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F0600
D

Failure to Prevent Sexual Abuse Between Residents

San Gabriel, California Survey Completed on 04-15-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident was subjected to sexual abuse by another resident in the facility. The incident took place in the early morning hours when one resident, while waiting for medication at the nursing station, was approached by another resident in a wheelchair. The second resident touched the first resident inappropriately on the buttocks and subsequently exposed his genitalia to both the resident and a Certified Nursing Assistant (CNA) who was present at the scene. The CNA immediately confronted the perpetrator, informing him that such behavior was not allowed. The incident was witnessed by the CNA, who reported it to the Charge Nurse. Documentation and interviews confirm that the inappropriate touching and exposure were observed and that the events were communicated to facility leadership, including the Director of Nursing (DON) and Registered Nurse Supervisor (RN Sup 1). The victim provided a written statement detailing the sequence of events, including the physical contact and exposure, and described the emotional impact of the incident. The facility's records indicate that both residents involved had the mental capacity to understand and make decisions at the time of the incident. The facility's policy on abuse prevention, which states that residents have the right to be free from abuse by anyone, was not upheld in this instance. The failure to prevent the sexual abuse resulted in a violation of the resident's rights and had the potential to cause negative psychosocial outcomes. The report documents the sequence of events and the immediate actions taken by staff who witnessed the incident, but does not include any corrective or follow-up actions taken by the facility after the event.

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