Health inspection·April 16, 2025

California Code of Regulations, Title 22, Section 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. Code of Federal Regulations, Title 42 F609 42 CFR §483.12(b) The facility must develop and implement written policies and procedures that: (b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. 42 CFR §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 42 CFR §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. An unannounced visit was conducted by California Department of Public Health (CDPH) on 3/7/2025 to investigate a complaint regarding an allegation of sexual abuse (non-consensual sexual contact (touching of the sexual or other intimate parts of the person of another, directly or through clothing) of any type with a resident) at Facility 1 on 3/5/2025. Resident 2 (currently resides at Facility 2) stated Resident 1 sexually assaulted (any type of sexual contact without consent) Resident 2 when Resident 2 was residing in the Facility 1. Facility 1 failed to report an allegation of alleged sexual abuse for Residents 1 within 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), ombudsman (OMB-advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement when OMB and local law enforcement- Police Department (PD) went to the facility to investigate the allegation of sexual abuse of Resident 2 by Resident 1. As a result, the Facility 1 had the potential unidentified abuse and failure to protect other residents from abuse in the facility. A review of Resident 1’s Admission Record, the Admission Record indicated Resident 1, a 56-year-old-male, was admitted to the facility on 9/21/2024 with diagnoses of schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety (a group of mental health conditions that cause excessive fear and worry), and limitation of activities due to disability. A review of Resident 1’s Minimum Data Set (MDS – resident assessment tool), dated 1/30/2025, the MDS indicated Resident 1 had moderately impaired (decisions poor; cues/supervision required) of cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 1 is independent (resident completes the activity by themself with no assistance from a helper) with eating. The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with oral hygiene and upper body dressing. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and /or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with toileting hygiene, shower/ bathe self, lower body dressing, and putting on/taking off footwear, lying and sitting on the side of the bed, sit to stand position, toilet transfer and tub/shower transfer. A review of Resident 2’s Admission Record, the Admission Record indicated Resident 2, a 60-year-old-female, was admitted to the facility on 12/26/2024 with diagnoses of diabetes mellitus type 1 (DM type 1 , is a life-long autoimmune disease that prevents the pancreas from making insulin), schizoaffective disorders a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder), and anxiety disorders (a group of mental health conditions that cause excessive fear and worry). A review of Resident 2’s MDS, dated 1/7/2025, the MDS indicated Resident 2 had intact (sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment) cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 2 required set up or clean-up assistance with eating. The MDS indicated Resident 2 required supervision or touching assistance with oral hygiene, shower/bathe, upper body dressing, and personal hygiene. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, lower body dressing, and putting on/taking off footwear. A review of Resident 2’s discharge summary dated 2/21/2025, timed at 5:10 PM, indicated Resident 2 was transferred to Facility 2 for change of environment. During an interview on 3/7/2025 at 4:54 PM with Licensed Vocational Nurse (LVN 1), LVN 1 stated PD was at the facility on 3/5/2025 to interview Resident 1. LVN 1stated he should have asked PD the nature of the PD’s visit to Resident 1. LVN 1 stated after few days (unable to recall when), she found out that Resident 1 was being accused of sexual abuse to Resident 2 (a previous resident in the Facility 1). LVN 1 stated facility staff need to report to the Administrator (ADM) for any abuse or allegation of abuse within two (2) hour time frame. During an interview on 3/7/2025 at 4:27 PM with Infection Preventionist Nurse (IPN), IPN stated staff are mandated reporters and the facility need to report any abuse incident or allegation of abuse within two hours to SA, ombudsman and local law enforcement. IPN stated that on 3/5/2025, PD was in the facility and spoke to Resident 1. IPN stated she asked PD regarding the reason for the visit to Resident 1, IPN stated “PD mention sexual encounter.” IPN stated she informed ADM through telephone call. IPN stated “I assumed it was the Director of Nursing (DON) who reported it to the PD, that is why PD came to interview Resident 1. IPN stated there is a form titled SOC 341 (form used by Californian to report suspected dependent adult or elder abuse) that needs to be filled out in case of any abuse and suspected abuse happened to residents. IPN stated that she did not review and should have reviewed if there is a SOC 341 completed for the allegation of sexual abuse by Resident 1 to Resident 2 when PD came to investigate the allegation of sexual abuse on 3/5/2025. During an interview with the ADM on 3/7/2025 at 6 PM, ADM stated OMB was in the Facility 2 on 3/5/2025 and OMB called the police for a female resident (Resident 2) who was previously residing at the Facility 1 after OMB listened to Resident 2’s story and the resident made the sexual abuse allegation by Resident 1 that happened during the time Resident 2 was still at the Facility 1. ADM stated, PD went to the facility on 3/5/2025 to investigate the allegation of sexual abuse and the police also went to Facility 2 (where Resident 2 is currently residing) and did the investigation over at Facility 2 with the OMB. ADM stated she did not start any investigation and reported to SA when Facility 2 was made aware regarding Resident 2’s allegation for sexual abuse by Resident 1 on 3/5/2025. ADM also stated she will start the investigation right away and report it to the agencies only if there is a real abuse case. A review of the facility’s Policy and Procedure (P&P) titled, “Abuse Investigation and Reporting,” revised July 2017, the P&P indicated all reports of resident abuse, neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress), exploitation (treating someone unfairly in order to benefit from their work) and misappropriation (unauthorized use of another’s name. likeness, identity, property without permission resulting to harm to that person) of resident property, mistreatment and/or injuries of unknown source ("abuse") shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Facility 1 failed to report an allegation of alleged sexual abuse for Residents 1 within 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), ombudsman (OMB-advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement when OMB and local law enforcement- Police Department (PD) went to the facility to investigate the allegation of sexual abuse of Resident 2 by Resident 1. As a result, the Facility 1 had the potential unidentified abuse and failure to protect other residents from abuse in the facility. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.