F0610

E

Failure to Investigate Multiple Alleged Sexual and Physical Abuse Incidents

Lawndale, California Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to investigate multiple alleged incidents of sexual and physical abuse by one resident against other residents, as required by its Abuse Prevention and Management policy. Resident 1, who had dementia and was documented as not having capacity to consent, was assessed as usually able to understand and be understood, and required varying levels of assistance with ADLs and mobility. An SBAR dated 12/19/2025 documented that Resident 1 was exposed to “inappropriate behavior,” was promptly assessed with no injuries or distress noted, and that she would be monitored and kept separated from Resident 2. However, the clinical record contained no documentation that an abuse investigation was conducted regarding Resident 2’s sexually abusive behavior toward Resident 1 on that date.

Resident 2 had diagnoses including muscle weakness and schizoaffective disorder, bipolar type, with a history of increasing psychosis resulting in inappropriate exposure of his private parts and harassment of female staff and residents. An SBAR for Resident 2 dated 12/19/2025 documented that he entered Resident 1’s bedroom, lowered his pants, and exhibited sexually inappropriate behavior toward her, after which staff redirected him, administered medication, and planned transfer to an acute care hospital for further evaluation and behavior management. Despite these documented behaviors and his known history, Resident 2’s clinical record contained no documentation that an investigation was conducted into the incidents of sexually assaulting two residents and physically assaulting one of them on 12/19/2025.

Resident 6, who had muscle weakness and low back pain and was dependent or required significant assistance for most ADLs and mobility, reported that Resident 2 entered his room, repeatedly requested to perform oral sex, attempted to pull down his blanket to expose his penis, and, when resisted, punched his right leg three times. A police crime/incident report corroborated that Resident 6, who was bedridden, described Resident 2’s repeated sexual requests, attempts to pull down his blanket near his genital area, and punching of his right knee with a balled fist. Resident 6’s clinical record, however, contained no documentation that an investigation was conducted into the sexual abuse and physical assault by Resident 2 on that date. In an interview, the Administrator acknowledged being informed that day about Resident 2 sexually assaulting two residents and hitting one resident, and stated that no investigation was done because the events occurred on a Friday afternoon, despite the facility’s policy requiring the Administrator or designee to interview residents, witnesses, family, and others who may have relevant information.

The facility’s Abuse Prevention and Management policy, dated 6/12/2024, specified that the Administrator or designated representative conducting an investigation should interview individuals who may have information relevant to the allegation or suspected crime, including the resident, witnesses to the incident, other residents under the care of the staff member involved, roommates, family, and visitors. The absence of any documented investigations in the clinical records of Residents 1, 2, and 6, combined with the Administrator’s admission that no investigation was initiated after being informed of the alleged sexual and physical assaults, demonstrates that the facility did not follow its own policy and procedures for responding to and investigating alleged abuse incidents involving Resident 2 and the affected residents.