F0600

E

Failure to Care Plan and Monitor Resident With Known Sexual and Physical Aggression Resulting in Abuse of Two Residents

Lawndale, California Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from abuse by not developing and implementing care plans and abuse-prevention measures for a resident with known sexually inappropriate and aggressive behaviors. Resident 2 was admitted with diagnoses including muscle weakness and schizoaffective disorder, bipolar type, and a documented history from an acute care hospital of increasing psychosis resulting in inappropriate exposure of his private parts and harassment of female staff and residents. Despite this history, the facility did not create a care plan upon admission to address Resident 2’s sexual misconduct risk. Progress notes dated 12/13/2025 documented that Resident 2 made sexually explicit and inappropriate verbal comments toward a CNA on two occasions, and on 12/15/2025 he was seen touching a CNA inappropriately and telling her he wanted to go to bed with her. These behaviors were only redirected in the moment, and no corresponding care plan interventions were developed to manage or monitor his sexually inappropriate behavior.

Resident 1, who had dementia and was documented as lacking capacity to consent due to dementia, required moderate to total assistance with most ADLs and had a care plan for cognitive impairment that included visual monitoring for safety. Her MDS indicated she was usually able to understand and be understood. On 12/19/2025, an SBAR documented that she was exposed to inappropriate behavior by Resident 2, that she was assessed with no injuries and no immediate distress, and that she would be monitored for emotional distress and kept separated from Resident 2. However, her clinical record did not contain any indication of consent to sexual activity with Resident 2. A police incident report documented that Resident 1 stated Resident 2 entered her room, sat on her bed, shook her shoulders aggressively, kissed her cheeks multiple times, pulled his pants down to his thighs, reached into his shorts to touch his penis (though she did not see it exposed), then put his hands inside her shorts, past her diaper, and penetrated her vagina with his fingers while she called for help. Staff interviews corroborated that Resident 1 reported that Resident 2 kissed her, touched her, and put his fingers inside her vagina, and that staff observed Resident 2 pulling his pants up when they entered the room. Resident 1 later stated she was traumatized by the incident, had to sleep with the lights on for two weeks, and was afraid Resident 2 would enter her room again.

Resident 6, who had muscle weakness and low back pain and was dependent or required significant assistance for most ADLs, had capacity to understand and make decisions and was able to communicate effectively. On 12/19/2025, his progress notes and a change-of-condition form documented that he reported being struck three times on his legs by Resident 2 and that Resident 2 was removed from his room. A police incident report further documented that Resident 6 reported Resident 2, his roommate, entered the room, repeatedly requested to perform oral sex on him, advanced toward him despite being told to leave, attempted to pull down his blanket to potentially expose his penis, and, when resisted, punched his right knee approximately three times with a balled fist before leaving. Resident 6 confirmed in interview that Resident 2 asked to suck his penis, tried again after being told no, attempted to pull down his blanket, and then hit his right leg three times. A CNA reported hearing Resident 6 screaming for help and that he alleged Resident 2 had asked to suck his penis. Resident 6’s record contained no indication of consent to sexual activity with Resident 2.

Despite Resident 2’s known history of sexual misconduct and the documented sexually inappropriate behaviors toward staff shortly after admission, the facility did not develop or revise a comprehensive, person-centered care plan to address his sexual behaviors, monitor his whereabouts, or implement specific safety interventions for other residents. The existing care plan for Resident 2 addressed risk for wandering/elopement but did not address his sexually inappropriate behavior. After the sexually abusive and physically aggressive incidents toward Residents 1 and 6 on 12/19/2025 and Resident 2’s transfer and readmission from an acute care hospital for management of aggression and sexually inappropriate behavior, his care plan still did not include interventions related to his sexually inappropriate behavior toward other residents or monitoring for behavioral changes and safety concerns. The DON acknowledged that no care plan was created at admission or after the documented incidents on 12/13/2025 and 12/15/2025, and stated that if care plans had been created, they might have protected Residents 1 and 6 from Resident 2’s sexually inappropriate behavior and physical aggression. The facility’s own policies on Comprehensive Person-Centered Care Planning and Abuse Prevention and Management required review and revision of care plans with new problems or behavior changes and required identification, correction, and intervention in situations where abuse is more likely to occur, but these were not implemented in relation to Resident 2’s behaviors.