**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe environment free from potentially serious accident hazards for all residents when its policies and procedures were not implemented for the following practices:1. The facility failed to ensure hot water in 6 of 8 residents' bathroom sinks were at a comfortable and safe temperature level.This deficient practice placed the residents (Residents 165, 187, and 259) at increased risk for scalding.An Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was declared at the [NAME] campus on 6/23/25 at 5:27 PM in the presence of the Administrator, Director of Nursing (DON), Regional Quality Management Consultants (RQMC), Assistant Chief Clinical Officer (ACCO), and [NAME] President of Operations (VPO) for the following deficient practice:Hot water temperatures were found to be between 121.6 F to 136.7 F in 6 of 8 sample rooms as evidenced by:a. room [ROOM NUMBER] = 132.2 Fb. room [ROOM NUMBER] = 136.0 Fc. room [ROOM NUMBER] = 136.7 Fd. room [ROOM NUMBER] = 121.6 Fe. room [ROOM NUMBER] = 131.9 Ff. room [ROOM NUMBER] = 130.5 F.On 6/24/25 at 10:38 AM, the facility submitted an unacceptable IJ Removal Plan (action to correct the deficient practices).On 6/24/25 at 2:36 PM, the facility submitted an unacceptable IJ Removal Plan #2.On 6/24/25 at 4:23 PM, the facility submitted an acceptable IJ Removal Plan #3.On 6/25/25 at 2:43 PM, the IJ was removed after the survey team validated onsite the IJ Removal Plan was implemented through observation, interview, and record review.2a. The facility failed to ensure safe smoking practices were followed when Resident 208 ignited her lighter inside the room while roommate (Resident 195) was actively receiving continuous supplemental oxygen.2b. The facility failed to implement their smoking policy and procedures (P&P) when it allowed five (5) of 14 residents (Resident 208, Resident 2, Resident 138, Resident 139, and Resident 81) who smoked in the facility to keep in possession of their own lighters and cigarettes inside the resident care area.These deficient practices posed an increased risk for combustion and/or fire, serious injury and/or death to residents, staff, and visitors.On 6/26/25 at 5:10 PM, an IJ was declared at the [NAME] campus in the presence of the Administrator, DON, RQMC, ACCO, and VPO for the following deficient practices:a. Without being prompted, Resident 208 ignited her lighter in the room while roommate (Resident 195) was actively receiving continuous oxygen at 2L(liters)/minute via nasal cannula. In addition, Resident 208 was in possession of three lighters and one opened pack of cigarettes.b. Resident and Staff interviews indicated, Resident 2, Resident 138, Resident 139, and Resident 81 were in possession of their own lighters and cigarettes.c. The facility failed to implement its smoking policy when it allowed Residents to keep in possession of their own lighters and cigarettes.On 6/27/25 at 11:13 AM, the facility submitted an unacceptable IJ Removal Plan.On 6/27/25 at 2:04 PM, the facility submitted an acceptable IJ Removal Plan #2.On 6/27/25 at 4:10 PM, the IJ was removed after the survey team reviewed and verified onsite the implementation of the IJ Removal Plan through observation, interview, and record review.3. The facility failed to ensure that one out of two sampled residents (Resident 898) receive adequate supervision to prevent elopement. This deficient practice resulted in Resident 898 eloping on 6/17/25 and putting Resident 898 at risk for serious injury or death.4. The facility failed to consistently implement effective interventions to prevent Resident 234 from elopement. This deficient practice resulted in Resident 234 eloping on 06/15/2025 and putting Resident 234 at risk for serious injury or death. Findings: 1. During an initial tour observation on 6/23/25 at 11:43 AM, in Residents' 195 and 208's room, while hand was held under running water in the bathroom sink faucet with hot and cold handles, the hot water was hot to touch. The bathroom was shared with Residents 1 and 214. During an initial tour observation on 6/23/25 at 11:57 AM, in Residents' 165 and 187's room, while hand was held under running water in the bathroom sink faucet with hot and cold handles, the hot water was hot to touch. During an initial tour observation on 6/23/25 at 1:05 PM, in Residents' 271 and 188's room, while hand was held under running water in the bathroom sink faucet with hot and cold handles, the hot water was hot to touch. The bathroom was shared with Resident 151. Resident 165 was admitted on [DATE] with diagnoses that included schizoaffective disorder (a mental health condition characterized by a combination of symptoms like hallucinations and delusions and mood disorder symptoms like depression or mania), cataract (a medical condition in which the lens of the eye becomes progressively opaque resulting in blurred vision), and glaucoma (a condition on increased pressure within the eyeball, causing gradual loss of sight). Resident 165's Minimum Data Set (MDS - an assessment tool), dated 5/14/25 indicated, vision and cognition were severely impaired. Resident 165's care plan for activities of daily living (ADL) indicated, .Date Initiated: 3/30/22 .Toilet Use: The resident is able to: ambulate to the bathroom (BR) on her own familiar to the location of the BR in her room and back . Resident 187 was admitted on [DATE] with diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), peripheral vascular disease (PVD - a slow and progressive circulation disorder affecting blood vessels in the arms and legs), and cognitive communication deficit (difficulties in communication arising from impairments in cognitive processes, rather than primary language or speech problems). Resident 187's MDS dated [DATE] indicated, cognition was moderately impaired, and resident can walk independently. Resident 187's ADL care plan indicated, .Toilet Use: The resident is able to transfer self to the BR .Revised on: 8/29/24 . Resident 259 was admitted on [DATE] with diagnoses that included cognitive communication deficit, Alzheimer's disease (a progressive brain disorder that gradually destroys memory and thinking skills, ultimately impacting the ability to carry out even simple tasks), and type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Resident 259's MDS dated [DATE] indicated, impaired vision, moderate cognitive impairment, can walk independently, and independent with ADLs. During an observation on 6/23/25 at 3:40 PM, with the MS, the hot water in the residents' bathroom sink faucet was turned on and ran for 10-15 seconds, then MS tested the hot water using the facility's thermometer. The hot water temperature for each of the following residents' rooms were room [ROOM NUMBER] = 132.2 °F, room [ROOM NUMBER] = 136.0 °F, room [ROOM NUMBER] = 136.7 °F, room [ROOM NUMBER] = 121.6 °F, room [ROOM NUMBER] = 131.9 °F, and room [ROOM NUMBER] = 130.5 °F. During an interview on 6/23/25 at 4:00 PM, the MS said that random bathroom water temperature check was done each day. MS stated, Anything over 120 °F is too hot. Review of facility's undated policy titled Water Temperatures indicated, .The Facility ensures water is maintained at temperatures suitable to meet residents' needs. Tap water in the Facility is maintained within a temperature range to prevent scalding of residents. Procedure: I. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas are set to temperatures of no more than 120 °F (49 °C) . 2a. The list of smokers provided by the facility dated 6/23/25 indicated, there were 14 residents who smoke in the facility (Resident 208, 2, 138, 139, 81, 116, 57, 140, 5, 241, 263, 285, 58, and 182). During an observation on 6/26/25 at 10:27 AM, a “No Smoking Oxygen In Use sign was posted by the door of Resident 208 and Resident 195’s room. Resident 208’s roommate (Resident 195) was observed lying in bed receiving oxygen at two (2) liters per minute via a nasal cannula (NC, thin flexible tube with small prongs inserted into the nostrils). During an interview on 6/26/25 at 10:28 AM, Resident 208 stated the facility allowed her to smoke in the designated smoking area with staff supervision during smoking hours. When asked where she keeps her smoking materials, Resident 208 stated, “15 cigarettes are in the locked box in the utility room. [Staff Name] from Activities keeps them. But I keep [five] 5 cigarettes with me.” Resident 208 added, “I have a collector’s item lighter that I keep.” During concurrent observation and interview on 6/26/25 at 10:32 AM, in Resident 208’s room, without being prompted, Resident 208 opened the left bedside drawer and took out two (2) objects. Resident 208 showed a brown, pen shaped object with a skull design on one end and a silver, square shaped object with engraved letters on one side. Resident 208 identified the two objects as lighters and stated that she keeps these “two collector’s item lighters” in her possession. After showing the two lighters, Resident 208 suddenly removed the skull shaped part and without being prompted, ignited the lighter which sparked and produced a small yellow/orange flame. Furthermore, Resident 208’s roommate (Resident 195) was on the other bed actively receiving oxygen at 2 liters per minute via a nasal cannula. Review of Resident 195’s “Order Review History Report” for 6/1/25 to 6/30/25, indicated an order to administer “Oxygen 2L/min (liters per minute) via NC continuous to keep O2 Sat (oxygen saturation, amount of oxygen that’s circulating the blood) at/above 92 % (percent, a unit of proportion) for low oxygen every shift related to chronic respiratory failure (occurs when the lungs can't adequately oxygenate the blood or remove carbon dioxide, leading to long-term breathing difficulties) with hypoxia (low levels of oxygen in your body tissues). During a follow up interview on 6/26/25 at 10:42 AM, Resident 208 stated that she was informed of the “rules for smoking” six months ago. During an observation on 6/26/25 at 10:46 AM, in resident’s room, Resident 208 showed the brown and silver colored (collector’s item) lighters and without being prompted, Resident 208 ignited again the pen shaped lighter which immediately sparked. Further observation and interview on 6/26/25 at 10:48 AM, in Resident 208’s room, Resident 208 stated that she keeps some cigarettes and a disposable lighter in her possession because staff are not available at times to provide their smoking materials. During concurrent observation, Resident 208 took something out from the side of her wheelchair next to her bed and showed an opened cigarette pack. Resident 208 then opened the cigarette pack and showed the contents which included a few cigarettes sticks and a pink disposable lighter that had the last four letters of Resident 208’s name. Review of Resident 208’s admission record indicated, was admitted on [DATE] with diagnoses including nicotine dependence (an addiction to tobacco products caused by the drug nicotine), mild cognitive impairment (a condition in which people have more memory or thinking problems than other people their age), fracture of unspecified part of neck of right femur (refers to a broken bone in the neck of the right thigh bone, where the exact location of the fracture within the neck is not specified), presence of left artificial hip joint (indicates a hip replacement surgery where the damaged or diseased parts of the left hip joint have been replaced with artificial components, typically made of metal, ceramic, and/or plastic), and muscle weakness. Review of Resident 208's Minimum Data Set (MDS, a federally mandated resident assessment tool) assessment, dated 5/26/25, indicated no cognitive impairment. Under the Active Diagnoses section of the MDS assessment indicated, Resident 208’s active diagnoses included nicotine dependence, psychotic disorder (a group of serious mental illnesses characterized by psychosis, a condition where a person has difficulty distinguishing between what is real and what is not), and mild cognitive impairment. Review of Resident 208’s “Smoking and Safety” assessment dated [DATE], indicated, “Resident is not consistent with following smoking times. Spoke with resident again and reiterated rules and regulations of smoking protocol.” Resident 208’s “Smoking and Safety” assessment did not indicate Resident 208 was safe to have smoking materials in her possession. Furthermore, the assessment did not address the “Smoking Care Planning” section. Review of Resident 208’s smoking care plan revised on 12/2/24 indicated, individualized plan for safe use and storage of smoking materials was not addressed. Further review of Resident 208’s clinical record indicated, Resident 208 acknowledged and signed a copy of the facility’s “Smoking Policy” on 3/5/25. Review of the facility’s policy and procedures titled “Oxygen Therapy”, revised 11/2017, indicated, “Oxygen is administered under safe and sanitary conditions to meet resident needs … II. A. No smoking signs will be prominently displayed wherever oxygen is being stored or administered. B. Smoking is not allowed near where the oxygen is being stored or administered …” 2b. During an observation on 6/26/25 at 11:40 AM, in Resident 548 and Resident 2’s room, CNA 4 was attending to Resident 548 who was sitting on the bed receiving oxygen at 2 L/min via a nasal cannula. Resident 548’s roommate (Resident 2) was not in bed. During further observation, Resident 2 had an oxygen concentrator attached to an oxygen tubing next to her bed. During an interview on 6/26/25 at 11:41 AM, CNA 4 stated Resident 2 was out for an appointment and confirmed that Resident 2 uses the oxygen concentrator next to her bed whenever she’s in bed/room. CNA 4 also confirmed Resident 2 was an active smoker in the facility. CNA 4 stated that Resident 2 usually goes out to smoke with supervision and always keeps her smoking materials in her pocket. Review of Resident 548’s Order Review History Report for 6/1/25 to 6/30/25, indicated an order to administer Oxygen at 2L/min via nasal cannula to keep O2 Sat at/above 92% continuous for COPD (Chronic Obstructive Pulmonary Disease, a group of lung diseases that block airflow and make it difficult to breathe) / CHF (Congestive Heart Failure, a chronic condition in which the heart doesn't pump blood as well as it should). Review of Resident 2’s admission record indicated, was admitted on [DATE] with diagnoses including asthma (a chronic respiratory disease that affects the airways in the lungs, causing them to become inflamed and narrowed, making it difficult to breath), heart failure, and seizure disorder (abnormal electrical activity in your brain). Review of Resident 2’s Order Review History Report for 6/1/25 to 6/30/25, indicated an order to administer Oxygen at 2L/min via nasal cannula for mild SOB (shortness of breath) as needed. During concurrent observation and interview on 6/26/25 at 11:43 AM, Resident 81 was lying in bed, alert and oriented. Resident 81 stated he smokes in front of the building and keeps his cigarettes and lighter with him in the room. Resident 81 further stated, “I don’t give it to the nurse. I want it with me. It’s easier.” During an observation on 6/26/25 at 11:44 AM, Resident 138 was sitting in his wheelchair outside his room watching on a computer tablet. Resident 138 agreed for interview and went inside his room. During concurrent observation and interview at 11:45 AM, in the resident’s room, Resident 138’s bedside (top) drawer was unlocked and slightly opened. Resident 138 stated he keeps the lighter and cigarettes in his possession and was saying, “here, there”, while pointing to his pocket and to the unlocked bedside (top) drawer. Resident 138 refused to open and check the bedside drawer. During an interview on 6/26/25 at 11:47 AM, Certified Nursing Assistant (CNA) 3 stated, Resident 138 had a lighter and cigarettes kept in his pocket and bedside drawer. CNA 3 also stated that residents’ smoking materials were stored in the Activities Department. CNA 3 further stated that residents should not keep smoking materials in the room for safety reasons. During an interview on 6/26/25 at 11:48 AM, CNA 5 stated, residents should not keep cigarettes or lighters in their rooms and that she would report to the nurse immediately when she finds them in a resident’s room. During an interview on 6/26/25 at 11:54 AM, Resident 139 stated she smokes and vapes occasionally, and that she keeps her cigarettes and lighter in her fanny pack at all times. Resident 139 also stated, she is aware of the facility’s smoking policy which includes safe storage of smoking materials. Review of the facility’s undated “Smoking Policy” acknowledgement form indicated, “… 8. All residents that smoke will have their smoking materials (lighter, cigarettes, e-cigs [electronic cigarettes], etc.) kept in a safe place at Nursing Stations . 10. No resident is allowed to keep any smoking materials in their room . 14. Residents whether it is traditional tobacco cigarettes, pipes, cigars, or electronic (e-cigarettes) cigarettes are governed by this policy.” 3. During an interview on 07/02/2025 at 1:13 PM, with the Administrator, stated Resident 898 was found approximately 3 to 4 hours after Resident 898 was found missing from the facility on 06/17/2025 at 5:15 PM. Code Purple alarm was activated at the facility when Resident 898 was discovered to be missing, which involved an announcement of Code Purple through the overhead paging system (a system that allows a person to speak into a microphone and have their voice broadcast through speakers located throughout the facility). The facility defines Code Purple to mean a resident left the facility without the expectation for leaving the facility or supervision.During an interview on 07/02/2025 at 1:31 PM with the Director of Staff Development (DSD), Resident 898 had exit seeking behavior in the past.During an interview on 07/02/2025 at 2:18 PM with the Director of Nursing (DON), Resident 898 had a wander guard (a special bracelet worn by residents at risk for wandering and elopement, that alerts facility staff when resident leaves a safe area defined by the facility) in place prior to the elopement. During concurrent observation and interview on 07/02/2025 at 10:09 AM with Resident 898, Resident 898 was unable to remember the elopement. Resident 898 was also unable to correctly state the day of the week or current city. Resident 898 had difficulty stating names of siblings. Resident 898 was wearing both an identification wrist band on the right wrist and a wander guard wrist band on the left wrist. During a review of Progress Note entitled Communication with Physician and dated 06/17/2025 at 18:26 for Resident 898, the situation described was, Resident eloped from the facility. The background described is, Resident has a history of elopement and wandering. A recommendation that was made was, Send resident to [emergency room] ER if or when he returns to the facility to be evaluated.During an interview on 07/03/25 at 10:54 AM with the DON, Resident 898 was admitted to the facility on [DATE] for dementia and worsening mental status. Resident 898 was evaluated for elopement risk on 06/02/2025 and was determined to be at risk for elopement with a score of 6 out of 10. Resident 898 was evaluated again for elopement risk on 06/17/2025 and was determined to be at risk for elopement with a score of 6 out of 10, with no change in the elopement risk score. The higher the elopement risk score the higher the risk for elopement. The DON stated the facility has cameras in the hallway, but the facility was unable to identify Resident 898 on any of the camera recordings on the day of the elopement 06/17/2025. During a record review of Elopement Evaluations dated 06/02/2025 and 06/17/2025 did not reveal a specific total score for each evaluation. Both documents note, Score value of 1 or higher indicates Risk of Elopement. Elopement Evaluation for 06/02/2025 at 21:26 has 6 marked questions as yes answers from a total of 10 questions. Elopement Evaluation for 06/17/2025 at 17:40 has 3 marked questions yes answers from a total of 10 questions. The questions answered yes for the Elopement Evaluation for 06/02/2025 include the following: Does the Resident have a history of elopement or an attempted elopement while at home; Does the resident have a history of elopement or attempted leaving the facility without informing staff; Has the Resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door; Does the Resident wander?; Is the wandering behavior a pattern, goal-directed (i.e. specific destination in mind, going home etc.; and, Is the Resident's wandering behavior likely to affect the safety or well-being of self/others. The questions answered yes for the Elopement Evaluation for 06/17/2025 include the following: Does the resident have a history of elopement or attempted leaving the facility without informing staff; Does the Resident wander?; and, Is the wandering behavior a pattern, goal-directed (i.e. specific destination in mind, going home etc.). During a record review of the Medication Administration Record (MAR) for June 2025 shows 3 separate orders for, Check placement of wander guard . with different stop and start dates. The order to Check placement of wander guard every shift is it in place, Yes or No? with start date of 06/10/2025 to 06/12/2025 is marked as completed for 2 days in June, 06/10/2025 and 06/11/2025. The order to, Check placement of wander guard on left wrist every shift is it in place, Yes or No? with start date of 06/14/2025 and no stop date is marked as completed for Day, Evening, and Night shifts from 06/15/2025 to 06/30/2025, and marked as completed for Evening and Night shift for 06/14/2025. The order to, Check placement of wander guard every shift for wanderer is it in place, Yes or No? with start date 06/02/2025 and end date of 06/10/2025 is marked completed for Day, Evening, and Night shifts for 06/03/2025 to 06/09/2025 and marked completed for Night shift only for 06/02/2025. During an interview on 07/03/25 at 1:38 PM with ADON 2, Resident 898's reason for admission to the facility was because Resident 898's caregiver was in the hospital. Resident 898 was found wandering around the vicinity of the caregiver's hospital and identified by police. Resident 898 was evaluated by Hospital 1 and later transferred to the facility for care, while Resident 898's caregiver was hospitalized and unable to care for Resident 898. During a record review of Discharge Summary from CPMC Mission [NAME] Campus dated 06/02/2025, Resident 898's principal problem is AMS (altered mental status) with active problems including, wandering behavior due to dementia, schizophrenia. During a record review of Physical History and Physical (H&P) dated 06/02/2025, the main reason Resident 898 had been admitted to Hospital 1 for 8 days, from 05/25/25 to 06/02/25, was because of AMS and family is unable to care for Resident 898.During a record review of Progress Note dated 06/17/2025 at 10:56 PM, Resident 898 was returned to the facility by [NAME] Police Department and there was no mention of injuries or where Resident 898 had been found. Pickup of Resident 898 was requested by Royal Ambulance. Resident 898 was picked up from the facility at 10:50 PM and taken to a Hospital 2 for evaluation. During a record review of Care Plan Report with no date, notes one of Resident 898's care plan focuses is an elopement risk/wanderer r/t [related to] Impaired safety awareness, cognitive impairment, history of elopement initiated on 06/03/2025 by ADON 2.During a record review of facility procedure entitled P-AP17 Wandering and Elopement and with revision date 01/31/2023, defines elopement as a behavior that may lead to the resident leaving the facility unsupervised and/or without permission. The procedure notes that if Facility Staff observes a resident leaving the premises unaccompanied or without having followed proper procedures, he/she may: a. Try to prevent the departure in a courteous manner. b. Get help from other Facility Staff in the immediate vicinity, if necessary. c. If the resident exits the facility despite efforts to stop the resident, a staff member will accompany or follow the resident to ensure the resident's safety until assistance arrives. 4. Review of Resident 234's records, titled RESIDENT INFORMATION, printed on 07/01/2025, indicated she had multiple diagnoses including: alcohol abuse (an impaired ability to stop/control alcohol use despite adverse consequences), .alcohol -induced persisting amnestic disorder (severe memory loss associated with chronic alcohol abuse), abnormal walking pattern, anxiety disorder (a mental disorder associated with excessive worry, fear, or nervousness that interferes with daily life), delusional disorder (a mental disorder when one cannot tell what is real from what is imaginary), and history of falls. During an interview on 07/01/2025 at 11:40 AM, CNA 1 stated she has cared for Resident 234 for 2-3 years. CNA 1 stated Resident 234 was very .forgetful, she is always trying to find her husband, constantly asking staff how to get a hold of her husband. She doesn't remember her husband passed away two years ago. CNA 1 stated Resident 234 has a history of trying to get out (elope). To keep her from elopement, CNA 1 stated she tries to distract (Resident 234) to activity (and Resident 234) wears a wanderguard. Wanderguard: a bracelet type device that activates an audible alarm when a resident is approaching an exit. Review of Resident 234's record titled Elopement, dated 07/10/2024, indicated Resident 234 eloped from the facility At .(1:15 PM, nurses were) alerted by staff that .(Resident 234) was seen exiting the facility .staff did a search of the facility and unable to locate her.[NAME] .(police department was) . contacted and a missing persons report filed. The document indicated Resident 234 was found 2 hours and 35 minutes later approximately 1 mile away from the facility. During a concurrent interview and record review on 06/26/2025 at 10:18 AM with LVN 1, review of the facility's daily log communication between shifts on the facility's computer (not titled), indicated Resident 234 Eloped on 06/15 at around 7:30 pm, went out on the street. LVN 1 was asked to search Resident 234's record for any documentation regarding this elopement. LVN 1 was unable to find any documentation in Resident 234's medical records regarding this elopement. During an interview on 07/02/2025 at 10:09 AM, CNA 2 stated Resident 234 was a high elopement risk because she .wanders around the facility she very active . We really need to keep an eye on her. she always says I need to go home. Things like that. We always keep an eye on her. CNA 2 stated on 06/15/2025, she does not . remember the exact time around break time so I was at the break room eating .(when)one of my co-workers called me that she saw .(Resident 234) outside so I ran out of the break room .ran out of the building .and we saw.(Resident 234) across . the road . On 07/01/2025 at 3:20 PM, the Registered Nurse Supervisor (RNS1) and the Director of Nursing (DON) were interviewed regarding Resident 234's elopement on 06/15/2025. The RNS 1 and the DON searched Resident 234's records and confirmed there was no documentation regarding the elopement. The DON stated her expectations were staff would initiate a change of condition charting, notify the responsible party, physician, ombudsman and CDPH (California Department of Public Health). The DON stated she expected staff to conduct an investigation to identify potential weakness in the facility's so the facility could put interventions in place to prevent Resident 234 from elopement. Review of the facility's policy titled Wandering and Elopement, Revised on 01/31/2023, indicate .Elopement - A behavior that may lead to the resident leaving the facility unsupervised and/or without permission. When the resident who eloped returns to the Facility, the Licensed Nurse should: i. Assess the resident for possible injuries, changes of condition and vital signs. ii. Notify the Attending Physician of the return of the resident and the result of the exam; and iii. Notify the resident's responsible party of the return of the resident and the result of the exam. iv. Upon return the Licensed Nurse will implement immediate interventions to prevent further elopement of the resident and update the plan of care. b. The Interdisciplinary Team as part of the investigation will conduct a post elopement meeting to determine if alternate prevention measures can be put in place (activities, rehab, etc.) and if necessary, determine if the resident can safely remain in the facility. c. If the resident cannot be safely kept in the facility the Interdisciplinary team will discuss with the physician and responsible party/surrogate decision maker, the transfer of the resident to a safe environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect three of 3 sampled residents (Resident 2 and Resident 3, and Resident 8) from sexual abuse (non-consensual sexual contact of any type with a resident) by Resident 1 when: 1. Facility did not identify, report, and initiate an investigation of Resident 1 touching Resident 3's breast in the dining room in July 2023. Additionally, the facility did not develop and implement interventions to address Resident 1's behavior of touching female resident's sensitive area. This resulted in delayed identification and implementation of interventions to address Resident 1's sexually inappropriate behavior towards a female resident. 2. Facility did not report, investigate, develop, and implement interventions when Certified Nursing Assistant (CNA) 2 witnessed Resident 1 attempted to touch the private part of Resident 2 in August 2023. These failures resulted in continued access to Resident 2 and further sexual contact instigated by Resident 1 on 8/31/23. 3. Facility did not conduct a thorough investigation and implement interventions on an incident on 8/31/23 at 2:10 PM where CNA 2 observed Resident 2 standing in front of Resident 1, holding (in a sexual way) his penis while seated on a wheelchair in his room, with disposable brief and pants down. Resident 2 has communication deficit, cognitive (thought process) impairment, and lacked capacity to consent to sexual activity. These failures resulted in Resident 2 being subjected to a nonconsensual (not agreed to by one or more of the people involved) sexual contact instigated by Resident 1 and the potential to affect other vulnerable residents in the facility to experience sexual abuse. 4. Facility failed to protect Resident 8 from sexual abuse when one-to-one supervision was not provided to Resident 1, who briefly touched the right breast of Resident 8 on 10/12/23, at 4:55 PM. There was no documented evidence the facility implemented every 15 minutes monitoring for Resident 1. Additionally, the facility did not thoroughly assess and revise the care plan for Resident 1 to identify the potential risk to other female residents in the facility. These failures resulted to Resident 8 crying, feeling shocked, and upset; and placed other vulnerable residents in the facility at risk for sexual abuse by Resident 1. On 10/17/23 at 4:44 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) situation was identified in the presence of the Administrator, Administrator in Training (AIT), Director of Nursing (DON), Assistant Director of Nursing (ADON) 2, and Senior [NAME] President of Operations (SVPO) for facility's failure to protect Resident 8 and other female residents in the facility from Resident 1's sexually inappropriate behavior. Five (5) IJ Removal Plan were not accepted. On 10/20/23 at 11:20 AM, the IJ was removed in the presence of the Administrator after the surveyors verified onsite through observation, interview, and record review the implementation of the facility's submitted and accepted IJ Removal Plan #6 (action to correct the deficient practices). The IJ Removal Plan #6 included the following information: 1. Resident 1 was sent to the acute hospital for an evaluation due to increase sexual behavior on 10/17/23 and returned to facility with new medication order. 2. Resident 8 was visited by Social Services Assistant (SSA) and Licensed Vocational Nurse (LVN) from the day of the incident and subsequent visits resulted in no reports or evidence of emotional distress or change in daily routines. 3. The Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together toward the goals of the residents) met on 10/17/23 and updated Resident 8's care plan. 4. The IDT reviewed Resident 1's chart on 10/17/23 to determine root cause of behaviors, possible triggers and interventions that can be used to ensure safety of all residents in the facility. Resident 1's care plan was updated on 10/17/23 to reflect these findings. 5. SSAs and Administrator in Training (AIT) conducted interviews on 10/17/23 for all alert females to see if they feel safe and if they had been touched inappropriately. All residents stated they felt safe and no inappropriate touching had taken place. 6. Director of Nursing (DON)/Designee reviewed all change of condition and behavior monitoring on 10/18/23 for all nonverbal residents from July of 2023 to present to see if there were any indications of abuse. There was no nonverbal resident identified from those with change of condition and behavior monitoring. 7. The AIT in-serviced the Health Care Partners (HCP, non-licensed staff providing one-to-one [1:1] supervision to residents) on 10/13/23 regarding procedure for one-to-one monitoring. All HCPs will pass competency evaluation by 10/19/23. After 10/19/23, they will be allowed back on the floor until the competency evaluation is completed by the AIT/Designee. 8. One-to-one sitter was in place from 7:00 AM to 10:00 PM. Every (Q) 15-minute checks from 10:00 PM to 7:00 AM by CNA/Designee while resident is in his room and 1:1 if he wants to come out of his room. 9. Night shift CNAs, LVNs and RNs (Registered Nurse) were in-serviced on monitoring and Q 15-minute checks of Resident 1 by the Administrator on 10/18/23. 10. The Administrator checked the Q 15-minute log on 10/18/23 from the time Resident 1 returned from the acute hospital on [DATE]. The log was complete, and no gaps or issues were noted. The Administrator/Designee will check the log daily. Cross referenced to F607, F609, and F610. Findings: Review of Resident 1's admission record indicated, was admitted to facility on 8/30/22 with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), dementia (a group of symptoms affecting memory, thinking and social abilities), history of alcohol abuse, mild cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions), and cognitive communication deficit (difficulty thinking and communicating). Further review, indicated, Resident 1 was his own responsible party (decision maker). Review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 9/1/23, indicated, Resident 1's cognition (thought process) was moderately impaired. The MDS indicated, Resident 1 did not exhibit any mood symptoms and physical behavioral symptoms directed towards others such as scratching, grabbing, and abusing others sexually. Further review of the MDS indicated, Resident 1 required supervision with set up help to one-person physical assist for bed mobility, transfer, walking, locomotion (ability to move from one place to another), eating, and toilet use. The MDS also indicated Resident 1 required extensive assistance with one-person physical assist for dressing and personal hygiene. Review of Resident 3's admission record indicated, was admitted to facility on 12/21/22 with diagnoses including hemiplegia (complete paralysis of side of the body), hemiparesis (partial weakness or paralysis of on one side of the body), dementia, and cognitive communication deficit. Review of Resident 3's MDS dated [DATE], indicated, Resident 3's cognition was severely impairment. The MDS indicated, Resident 3 did not exhibit any mood and behavioral symptoms. Further review of the MDS indicated, Resident 3 required extensive assistance with one-person physical assist for bed mobility and total dependence with one-person physical assist for transfer, walking, locomotion, eating, toilet use, and personal hygiene. Review of Resident 2's admission record indicated, was admitted to facility on 5/11/23 with diagnoses including encephalopathy (damage or disease that affects the brain), cognitive communication deficit, and catatonic disorder (a behavioral syndrome marked by an inability to moved normally). Review of Resident 2's MDS dated [DATE], indicated, Resident 2 has memory problem and moderately impaired decision-making skills under the staff assessment for mental status. The MDS indicated, Resident 2 had episodes of feeling or appearing down, depressed, or hopeless for 2 to 6 days under the staff assessment of resident mood. The MDS did not indicate any behavioral symptoms for Resident 2. Further review of the MDS indicated, Resident 2 required supervision with one-physical assist for transfer, walk in room, locomotion, and eating; limited assistance with one-physical assist for bed mobility and walk in corridor; extensive assistance with one-physical assist for dressing, toilet use, and personal hygiene. 1. Review of facility's untitled letter document dated 9/7/23, indicated, .On 8/31/2023, our resident [Resident 1] was observed in his room with a female resident (referring to Resident 2) who was touching his penis. The nurse separated the two residents. During the course of the investigation, it was found that [Resident 1] was involved in previous incident in July, in which he was seen touching a different resident on the breast . Review of CDPH's document titled, Complaint/Incident Intake Report, known as HS 802 indicated, the incident of Resident 1 touching Resident 3's breast was received on 9/1/23 at 5:20 PM by fax. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, date completed on 8/31/23, indicated, date and time of the incident Resident 1 touching Resident 3's breast was sometime in July. This alleged incident was reported to the police by phone and to CDPH (California Department of Public Health) and Ombudsman by fax on 8/31/23, no time indicated. Review of Resident 3's Change in Condition dated 9/1/23, indicated, Resident was reported to have been touched in the breast area by another resident. Assessment done without issues noted. SOC 341 completed. Ombudsman and [NAME] Police Department notified. Resident unable to verbalize any information. Daughter and MD notified. During an observation on 9/14/23 at 3:07 PM, Resident 1 was wearing a pair of green socks with a hole exposing his right big toe and was pushing his wheelchair while walking by himself towards his room. During an interview on 9/14/23 at 3:11 PM, Resident 1 stated he doesn't remember an incident of touching female residents in the facility. Resident 1 then started asking for the phone to call his sister. Resident 1 was asked once again if he remembers any encounter with female residents in the facility. Resident 1 then stated, Are you criticizing me for liking women? Resident 1 then started wheeling himself towards the front desk. During concurrent observation and interview on 9/14/23 at 3:16 PM, Resident 3 was not in her room. CNA 1 stated, Resident 3 was up on her wheelchair in the dining room. CNA 1 stated she was not present when Resident 1 allegedly touched the breast of Resident 3 in July 2023 but have heard about it. CNA 1 explained, Resident 3 used gestures when communicating her needs and was total dependent with ADLs (activities of daily living). During an observation on 9/14/23 at 3:19 PM on the second-floor dining room, Resident 3 was sitting on a reclining wheelchair and was verbally responsive in Cantonese. During an interview on 9/14/23 at 3:22 PM, Licensed Vocational Nurse (LVN) 1 stated, a CNA said that one resident tried to touch the breast of Resident 3 and that there was no report or documentation of the incident in resident's chart. During an interview on 9/14/23, at 3:30 PM, CNA 2 stated, this was the first incident she witnessed that involved Resident 1 and Resident 3 in July 2023 on the second-floor dining room. CNA 2 recalled the incident and stated, [Resident 1] was wheeling himself towards the dining area. I saw [Resident 1] rubbing left breast of [Resident 3] in circular motion. CNA 2 also stated, she reported the incident immediately to LVN 1 and took Resident 1 back to his room. During an interview on 9/14/23 at 3:46 PM, LVN 1 confirmed and stated, CNA 2 reported to her regarding Resident 1 touching Resident 3's breast but cannot remember the exact date of the incident. LVN 1 stated, I reported it (referring to touching Resident 3's breast) to Resident Care Coordinator (RCC). I don't know what happened after. No investigation after. LVN 1 explained that the witness should report to RCC and Administrator (ADM) and that she doesn't do anything after reporting an allegation of abuse. LVN 1 added, the RCC will then report to the Administrator and complete the documentation and investigation. During further interview on 9/14/23 at 3:48 PM, LVN 1 stated, Everybody are mandated reporters. LVN 1 also stated, I don't report (to the State Agency/Ombudsman). Only (report) to RCC. Review of Resident 3's clinical record indicated, there was no progress notes in July 2023 regarding the incident of Resident 1 touching Resident 3's breast. Further review indicated, there was no documented evidence a plan of care was initiated to address the incident. Review of Resident 1's clinical record indicated, there was no progress notes in July 2023 regarding the incident of Resident 1 touching Resident 3's breast. Further review indicated, there was no documented evidence a plan of care was initiated to address Resident 1's sexually inappropriate behavior. During concurrent interview and record review on 9/14/23 at 3:53 PM, LVN 1 was unable to find documentation of the incident in Resident 1 and Resident 3's clinical record. LVN 1 stated, I don't see it here. During an interview on 9/14/23 at 4:23 PM, RCC stated, she received two reports that involved Resident 1. RCC stated, the incident of Resident 1 touching Resident 3's breast was not reported to the Administrator/Abuse Coordinator. RCC stated, the way she understood the report was that Resident 1 tap or grab Resident 3's shoulder, therefore concluded that it was not abuse. Thus, no report and no further investigation was conducted. During further interview on 9/14/23 at 4:28 PM, RCC stated, any alleged incidents should be reported directly to the Administrator and/or designee and reporting should be whoever witness the incident. RCC further stated, a change of condition and staff interview should be conducted after a report of alleged abuse was made. During an interview on 9/14/23 at 4:57 PM, Social Worker (SW) 1 stated, she learned about the incident of Resident 1 touching Resident 3's breast during her interview with CNA 2 regarding the incident between Resident 1 and Resident 2 on 8/31/23. During an interview on 9/14/23 at 4:59 PM, Assistant Director of Nursing (ADON) 2 stated, the Abuse Coordinator was not notified of the touching of the breast. ADON stated, Abuse Coordinator should have been notified immediately which did not happen. During further interview on 9/14/23 at 5:03 PM, SW 1 stated that the alleged incident of Resident 1 touching Resident 3' breast was not investigated after learning about the incident. SW 1 stated, At that time the DON and Administrator said it will be taken care of but did not happen (referring to reporting and investigation of the incident). During an interview on 9/14/23 at 5:09 PM, DON stated, There was a miscommunication between LVN 1 and RCC. RCC did not understand what LVN explained. No follow-up interview to clarify the reported incident of Resident 1 touching Resident 3's breast. During a follow-up interview on 9/14/23 at 5:14 PM, RCC stated, I should have followed up more. Get more information. RCC also stated that there was no report or documentation regarding the alleged incident (referring to Resident 1 touching Resident 3's breast), I didn't do anything. No action done. 2. During an interview on 9/14/23 at 3:34 PM, CNA 2 stated, a month later, she witnessed and reported two incidents that involved Resident 1 and Resident 2. CNA 2 stated, on the same month (August 2023), prior to the reported incident on 8/31/23, [Resident 1] attempted to touch [Resident 2] vagina by the social worker's office. CNA 2 added, she reported the incident to the evening nurse and was told to monitor Resident 1 since it was only an attempt. CNA 2 further stated, she did not document the incident and cannot remember the exact date it happened. Review of Resident 1 and Resident 2's progress notes for August 2023 indicated, there was no documentation regarding Resident 1's attempt to touch Resident 2's vagina (female's private part). During an interview on 9/14/23 at 4:52 PM, SW 1 stated, she was not aware of Resident 1 attempted to touch Resident 2's vagina. During an interview on 9/14/23 at 5:19 PM, RCC stated, she did not get a report regarding Resident 1 attempted to touch Resident 2's vagina in August 2023. During a follow up telephone interview on 9/26/23 at 11:58 AM, CNA 2 stated, she reported the incident of Resident 1 attempted to touch Resident 2's vagina to the evening shift nurse (LVN 3) since the incident happened before dinner. CNA 2 added, [LVN 3] told me to monitor [Resident 1] since it was only an attempt. During a telephone interview on 9/27/23 at 10:35 AM, LVN 3 confirmed and stated, CNA 2 reported Resident 1 attempted to touch Resident 2's vagina during the evening shift and the two residents were separated immediately and monitored. LVN 3 also stated, I didn't document (referring to the incident). It was an attempt. I can't remember if I reported it. During an interview on 9/27/23 at 10:38 AM, ADON 1 stated, she was not aware of the attempt of Resident 1 touching Resident 2 that was reported by CNA 2 to LVN 3. ADON 1 added, If there's a report attempting to touch, it needs to be reported immediately. We need to do something right away. Review of Resident 2's care plan indicated, there was no documented evidence a care plan was initiated to address Resident 1's attempt to touch Resident's vagina in August 20223. 3. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 8/31/23, indicated, date and time of the incident of Resident 2 touching Resident 1's penis was 8/31/23 at 2:10 PM. The incident was reported to the police by phone on 8/31/23 at 4:30 PM; the facility reported to CDPH and Ombudsman by fax on 8/31/23, no time indicated. Review of Resident 2's Change in Condition dated 9/1/23, indicated, Resident was found in male resident room his [sic] hand in his penis. Resident separated from resident. Head to Toe assessment completed without issues noted. SOC 341 completed. Ombudsman and BPD ([NAME] Police Department) notified. BPD on scene and interviewed resident. Resident unable to verbalize any information. Family-Daughter and Dr [doctor] notified. Review of Resident 1's Change in Condition dated 9/1/23, indicated, At around 1410 (2:10 PM) on 08/31/2023 .the male resident on [room number] was witnessed by CNA inside [room number] with another female resident [room number], the alleged victim. The alleged abuser was sitting on the wheelchair, pants was down while the alleged victim is touching the alleged abuser's penis. Both residents were separated, and the alleged victim was escorted back to her own room for safety while the alleged abuser stayed inside the room . An SOC-341 (known as Report of Suspected Dependent Adult/Elder Abuse) was completed and filed . CDPH and Ombudsman were also notified of the incident . During an interview on 9/14/23 at 3:40 PM, CNA 2 stated that on 8/31/23, she was walking by Resident 1's room towards the nursing station and noticed the door was open and saw Resident 2 standing in front of Resident 1 who was sitting on his wheelchair. CNA 2 stated, [Resident 1] pull-ups (disposable brief) were down. [Resident 2] was touching his penis. CNA 2 further stated, she called Resident Care Coordinator (RCC) and was told to separate the two residents and bring Resident 2 back to her room. During further interview, CNA 2 stated, she was suspended during the investigation of the incident on 8/31/23 (Resident 1 and Resident 2) because she did not report the July 2023 (breast) incident directly to the Administrator. CNA 2 added that she reported the incident immediately to the charge nurse. CNA 2 then stated, It doesn't make sense to suspend me. Now I'm afraid to report. I might get suspended again. During an interview on 9/14/23 at 4:19 PM, RCC stated, CNA 2 called her to go to Resident 1's room whose sitting on a wheelchair with his pants down while Resident 2 was standing in front holding his penis. RCC stated, the two residents were separated immediately and told CNA 2 to assist Resident 2 to her room. RCC also stated that she brought CNA 2 to the ADON to report the incident. During an interview on 9/14/23 at 4:52 PM, SW 1 stated, she interviewed the staff regarding the incident and assisted the ADON in completing form SOC 341. SW 1 then stated, the DON and Administrator did the reporting and investigation of the incident. Review of Resident 2's care plan for At risk for decline in psychosocial well-being due to sexual contact instigated by male resident, initiated on 9/1/23, indicated, Resident 2 will express/demonstrate feeling safe in facility through the review date. The care plan indicated the following interventions: observe resident for occurrence of or changes in sleep pattern, depression, anxiety, anger, confusion, behavior, and appetite changes. Refer the resident to psych evaluation for a psychosocial wellbeing assessment. Report s/s (signs/symptoms) of psychosocial distress to nurse. Review the daily routine of the facility with the resident and accommodate wishes. Review the resident's coping skills and support the use of the coping mechanism as much as possible. Review of Resident 1's Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together toward the goals of the residents) Note dated 9/7/23, indicated, Staff reported this resident (Resident 1) was with a female resident (Resident 2) in his room, touching his penis on 8/31/23 . Upon investigation of this incident on 8/31/23, we found that this same resident (Resident 1) was involved with another incident of touching the breast area of a female resident (Resident 3) in the dining hall in the month of July . The IDT Note indicated, Administrator, Abuse Coordinator, DON (Director of Nursing), MD (Medical Doctor), RP (responsible party), police, CDPH and Ombudsman were notified of the incident. Further review of the IDT Note indicated, the alleged perpetrator (Resident 1) was placed on 15-minute monitoring for signs and symptoms of adverse effects from the alleged incident, was transferred to another floor and room, referred for psych evaluation, and olanzapine (medication used to treat mental disorders) was increased to 10 mg (milligrams, a unit of measurement). The IDT Note did not indicate the incident of Resident 1 touching Resident 3's breast was further discussed and investigated. Review of Resident 1's Psych Assessment dated 9/1/23, indicated, Resident 1 was referred for psych evaluation due to the following targeted symptoms: sexually pre-occupied, impulsivity, and poverty of thought. The Psych Assessment indicated a diagnostic impression of schizophrenia with interventions including supportive psychotherapy (a type of therapy that primarily focuses on providing emotional support, encouragement, and validation during difficult life circumstances or psychological challenges), discontinue olanzapine 7.5 mg, start with olanzapine 10 mg 1 tablet per orem (po, per mouth) at hours of sleep (hs), and refer accordingly. Review of Resident 1's care plan for The resident was involved in alleged sexual abuse, initiated on 9/3/23, three days after the incident, indicated, the alleged abuser was sitting on the wheelchair, pants were down while the alleged victim is touching the alleged abuser's penis. The care plan indicated Resident 1 will have no evidence of behavior problems or will not display the same behavior until the next review. The care plan indicated the following interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove form situations. Document behavior and potential causes. Observed the behavior and report any abnormal findings. Separate/transfer the room of the abuser to [room number/unit]. SOC-341 was completed and filed. Further review of Resident 1's care plan indicated, there was no documented evidence a care plan was initiated to address Resident 1 touching Resident 3's breast and attempt to touch Resident 2's vagina. During an interview on 9/14/23 at 5:20 PM, ADON 1 stated, a plan of care was put in place after the reported incident on 8/31/23 between Resident 1 and Resident 2 and no other plan of care initiated after the incident in July 2023 between Resident 1 and Resident 3. During a joint interview on 9/14/23 at 5:27 PM, ADM and Regional Quality Management Consultant (RQMC) stated, the two staff (CNA 2 and LVN 1) were suspended for not reporting immediately to the Administrator. During an interview on 9/19/23 at 1:54 PM, Activity Assistant (AA) 2 stated, she observed Resident 1 winking at female residents during group activities and when he's out in the hallway. AA 2 also stated Resident 1 was just friendly and did not think of it as sexually inappropriate. During a concurrent interview and record review on 9/27/23 at 10:44 AM, ADON 1 stated there was no investigation and IDT conducted regarding the two incidents of Resident 1 touching Resident 3's breast and the attempt to touch Resident 2's vagina. During an interview on 9/27/23 at 1:08 PM, ADM stated, any allegations of abuse need to be reported by phone right away and faxed SOC 341 to SSA within two hours of the incident. ADM also stated, a 5-day follow-up or written result of the investigation should be faxed to the State Agency within five days from the incident or up to seven days including weekends, which did not happen. Review of facility's untitled letter document dated 9/7/23, indicated, This letter is to inform you the results of our investigation regarding a resident-to-resident sexual interaction that was reported to you on 8/31/23. Since the date of that report, there has been a change in two key positions which resulted in this letter not being completed within the five day time frame. Thank you for your understanding in this matter . During the course of the investigation, it was found that [Resident 1] was involved in previous incident in July, in which he was seen touching a different resident on the breast . [Resident 1] has been placed on increased monitoring to observe for behaviors and for psychosocial well-being. He was also moved to the first floor of the building near the nurse's station, away from the two female residents. he was evaluated by a psychiatrist who ordered a medication change. There have been no further incidents of inappropriate behavior . During further review, the untitled letter document did not indicate the result of the facility's investigation of the incident. 4. Review of Resident 8's admission record indicated, was admitted to facility on 3/17/21 with diagnoses including heart disease, stroke, functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord), and anxiety disorder (persistent and excessive worry that interferes with daily activities). Review of Resident 8's MDS dated [DATE] indicated, Resident 8 has a BIMS (Brief Interview of Mental Status, a brief screener that aids in detecting cognitive impairment) score of 15, a score of 15 means no cognitive impairment. The MDS also indicated, Resident 8 was non-ambulatory and required extensive assistance with two-person assist for bed mobility, transfer, and locomotion on and off the unit; and one-person assist for dressing, eating, toilet use, and personal hygiene. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 10/12/23, indicated, date and time of the incident was on 10/12/23 at 4:55 PM, Staff heard Resident in room [number] who was in the hallway by her room in her wheelchair crying loudly. Staff asked resident what was wrong she stated a 'male resident down the hall was passing her and touched her on her right breast.' Resident stated that she wasn't in any pain from the incident. Male resident relocated to a different room and hallway. Continue current interventions in place. During an interview on 10/16/23 at 2:38 PM, the ADM stated, on 10/12/23 at 4:55 PM, Resident 8 was heard crying loudly in the hallway saying, He touched my boob (breast). Resident 8 was asked who touched and claimed it was Resident 1. The ADM further stated, CNA 5 was going to give a shower to Resident 1 however, CNA 5 left Resident 1 in his room unaccompanied to check if the shower room was available. The ADM stated, CNA walked away from resident. The ADM added, Resident 1 was transferred to another room in the same Unit as Resident 8 but in a different hallway. Resident 1 continued to have a one-to-one sitter in the morning and evening shift while every 15 minutes monitoring during night shift. During an interview on 10/16/23 at 2:56 PM, ADON 1 stated, she went to check on Resident 8 after she heard her yelling in the hallway he touched me on the breast. ADON 1 then stated, she asked and wheeled Resident 8 to Resident 1's room, which was one room away from her, to show and confirm if it was Resident 1 who touched her on the breast. Resident 8 confirmed it was Resident 1 who touched her on the breast. During further interview, ADON 1 explained that CNA 5 brought the shower chair in Resident 1's room and informed him it was his shower time. ADON 1 added, CNA 5 stepped out of the room to check if the shower room was available. ADON 1 further stated, The sitter (a person who looks after or takes care of someone) left resident unfortunately. She thought the CNA was with him. During an observation on 10/16/23 at 3:04 PM, in Unit 1 hallway, Resident 1's room was located next to the Administrator's office and one room/door away from Resident 8's room, which was located on the same side of the hallway. Resident 8 was inside her room, sitting on a wheelchair next to her bed watching television (TV). Resident 8 was alert, verbally responsive, oriented to time, place, and person. During an interview on 10/12/23 at 3:05 PM, Resident 8 recalled the incident with Resident 1 on 10/12/23 and stated, I was sitting on the chair outside the room and then there's this man [Resident 1's Name was mentioned], wheeling. I thought he's just gonna (going to) wave at me. He squeezed my right breast. I was screaming out loud, crying. I screamed for help, 'maniac'. Resident 8 also stated, the social worker and supervisor came to asked what happened. Resident 8 then asked if Resident 1 can be in jail or moved somewhere. Resident 8 further stated, I was shocked. I was already crying. They (referring to supervisor and social worker) didn't ask me how I feel. During an observation on 10/16/23 at 3:12 PM, the shower room where CNA 5 went to check was located in Unit 2 hallway, across room [ROOM NUMBER], and back end of Unit 1 hallway. During an[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide process oversight and ensure effective implementation of its abuse policies and procedures to protect three of three sampled residents (Resident 2, Resident 3, and Resident 8) when: 1. Facility did not ensure three allegations of sexual abuse (non-consensual sexual contact of any type with a resident) were reported to the State Survey Agency (SSA) within the required timeframe of two (2) hours for Resident 2 and Resident 3. Additionally, Certified Nursing Assistant (CNA) 2 and Licensed Vocational Nurse (LVN) 1 who witnessed and reported the sexual abuse allegations to the nurse-in-charge were placed on suspension. 2. Facility did not conduct a thorough investigation of the three allegations of sexual abuse for Resident 3 in July 2023 and two incidents for Resident 2 in August 2023. In addition, the facility did not report the results of the investigation for all three allegations of sexual abuse to the SSA within five (5) working days. 3. Facility did not identify triggers of Resident 1 to manifest the sexually abusive behavior which resulted to another incident of inappropriate touching of Resident 8's right breast on 10/12/23. The cumulative effects of these failures resulted in delayed identification of Resident 1's sexually inappropriate behavior towards Resident 2 and Resident 3; did not prevent further sexual abuse towards Resident 2 and Resident 8; and staff including CNA 2 and LVN 1, being afraid to report witnessed abuse incidents. Additionally, these failures placed other vulnerable residents in the facility to experience sexual abuse and the potential to compromise resident's safety from unreported and uninvestigated allegations of abuse. On 10/17/23 at 4:44 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) situation was identified in the presence of the Administrator, Administrator in Training (AIT), Director of Nursing (DON), Assistant Director of Nursing (ADON) 2, and Senior [NAME] President of Operations (SVPO) for facility's failure to provide process oversight and ensure effective implementation of the facility's abuse policies and procedures during the provision of care and services for Resident 2, Resident 3, and Resident 8. Five (5) IJ Removal Plan were not accepted. On 10/20/23 at 11:20 AM, the IJ was removed in the presence of the Administrator after the surveyors verified onsite through observation, interview, and record review the implementation of the facility's submitted and accepted IJ Removal Plan #6 (action to correct the deficient practices). The IJ Removal Plan #6 included the following information: 1. CNA 2 and LVN 1 were both placed on suspension on 9/1/23 for 10 days and were given in-service on 9/1/23 regarding their duty as mandated reporter. 2. In-services were started by the Director of Staff Development (DSD) on 10/18/23 for all staff on abuse prevention and reporting. Any staff who did not receive training by 10/19/23 were not allowed back on the floor until they have received training and completed a Post Test and an Acknowledgement of Abuse and Neglect Training. In-services by the DSD will continue until all staff have been retrained. 3. The DSD/Designee started a weekly audit of all employees' file to ensure they received training on prohibiting and preventing abuse, identifying what constitutes abuse, recognizing signs of abuse, reporting abuse, and understanding resident behavioral symptoms that may increase the risk of abuse and neglect and how to respond. 4. SSAs and Administrator in Training (AIT) conducted interviews on 10/17/23 of all alert female residents to see if they feel safe and if they had been touched inappropriately. All residents stated they felt safe and no inappropriate touching had taken place. 5. Director of Nursing (DON)/Designee reviewed all change of condition and behavior monitoring on 10/18/23 for all nonverbal residents from July of 2023 to present to see if there were any indications of abuse. There was no nonverbal resident identified from those with change of condition and behavior monitoring. 6. The IDT reviewed Resident 1's chart on 10/17/23 to determine root cause of behaviors, possible triggers and interventions that can be used to ensure safety of all residents in the facility. Resident 1's care plan was updated on 10/17/23 to reflect these findings. Cross referenced to F600, F609, and F610. Findings: Review of Resident 1's admission record indicated, was admitted to facility on 8/30/22 with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), dementia (a group of symptoms affecting memory, thinking and social abilities), history of alcohol abuse, mild cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions), and cognitive communication deficit (difficulty thinking and communicating). Review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 9/1/23, indicated, Resident 1's cognition (thought process) was moderately impaired. The MDS indicated, Resident 1 did not exhibit any mood symptoms and physical behavioral symptoms directed towards others such as scratching, grabbing, and abusing others sexually. Further review of the MDS indicated, Resident 1 required supervision with set up help to one-person physical assist for bed mobility, transfer, walking, locomotion (ability to move from one place to another), eating, and toilet use. The MDS also indicated Resident 1 required extensive assistance with one-person physical assist for dressing and personal hygiene. Review of Resident 2's admission record indicated, was admitted to facility on 5/11/23 with diagnoses including encephalopathy (damage or disease that affects the brain), cognitive communication deficit, and catatonic disorder (a behavioral syndrome marked by an inability to moved normally). Review of Resident 2's MDS dated [DATE], indicated, Resident 2 has memory problem and moderately impaired decision-making skills under the staff assessment for mental status. The MDS indicated, Resident 2 had episodes of feeling or appearing down, depressed, or hopeless for 2 to 6 days under the staff assessment of resident mood. The MDS did not indicate any behavioral symptoms for Resident 2. Further review of the MDS indicated, Resident 2 required supervision with one-physical assist for transfer, walk in room, locomotion, and eating; limited assistance with one-physical assist for bed mobility and walk in corridor; extensive assistance with one-physical assist for dressing, toilet use, and personal hygiene. Review of resident 3's admission record indicated, was admitted to facility on 12/21/22 with diagnoses including hemiplegia (complete paralysis of side of the body), hemiparesis (partial weakness or paralysis of on one side of the body), dementia, and cognitive communication deficit. Review of Resident 3's MDS dated [DATE], indicated, Resident 3's cognition was severely impairment. The MDS indicated, Resident 3 did not exhibit any mood and behavioral symptoms. Further review of the MDS indicated, Resident 3 required extensive assistance with one-person physical assist for bed mobility and total dependence with one-person physical assist for transfer, walking, locomotion, eating, toilet use, and personal hygiene. Review of Resident 8's admission record indicated, was admitted to facility on 3/17/21 with diagnoses including heart disease, stroke, functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord), and anxiety disorder (persistent and excessive worry that interferes with daily activities). Review of Resident 8's MDS dated [DATE] indicated, Resident 8 has a BIMS (Brief Interview of Mental Status, a brief screener that aids in detecting cognitive impairment) score of 15, a score of 15 means no cognitive impairment. The MDS also indicated, Resident 8 was non-ambulatory and required extensive assistance with two-person assist for bed mobility, transfer, and locomotion on and off the unit; and one-person assist for dressing, eating, toilet use, and personal hygiene. 1a. Review of facility's untitled letter document dated 9/7/23, indicated, .On 8/31/2023, our resident [Resident 1] was observed in his room with a female resident who was touching his penis. The nurse separated the two residents. During the course of the investigation, it was found that [Resident 1] was involved in previous incident in July, in which he was seen touching a different resident on the breast . Review of California Department of Public Health (CDPH) document titled, Complaint/Incident Intake Report, known as HS 802 indicated, the incident of Resident 1 touching Resident 3's breast was received on 9/1/23 at 5:20 PM by fax. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 8/31/23, indicated, date and time of the incident Resident 1 touching Resident 3's breast was sometime in July. This alleged incident was reported to the police by phone on 8/31/23, no time indicated; and to CDPH and Ombudsman by fax on 8/31/23, no time indicated. Review of facility document titled, Transmission Result Report, indicated, the facility faxed to CDPH on 8/31/23 at 8:03 PM. 1b. Review of CDPH's document titled, Complaint/Incident Intake Report, known as HS 802 indicated, the incident of Resident 2 touching Resident 1's penis was received on 9/1/23 at 10:39 AM by fax. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 8/31/23, indicated, date and time of the incident of Resident 2 touching Resident 1's penis was 8/31/23 at 2:10 PM. The incident was reported to the police by phone on 8/31/23 at 4:30 PM; the facility reported to CDPH and Ombudsman by fax on 8/31/23, no time indicated. Review of facility document titled, Transmission Result Report, indicated, the facility faxed to CDPH on 8/31/23 at 6:10 PM and to Ombudsman on 8/31/23 at 6:11 PM (4 hours after the incident). 1c. During an interview on 9/14/23, at 3:30 PM, CNA 2 stated, she witnessed the first incident involving Resident 1 and Resident 3 in July 2023 on the second-floor dining room. CNA 2 recalled the incident and stated, [Resident 1] was wheeling himself towards the dining area. I saw [Resident 1] rubbing left breast of [Resident 3] in circular motion. CNA 2 also stated, she reported the incident immediately to Licensed Vocation Nurse (LVN) 1 and took Resident 1 back to his room. During further interview, CNA 2 stated, she was suspended during the investigation of the incident on 8/31/23 (Resident 1 and Resident 2) because she did not report the July 2023 (breast) incident directly to the Administrator. CNA 2 added that she reported the incident immediately to the charge nurse. During an interview on 9/14/23 at 3:34 PM, CNA 2 stated, a month later, she witnessed and reported two incidents that involved Resident 1 and Resident 2. CNA 2 stated, on the same month (August 2023), prior to the reported incident on 8/31/23, [Resident 1] attempted to touch [Resident 2] vagina by the social worker's office. CNA 2 added, she reported the incident to the evening nurse and was told to monitor Resident 1 since it was only an attempt. CNA 2 further stated, she did not document the incident and cannot remember the exact date it happened. During an interview on 9/14/23 at 3:40 PM, CNA 2 stated, she was suspended during the investigation of the incident on 8/31/23 (Resident 1 and Resident 2) because she did not report the July 2023 (breast) incident directly to the Administrator. CNA 2 added that she reported the incident immediately to the charge nurse. CNA 2 then stated, It doesn't make sense to suspend me. Now I'm afraid to report. I might get suspended again. Review of Resident 1 and Resident 2's progress notes for August 2023 indicated, there was no documentation regarding Resident 1's attempt to touch Resident 2's vagina. During an interview on 9/14/23 at 3:46 PM, LVN 1 confirmed and stated, CNA 2 reported to her regarding Resident 1 touching Resident 3's breast but cannot remember the exact date of the incident. LVN 1 stated, I reported it (referring to touching Resident 3's breast) to Resident Care Coordinator (RCC). I don't know what happened after. No investigation after. LVN 1 explained that the witness should report to RCC and Administrator (ADM) and that she doesn't do anything after reporting an allegation of abuse. LVN 1 added, the RCC will then report to the Administrator and complete the documentation and investigation. During further interview on 9/14/23 at 3:48 PM, LVN 1 stated, Everybody are mandated reporters. LVN 1 also stated, I don't report (to the State Agency/Ombudsman). Only (report) to RCC. During an interview on 9/14/23 at 4:23 PM, RCC stated, she received two reports that involved Resident 1. RCC stated, the incident of Resident 1 touching Resident 3's breast was not reported to the Administrator/Abuse Coordinator. RCC stated, the way she understood the report was that Resident 1 tap or grab Resident 3's shoulder, therefore concluded that it was not abuse. Thus, no report and no further investigation was conducted. During further interview on 9/14/23 at 4:28 PM, RCC stated, any alleged incidents should be reported directly to the Administrator and/or designee and reporting should be whoever witness the incident. RCC further stated, a change of condition and staff interview should be conducted after a report of alleged abuse was made. During an interview on 9/14/23 at 4:52 PM, Social Worker (SW) 1 stated, she learned about the incident of Resident 1 touching Resident 3's breast during her interview with CNA 2 regarding the incident between Resident 1 and Resident 2 on 8/31/23. SW 1 further stated, the CNA, LVN, or RCC were expected to report the alleged incident of Resident 1 touching Resident 2's breast immediately or within two hours from the time they knew about the incident. During an interview on 9/14/23 at 4:59 PM, Assistant Director of Nursing (ADON) stated, the Abuse Coordinator was not notified of the touching of the breast. ADON stated, Abuse Coordinator should have been notified immediately which did not happen. During further interview on 9/14/23 at 5:03 PM, SW 1 stated that the alleged incident of Resident 1 touching Resident 3' breast was not investigated after learning about the incident. SW 1 stated, At that time the DON and Administrator said it will be taken care of but did not happen (referring to reporting and investigation of the incident). During an interview on 9/14/23 at 5:19 PM, RCC stated, she did not get a report regarding Resident 1 attempted to touch Resident 2's vagina in August 2023. During a joint interview on 9/14/23 at 5:27 PM, ADM and RQMC stated, the two staff (CNA 2 and LVN 1) were suspended for not reporting immediately to the Administrator. Review of CNA 2's employee file indicated, Corrective Action Memo dated 9/12/23 was given to and signed by CNA 2 on 9/12/23 indicating, .Employer Statement: Staff did not follow policy in properly reporting an alleged sexual abuse case to the abuse coordinator. On 8/31/23, [CNA 2] notified us about the alleged abuse case that happened in July, but the abuse coordinator was not informed . Employee Statement (Optional): I did notify the nurse in-charge and it was [LVN 1] and the nurse reported to the supervisor [RCC] and did mention to [LVN 3]. Review of LVN 1's employee file indicated, Corrective Action Memo dated 9/12/23 was given to and signed by LVN 1 on 9/12/23 indicating, .Employer Statement: [LVN 2] did not follow policy in properly reporting an alleged sexual abuse case to the abuse coordinator on time . Under the Employee Statement (Optional) indicated LVN 1 did not write her statement. Review of CNA 2 and LVN 1's timesheet dated 9/1/23 to 9/15/23 indicated, CNA 2 and LVN 1 were taken off the schedule from 9/1/23 through 9/8/23. During a follow up telephone interview on 9/26/23 at 11:58 AM, CNA 2 stated, she reported the incident of Resident 1 attempted to touch Resident 2's vagina to the evening shift nurse (LVN 3) since the incident happened before dinner. CNA 2 added, [LVN 3] told me to monitor [Resident 1] since it was only an attempt. During a telephone interview on 9/27/23 at 10:35 AM, LVN 3 confirmed and stated, CNA 2 reported Resident 1 attempted to touch Resident 2's vagina during the evening shift and the two residents were separated immediately and monitored. LVN 3 also stated, I didn't document (referring to the incident). It was an attempt. I can't remember if I reported it. During an interview on 9/27/23 at 10:38 AM, DON stated, she was not aware of the attempt of Resident 1 touching Resident 2 that was reported by CNA 2 to LVN 3. DON added, If there's a report attempting to touch, it needs to be reported immediately. We need to do something right away. During an interview on 9/27/23 at 1:08 PM, ADM stated, any allegations of abuse need to be reported by phone right away and faxed SOC 341 to SSA within two hours of the incident. 2. Review of Resident 3's clinical record indicated, there was no progress notes in July 2023 regarding the incident of Resident 1 touching Resident 3's breast. Further review indicated, there was no documented evidence a plan of care was initiated to address the incident. Review of Resident 1's clinical record indicated, there was no progress notes in July 2023 regarding the incident of Resident 1 touching Resident 3's breast. Further review indicated, there was no documented evidence a plan of care was initiated to address Resident 1's sexually inappropriate behavior. Review of Resident 1 and Resident 2's progress notes for August 2023 indicated, there was no documentation regarding Resident 1's attempt to touch Resident 2's vagina. During an interview on 9/14/23 at 3:46 PM, LVN 1 stated, I reported it (referring to touching Resident 3's breast) to Resident Care Coordinator (RCC). I don't know what happened after. No investigation after. LVN 1 explained that the witness should report to RCC and Administrator (ADM) and that she doesn't do anything after reporting an allegation of abuse. LVN 1 added, the RCC will then report to the Administrator and complete the documentation and investigation. During concurrent interview and record review on 9/14/23 at 3:53 PM, LVN 1 was unable to find documentation of the incident in Resident 1 and Resident 3's clinical record. LVN 1 stated, I don't see it here. During an interview on 9/14/23 at 4:23 PM, RCC stated, she received two reports that involved Resident 1. RCC stated, the incident of Resident 1 touching Resident 3's breast was not reported to the Administrator/Abuse Coordinator. RCC stated, the way she understood the report was that Resident 1 tap or grab Resident 3's shoulder, therefore concluded that it was not abuse. Thus, no report and no further investigation was conducted. During further interview on 9/14/23 at 4:28 PM, RCC stated, a change of condition and staff interview should be conducted after a report of alleged abuse was made. During an interview on 9/14/23 at 4:52 PM, SW 1 stated that the alleged incident of Resident 1 touching Resident 3' breast was not investigated after learning about the incident. During a concurrent interview and record review on 9/27/23 at 10:44 AM, DON stated there was no investigation and IDT conducted regarding the two incidents of Resident 1 touching Resident 3's breast and the attempt to touch Resident 2's vagina. Review of facility's untitled letter document dated 9/7/23, indicated, This letter is to inform you of the results of our investigation regarding a resident-to-resident sexual interaction that was reported to you on 8/31/2023. Since the date of that report, there has been a change in two key positions which resulted in this letter not being completed within the five-day time frame . During an interview on 9/27/23 at 1:08 PM, ADM stated, any allegations of abuse need to be reported by phone right away and faxed SOC 341 to SSA within two hours of the incident. ADM also stated, a 5-day follow-up or written result of the investigation should be faxed to the State Agency within five days from the incident or up to seven days including weekends, which did not happen. 3. Review of Resident 1's Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together toward the goals of the residents) Note dated 9/7/23, indicated, Staff reported this resident (Resident 1) was with a female resident (Resident 2) in his room, touching his penis on 8/31/23 . Upon investigation of this incident on 8/31/23, we found that this same resident (Resident 1) was involved with another incident of touching the breast area of a female resident (Resident 3) in the dining hall in the month of July . The IDT Note indicated, Administrator, Abuse Coordinator, DON (Director of Nursing), MD (Medical Doctor), RP (responsible party), police, CDPH and Ombudsman were notified of the incident. Further review of the IDT Note indicated, the alleged perpetrator (Resident 1) was placed on 15-minute monitoring for signs and symptoms of adverse effects from the alleged incident, was transferred to another floor and room, referred for psych evaluation, and olanzapine (medication used to treat mental disorders) was increased to 10 mg (milligrams, a unit of measurement). The IDT Note did not indicate the incident of Resident 1 touching Resident 3's breast was further discussed and investigated. Review of Resident 1's Psych Assessment dated 9/1/23, indicated, Resident 1 was referred for psych evaluation due to the following targeted symptoms: sexually pre-occupied, impulsivity, and poverty of thought. The Psych Assessment indicated a diagnostic impression of schizophrenia with interventions including supportive psychotherapy (a type of therapy that primarily focuses on providing emotional support, encouragement, and validation during difficult life circumstances or psychological challenges), discontinue olanzapine 7.5 mg, start with olanzapine 10 mg 1 tablet per orem (po, per mouth) at hours of sleep (hs), and refer accordingly. Review of Resident 1's care plan for The resident was involved in alleged sexual abuse, initiated on 9/3/23, three days after the incident, indicated, the alleged abuser was sitting on the wheelchair, pants were down while the alleged victim is touching the alleged abuser's penis. The care plan indicated Resident 1 will have no evidence of behavior problems or will not display the same behavior until the next review. The care plan indicated the following interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a clam manner. Divert attention. Remove form situations. Document behavior and potential causes. Observed the behavior and report any abnormal findings. Separate/transfer the room of the abuser to [room number/unit]. SOC-341 was completed and filed. Further review of Resident 1's care plan indicated, there was no documented evidence a care plan was initiated to address Resident 1 touching Resident 3's breast and attempt to touch Resident 2's vagina. During an interview on 9/14/23 at 5:20 PM, ADON 1 stated, a plan of care was put in place after the reported incident on 8/31/23 between Resident 1 and Resident 2 and no other plan of care initiated after the incident in July 2023 between Resident 1 and Resident 3. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 10/12/23, indicated, date and time of the incident was on 10/12/23 at 4:55 PM, Staff heard Resident in room [number] who was in the hallway by her room in her wheelchair crying loudly. Staff asked resident what was wrong she stated a 'male resident down the hall was passing her and touched her on her right breast.' Resident stated that she wasn't in any pain from the incident. Male resident relocated to a different room and hallway. Continue current interventions in place. During an observation on 10/16/23 at 3:04 PM, in Unit 1 hallway, Resident 1's room was located next to the Administrator's office and one room/door away from Resident 8's room, which was located on the same side of the hallway. Resident 8 was inside her room, sitting on a wheelchair next to her bed watching television (TV). Resident 8 was alert, verbally responsive, oriented to time, place, and person. During an interview on 10/12/23 at 3:05 PM, Resident 8 recalled the incident with Resident 1 on 10/12/23 and stated, I was sitting on the chair outside the room and then there's this man [Resident 1's Name was mentioned], wheeling. I thought he's just gonna (going to) wave at me. He squeezed my right breast. I was screaming out loud, crying. I screamed for help, 'maniac'. Resident 8 also stated, the social worker and supervisor came to asked what happened. Resident 8 then asked if Resident 1 can be in jail or moved somewhere. Resident 8 further stated, I was shocked. I was already crying. They (referring to supervisor and social worker) didn't ask me how I feel. During an interview on 10/16/23 at 3:59 PM, RN 1 stated, [Resident 1] likes waving both hands like reaching out to you. Has a habit of reaching out. RN 1 further stated, Resident 1's habit of waving both hands and reaching out were not part of the behavior monitoring. During an interview on 10/16/23 at 4:47 PM, ADM stated that after the incident, new interventions were implemented for Resident 1 including room transfer close to the nurse's station, reminded staff not to leave resident alone, and to continue one-to-one sitter in the morning and evening shift, and Q 15 minutes check at night shift. During concurrent interview and record review on 10/16/23 at 5:06 PM, AIT reviewed and provided copies of Resident 1's Every 15 minutes Resident Monitoring for October 2023 and was unable to find documented evidence of Q 15 minutes monitoring on 10/12/23. Further review of the provided copies of Resident 1's Every 15 minutes Resident Monitoring for October 2023 indicated, monitoring sheets were missing on 10/1/23, 10/3/23, 10/6/23, 10/7/23, 10/8/23, 10/10/23, 10/11/23, 10/12/23, and 10/16/23. AIT stated, That's all of October's monitoring sheet. Review of Resident 1's care plan for A female resident claimed [Resident 1] allegedly touched her on the breast., initiated on 10/12/23, indicated, The resident will not exhibit any sexually inappropriate behavior problems until next review. The care plan indicated the following interventions: Continue with line sight supervision during the day and frequent checks while in room at night. Transfer to a different room . Monitor the resident for nay sexually inappropriate behavior and immediately intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Immediately remove from situation and take to alternate location as needed. Review of the facility's policy and procedure titled, Abuse - Prevention, Screening, & Training Program, revised July 2018, indicated, .Policy - The Facility does not condone any form of resident abuse .The Administrator as abuse prevention coordinator is responsible for the coordination and implementation of the Facility's abuse prevention, screening, and training program policies . Procedure 'Sexual abuse' is defines as non-consensual contact of any type, sexual harassment, sexual coercion, or sexual assault . III. Screening residents - A. The Facility conducts resident pre-admission, admission, and ongoing assessments (screening) and care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect. IV. Training - A. The facility conducts mandatory staff training programs during orientation, annually and as needed on: i. Prohibiting and preventing abuse . ii. Identifying what constitutes abuse . iii. Recognizing signs of abuse . iv. Reporting abuse . v. Understanding resident behavioral symptoms that may increase the risk of abuse and neglect and how to respond . V. Prevention . I. As appropriate, the Facility involves qualified psychiatrists, psychologists and other mental health professionals to help staff manage challenging or aggressive residents. J. The Facility establishes a safe environment that reasonably supports resident to the extent possible including, but not limited to, consensual sexual activity. K. The Facility identifies, corrects, and intervenes in situations in which abuse .is more likely to occur . M. The Facility conducts resident pre-admission, admission and ongoing assessments (screening) and care planning for appropriate interventions and monitoring of residents with needs and behaviors that might lead to conflict or neglect . Review of the facility's policy and procedure titled, Abuse Reporting and Investigations, revised 7/31/23 with effective date of 8/18/23, indicated, .The Facility promptly reports and thorough investigates allegations of resident abuse, mistreatment, neglect, exploitation, abuse facilitated or enabled by the use of technology, misappropriation of resident property, or injuries of unknown source, and suspicions of crimes . 1. Administrator as Abuse Prevention Coordinator . a. Allegations of abuse, neglect, mistreatment, exploitation, or reasonable suspicion of a crime to be reported to the Administrator or designated representative immediately. b. When the Administrator or designated representative receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, abuse facilitated or enabled technology, exploitation, or injuries of unknow source, or suspicion of a crime, the Administrator or designated representative will initiate an investigation immediately . ii. The facility will not inhibit facility staff/covered individuals from their mandated reporting obligations. iii. Facility staff/covered individuals will not be disciplined or retaliated against for good-faith reporting . 2. Immediate Action . b. The administrator or designated representative conducting the investigation will interview individuals who may have information relevant to the allegation or suspected crime . 3. Notification of Outside Agencies of Allegations of Abuse . b. Administrator or designed representative will notify the LTC (Long Term Care) Ombudsman, and CDPH (California Department of Public Health) by telephone and in writing (SOC 341) within two (2) hours of an initial report. 4. Notification of Outside Agencies of Allegations of Abuse Caused by a Resident with Dementia Diagnosed by a Physician . i. The Administrator or designated representative will notify within two (2) hours, notify by telephone, CDPH, the Ombudsman and Law Enforcement. ii. The Administrator or designated representative will send a written SOC 341 report to the Ombudsman and Law Enforcement and CDPH Licensing and Certification within 2 hours. 5. Notification of Outside Agencies of Allegation of Abuse With No Serious Bodily Injury - [TRUNCATED]