F0607

D

Failure to Report and Investigate Alleged Sexual Abuse and Remove Accused Staff

Los Angeles, California Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The facility failed to implement its abuse prevention and reporting policies when a cognitively intact resident, admitted with heart failure and requiring extensive assistance with ADLs, reported being inappropriately touched in the perineal/vaginal area by a CNA during personal care. The resident stated the incident occurred several days prior and that she informed the social services worker (SSW), but nothing was done. The resident’s MDS showed she needed maximal to total assistance for most personal care tasks, including toileting and hygiene, and setup assistance for eating, indicating reliance on staff for intimate care.

On the date the allegation was reported, the SSW acknowledged that the resident directly reported the alleged abuse to her but admitted she did not notify the Administrator, DON, or other leadership, did not complete the SOC 341, and did not contact law enforcement or the Ombudsman as required by facility policy. The Administrator and DON both stated they were unaware of the allegation at the time and confirmed that such an allegation should have been immediately reported and investigated. The Director of Staff Development (DSD) reported that the Ombudsman had previously informed her that the resident said she had been touched inappropriately by a staff member, but the DSD did not seek further details, assumed the resident was referring to back rubs, and did not initiate an investigation or remove the alleged perpetrator from resident contact. Review of the facility’s abuse reporting and investigation policy showed that all abuse allegations must be reported within two hours to the Administrator and appropriate agencies, and that any employee accused of abuse must be placed on leave with no resident contact until the investigation is complete, which did not occur in this case.