Solano Post Acute

Based on observation, interview and record review, the facility failed to timely investigate and report the results of investigation of abuse allegations within five days for one of four sampled residents (Resident 1), when Resident 1 complained of being inappropriately touched by another resident and by a staff member.This failure resulted to the delayed investigation of the allegation and had the potential to result in Resident 1's emotional and psychological distress and further abuse. Resident 1 was admitted to the facility in the summer of 2025 with multiple diagnoses which included left and right hemiplegia (left and right-side paralysis) and dysarthria (difficulty speaking).During a review of the Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 6/29/25, the MDS indicated Resident 1 had no memory impairment.During a review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation) Communication Form and Progress Notes (PN), dated 8/5/25, the SBAR and PN indicated that on 8/3/25, Resident 1 reported that a male resident allegedly kissed her forehead while she was asleep and also alleged that an X-ray tech touched her inappropriately in her shoulder, forehead and breast and called her beautiful.During a review of the 5-Day Investigation Letter in which Resident 1 was involved as the victim, dated 8/11/25, the letter indicated, On 8/3/25, Resident 1 reported to the charge nurse that a [staff name].touched her arm and her breast.During a review of the Staff to Resident 5-Day investigation Letter in which Resident 1 was involved as the victim, the letter indicated the report was received on 8/11/25 at 4:04 p.m., eight days after the Resident 1's allegation.During a review of the Resident-to-Resident 5-Day Investigation Letter which Resident 1 was involved as the victim, the letter indicated the report was received on 8/11/25 at 4:15 p.m., eight days after the Resident 1's allegation.

During an interview on 8/15/25 at 11:20 a.m. with the Administrator (ADM), the ADM confirmed Resident 1 reported the allegations of inappropriate touching by another resident to the nurse and the inappropriate touching by a staff member on 8/3/25.

The ADM confirmed he was the primary investigator and was expected to follow facility investigation policy.

The ADM indicated the investigation was not done in a timely manner.

During an interview on 8/15/25 at 11:45 a.m. with Resident 1, Resident 1 indicated that she notified the nurse on 8/3/25 about being inappropriately touched on her arm, forehead, and breast, and indicated she felt uncomfortable and felt ignored, and stated she was disappointed in the facility's lack of urgency.

During an interview on 8/15/25 at 1:30 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated that all abuse allegations, witnessed or unwitnessed, should be reported according to the facility's protocol and documented, and stated, I witnessed [Resident 1] her crying in her room after the incident.

During an interview on 8/15/24 at 3:07 p.m. with Registered Nurse 1 (RN 1), RN 1 stated that if she observed abuse or received a report from a resident, she would immediately report the incident to her supervisor within two hours.During a review of the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting dated 2017, the P&P indicated, Reporting: .5.

The Administrator, or their designee, will provide the appropriate agencies.with a written report of the finding of the investigation within five (5) working days of the occurrence of the incident.

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