequency, intensity, duration, outcomes, location, environment and precipitating factors or situation, targeted and individualized interventions for the behavioral and/or psychosocial symptoms, the rationale for the interventions an approaches, specific and measurable goals for targeted behaviors; and how the staff would monitor for effectiveness of the interventions. The policy indicated the SSD / Designee would conduct a psychosocial visit with the resident for 72 hours to ensure their needs were being met and they were adhering to the established care plan. As a result of the investigation, the Department determined that the facility failed to: 1. Prevent Resident 2 from being sexually abused by Resident 1 on 1/12/25 in accordance with the facility's policy and procedure titled "Abuse Prevention Program-Abuse Prohibition," revised May 2024, which indicated the facility shall uphold resident's right to be free from sexual and physical abuse. 2. Conduct a psychosocial visit for 72 hours after Resident 1 displayed new aggressive behavior when Resident 1 punched a staff member on 1/7/25 per facility policy. 3. Implement the facility's policy and procedure titled, "Behavior Assessment, Intervention, and Monitoring," revised May 2024, to ensure the IDT would thoroughly evaluate Resident 1's new or changing behavioral symptoms, which occurred on 1/7/2025, in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition. As a result, on 1/12/2025 at about 9 PM, Resident 1 sexually abused Resident 2 (the roommate) when Resident 2's incontinent brief was removed by Resident 1. Resident 1 used her left hand signaling to Resident 2 to stop crying and Resident 1 placed her right hand on Resident 2's vagina. Resident 2, a 91-year-old female, cried loudly and was angry with distress. Resident 2 was subjected to physical and sexual abuse by Resident 1 while under the care of the facility. 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 2.