Health inspection·December 24, 2025

|||| AMENDED SURVEY EXIT DATE |||| The following reflects the findings of the California Department of Public Health (CDPH) during the investigation of complaint number 2664875. A Class B Citation was written. §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; §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)(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 11/10/2025, the CDPH made an unannounced visit to the facility to investigate a complaint allegation regarding sexual abuse (non-consensual sexual contact of any type or sexual harassment). The facility failed to: 1. Supervise and monitor the whereabouts of Resident 2. Resident 2 had a history of inappropriate sexual behaviors, pulling off his pants, self-pleasuring throughout the day, and rubbing his genitals in the presence of residents in the facility according to Resident 2's care plan (CP) dated10/29/2025, on "(Resident 2) has altered behavior manifested by (m/b) invading roommate's space and episode of sexual inappropriate behavior (rubbing his crotch). 2. Protect Resident 1 from sexual abuse (non-consensual sexual contact of any type or sexual harassment) by Resident 2 (Resident 1's roommate). On 10/29/2025 at 8:33AM, a Certified Nursing Assistant (CNA-unknown) informed Social Service Assistant (SSA) that Resident 2 had inappropriately attempted to touched Resident 1's leg according to Resident 2's care plan (CP) on "(Resident 2) has altered behavior manifested by (m/b) invading roommate's space and episode of sexual inappropriate behavior (rubbing his crotch). 3. Develop/create a care plan upon admission that addressed Resident 2's inappropriate sexual behavior according to the facility policy and procedures (P&P) titled, "Care Plans, Comprehensive Person-Centered" dated 1/16/2025. 4. Conduct an Interdisciplinary Team (IDT- a collaborative group of diverse health care professionals from different fields who work together) to develop a plan of care and interventions when on 10/2/2025 Resident 2 was noted with inappropriate sexual behavior according to the facility policy and procedures (P&P) titled, "Care Planning - Interdisciplinary Team" dated 1/16/2025. 5. Report within 2 hours an allegation of resident-to-resident sexual abuse to CDPH by Resident 2 on Resident 1. On 10/29/2025 at approximately 7AM-8AM Resident 2 had one hand down his pants and was touching himself in the groin area (private parts) and with the other hand was trying to touch Resident 1's leg. These deficient practices resulted in Resident 1 being subjected to sexual abuse by Resident 2 while under the care of the facility. Delayed onsite inspection by the CDPH and had the potential for Resident 1 to experience ongoing abuse from Resident 2. Had a potential for Resident 2 to suffer emotional or psychological distress, and/or emotional discomfort, fear to Resident 1 and other residents in the facility. A review of Resident 1's Admission Record, indicated, the facility admitted Resident 1, a 91 year-old-male, on 6/13/2023 with diagnoses including metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the body), unspecified dementia (a progressive state of decline in mental abilities), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial weakness on one side of the body, affecting the arm, leg and sometimes the face) following cerebral infarction a stroke caused by a blocked blood vessel in the brain) affecting left non-dominant(less used) side and muscle weakness (generalized). A review of Resident 1's History and Physical (H&P) dated 8/22/2025, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 9/1/2025, the MDS indicated Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired (significant problems with thinking and memory). The MDS indicated Resident 1 had lower extremity (hip, knee, ankle, foot) impairment (loss of anatomical function). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting hygiene (practices and habits that maintain cleanliness and health of the body), showering/bathing, dressing, and personal hygiene. The MDS indicated 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 and rolling left to right. The MDS indicated Resident did not walk. A review of Resident 2's Admission Record, the Admission Record indicated the facility admitted Resident 2, a 66-year-old male, on 9/16/2025 with diagnoses including other encephalopathy (a general disturbance in brain function), psychotic disturbance (a state where a person loses touch with reality and has a hard time distinguishing it from reality) and mood disturbance(a mental health condition where a person's emotions are affected in a severe and prolonged way, going beyond normal ups and downs). A review of Resident 2's General Acute Care Hospital (GACH) 1 Discharge Summary dated 9/16/2025 (prior to admission to the skilled nursing facility [SNF]), provided to Skilled Nursing Facility (SNF) 2 by GACH 1 indicated Resident 2 was placed on a 5150 (a temporary, 72-hour involuntary psychiatric hold) for danger to others on 9/08/2025. The GACH Discharge Summary indicated SNF 1 documented that Resident 2 "has been sexually inappropriate, including episodes of pulling his pants down, attempting to engage in sexual activity with his male roommate, and frequently touching himself or self-pleasuring throughout the day." The GACH Discharge Summary indicated Resident 2 had a history of "poor impulse control" (acting without thinking about the consequences, driven by a desire for immediate gratification), "poor judgement and sexually inappropriate behaviors that placed (Resident 2) at a remained risk of harming others." A review of Resident 2's H&P dated 9/17/2025, indicated Resident 2 did not have capacity to understand and make decisions. The H&P indicated, "Patient (Resident 2) was placed on 5150 hold for danger to others on 09/08/2025. Patient was a previous resident at SNF1... He (Resident 2) has been sexually inappropriate, including episodes of pulling his pants down, attempting to engage in sexual activity with his male roommate, and frequently touching himself or self-pleasuring throughout the day." A review of Resident 2's MDS, dated 9/19/2025, the MDS indicated Resident 2 was able to walk 50 feet. The MDS indicated Resident 2 was independent and able to complete all activities by himself with or without assistive device, and with no assistance from a helper. The MDS indicated Resident 2 had no impairment in both upper and lower extremities. A review of Resident 2's Initial Psychiatric Evaluation dated 9/21/2025, the Psychiatric Evaluation indicated staff had reported Resident 2 had history of sexual inappropriateness. A review of Resident 2's care plan (CP) on "Resident noted with inappropriate behavior of pulling off his pant in the hallway..." initiated on 10/2/2025, CP the goal indicated, "Resident will maintain appropriate behavior through review date." The CP interventions included to, "Provide a safe environment. Teach resident safe practice (masturbation [stimulation of the genitals for sexual pleasure]). Transfer to the hospital for psych (psychiatry) evaluation ..." A review of Resident 2's Change of Condition (COC) Situation Background Assessment Recommendation (SBAR) document dated 10/2/2025 at 8 AM, indicated that on "10/2/2025 at 7:30AM, (Resident 2) was noted with inappropriate behavior of pulling off his pant in the hallway..." The COC SBAR indicated a Please review and triage the attached HS802 physician was notified who gave an order to transfer Resident 2 to GACH 2 for psych evaluation. A review of Resident 2's CP on "(Resident 2) has altered behavior manifested by (m/b) invading roommate's space and episode of sexual inappropriate behavior (rubbing his crotch) in the activity room initiated 10/29/2025, the CP goal indicated, "Resident will demonstrate coping mechanisms." The CP interventions indicated, "Continue to monitor behavior, provide redirection as needed, and ensure environmental safety. Document any recurrent or escalating behaviors. Psychiatry to evaluation for medication adjustment or behavioral intervention." A review of Resident 2's COC SBAR dated 10/29/2025 at 1:23PM, indicated that on "10/29/2025 at 1:23PM, (Resident 2) was noted approaching and invading his roommate's (Resident 1) personal space and episode of displaying behavior that was sexually inappropriate in nature (rubbing his crotch) in the activity room." The COC SBAR indicated Resident 2's attending physician was notified and referral to psychiatry will be made for further evaluation... A review of Resident 2's IDT Review record dated 10/29/2025 at 2:04PM, indicated, "Behavior Concern: Risk of Resident-to-Resident Altercation or Injury Invading another resident's personal space may trigger verbal or physical aggression from peers, potentially leading to injury to self or others. Risk of Emotional or Psychological Distress to Others Sexually inappropriate or intrusive behaviors may cause emotional discomfort, fear, or distress to roommates or other residents. Risk of Escalation of Inappropriate Behavior." A review of Resident 2's Social Service Note dated 10/29/2025 at 8:33AM, The Social Service Note indicated "Social Service Assistant (SSA) was informed that morning by staff (unidentified) that Resident 2 was exhibiting inappropriate sexual behavior toward fellow roommate (unidentified). Resident 2 was observed by staff doing inappropriate behavior to himself in his room daily but this issue that happened morning was wrong." During an interview on 11/10/2025 at 9:47AM, SSA stated that on 10/29/2025 a Certified Nurse Assistant (SSA could not remember CNA's name) informed SSA that she (CNA) saw Resident 2 being inappropriate with Resident 1 while Resident 1 was in his bed that Resident 2 was trying to touch Resident 1's leg. SSA stated the facility staff had witnessed Resident 2 having inappropriate behavior of masturbating (stimulate own genitals for sexual pleasure), and CNA would find Resident 2 being overly sexual with himself, touching himself inappropriately. SSA stated Resident 2's curtains should have been pulled for privacy, to have shown dignity. SSA stated she did not know if the incident between Resident 1 and Resident 2 that occurred on 10/29/2025 was reported to the state department. During an interview on 11/10/2025, at 10:29 AM Licensed Vocational Nurse (LVN) 1 stated a CNA (unable to recall the name) witnessed while in Resident 1 and Resident 2's room, Resident 2's one hand underneath Resident 1's blanket, and Resident 2's other hand was down Resident 2's own pants while masturbating. LVN 1 stated the incident between Resident 2 on Resident 1 happened inside Resident 1 and Resident 2's room and that the incident is considered sexual abuse. LVN 1 stated she notified RN 1 of the incident between Resident 1 and Resident 2 and did not know if anyone else was notified. LVN 1 stated any incidents of sexual abuse were reportable to the state and that she herself did not report to the state California Department of Public Health (CDPH). During an interview on 11/10/2025 at 11:02 AM, RN 1 stated Resident 2 walks around by himself in the facility unescorted and unmonitored. RN1 stated Resident 2 had "a lot of history of sexually inappropriate behavior when Resident 2's admission paperwork was reviewed." RN 1 stated that on 10/29/2025 at around 10AM, Resident 2 was moved to a room with residents who were alert. RN 1 stated that on 10/29/2025 at around 7AM to 8AM, a CNA (unidentified) reported to (unidentified staff), the incident between Resident 1 and Resident 2. RN 1 stated any physical, sexual behavior from one resident towards another resident had to be reported to CDPH. During an interview and record review on 11/10/2025 at 12:26 PM, with Licensed Vocational Nurse (LVN) 2, Resident 2's Care Plan Report initiated on 10/2/2025 and medical record were reviewed. LVN 2 stated, the Care Plan Report indicated Resident 2 was noted with inappropriate behavior of pulling off his pants in the hallway. LVN 2 stated the care plan report interventions included to teach resident safe practice (masturbation). LVN 2 stated the care plan report interventions were "not specific, they do not indicate what the safe practices are needed." LVN 2 stated there was no care plan before 10/2/2025, that addressed Resident 2's inappropriate sexual behavior and that a care plan should have been based on the hospital (GACH) records from 9/16/2025 (prior to admission). LVN 2 stated care plans have interventions to intervene before a behavior happens, to manage a behavior. LVN 2 stated an interdisciplinary team (meeting should have been done to identify concerns in Resident 2, to have been able to come up with a plan for Resident 2. LVN 2 stated an IDT was not done for the incident on 10/2/2025, for Resident 2 removing his pants in the hallway, that made sure the interventions are appropriate, realistic, and interventions had to be resident specific. LVN 2 stated if incidents happen and IDTs are not done, interventions are not created It would be a risk of an incident such as an altercation of some kind, abuse such as sexual assault, or sexual abuse. During an interview on 11/10/2025 at 3:36 PM with the Director of Nursing (DON), the DON stated reporting of abuse is anytime a resident is abused and reported within a 2-hour time frame to CDPH. The DON stated all facility staff were mandated reporters, if something had occurred and staff felt that they could not get something done by the administrative team, they are supposed to have reported to CDPH. The DON confirmed that she (DON) was not aware of the incident that occurred 10/29/2025 between Resident 1 and Resident 2 was anything sexual and that the incident was not reported to CDPH. During a concurrent interview on 11/10/2025 at 4:44 PM with the Administrator (ADM), stated that he (ADM) was the abuse coordinator and if a resident was doing something that affected other residents that he deemed (considered) to be harmful then that would be abuse and would report it immediately. The ADM stated abuse re