F0600

D

Failure to Follow Abuse Policy and Supervise High-Risk Resident During Smoking Break

Oakhurst, California Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its Abuse Prevention and Response Policy in response to an allegation of sexual abuse made by one resident against another, and in a separate incident, failure to supervise a resident at high risk for elopement during a smoking break. One resident, admitted with moderate cognitive impairment as evidenced by a BIMS score of 12, reported that another resident with severe cognitive impairment (BIMS score of 4) had inappropriately touched her breasts during what began as a mutual hug in a hallway. The resident stated she felt violated and only felt safe after she personally informed staff of the incident. Staff interviews confirmed that the allegation was reported to social services on a specific date, but no internal investigation or documentation of the allegation or subsequent actions was found in the resident’s electronic medical record.

The administrator and social services staff acknowledged that the incident was not reported per facility policy because the resident requested that it not be reported, and that the only external contact made was to local law enforcement, which did not take action. Social services stated that nothing else was done for the allegation beyond that call, and there were no social services visits or documented monitoring for psychosocial harm or behavioral changes after the report. Multiple staff members, including LVNs and the clinical coach, stated that the facility process for any abuse allegation was to ensure resident safety, separate involved residents, report the allegation immediately, conduct an investigation, document all findings, and monitor for emotional distress. Review of the alleged perpetrator’s care plan showed a prior history of inappropriate behavior toward a female resident, including grabbing a female resident’s breast in the social dining room, with interventions such as 15‑minute checks and monitoring during mealtimes to keep him away from female residents. Despite this history and the new allegation, staff reported there were no new interventions documented for the alleged victim, and no investigation or documentation of the March incident in the medical record.

In a separate incident, the facility failed to provide adequate supervision to a resident identified as high risk for elopement. This resident, admitted with dementia, schizophrenia, and muscle weakness, had an elopement risk assessment score of 20, which staff stated represented high risk. The resident reported leaving the facility through the front door during a smoke break, hitchhiking with an unfamiliar female to her home, receiving money, and then being driven to a casino several miles away, where the resident remained until local law enforcement arrived. Facility records and staff interviews indicated that an LVN left the resident sitting on a bench outside the front door, which was not a designated smoking area, and returned inside to complete an admission, leaving the resident unsupervised for approximately 10–15 minutes. The progress note documented that the front door alarm sounded, the nurse found the resident outside smoking, turned off the alarm, reminded the resident to come inside after smoking, and then, after 10–15 minutes, discovered the resident was gone, prompting a search of the building and surrounding area. Multiple staff, including social services, the clinical coach, the activities director, and another LVN, confirmed that facility process required staff to remain with and monitor residents during outings and smoking breaks, especially those at high risk for elopement, and that the resident should not have been left unattended outside the front entrance.