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F0609
D

Failure to Timely Report and Investigate Sexual Abuse Allegation

Los Angeles, California Survey Completed on 04-10-2025

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

The facility failed to investigate and report an allegation of sexual abuse involving a resident in accordance with its own policy and regulatory requirements. The resident, who had functional quadriplegia, schizophrenia, severe cognitive impairment, and was dependent on staff for toileting, reported that a staff member had touched her inappropriately and made sexually suggestive comments. The allegation was communicated to various staff members, including a Certified Occupational Therapy Assistant, the Director of Rehabilitation, the Social Services Director, and the Director of Nursing. The resident's care plan was updated to address emotional distress, and the accused staff member was suspended from working with the resident. Despite these internal actions, the facility did not report the allegation to the Department of Public Health, the Ombudsman, or local law enforcement within the required two-hour timeframe as outlined in the facility's Abuse Investigation and Reporting policy. Documentation and interviews confirmed that notifications to mandated entities were made after 7 PM on the day of the allegation and to law enforcement the following day, well beyond the two-hour window. Multiple staff interviews corroborated that the policy required immediate reporting, and the delay was acknowledged by the Director of Nursing and other staff. The failure to report the abuse allegation in a timely manner constituted a deficiency, as it delayed the involvement of external authorities and the initiation of an independent investigation. The report specifically notes that this delay had the potential to place the resident at further risk and to delay an onsite inspection by regulatory and law enforcement agencies.

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