F0600

D

Failure to Prevent and Report Non-Consensual Sexual Contact Between Residents

San Gabriel, California Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent sexual abuse between residents in a hallway. Resident 1, who had dementia and severely impaired cognitive skills for daily decision-making, required partial to moderate assistance for mobility and was not self-responsible, with a representative designated as responsible party. On the date of the incident, Resident 1 was seated in a wheelchair in the hallway next to Resident 2. An SBAR and Change in Condition Evaluation completed that afternoon documented that Resident 1 was at risk for emotional distress related to alleged inappropriate touching and that a witness had reported Resident 1 was being touched inappropriately by Resident 2 while seated in the hallway.

Resident 2 was also not self-responsible and had severely impaired cognitive skills for daily decision-making, with diagnoses including muscle weakness, gait mobility issues, and dysphagia. Resident 2 required partial to moderate assistance for sit-to-stand and walking. An SBAR and Change in Condition Evaluation for Resident 2 on the same date documented an allegation of inappropriate sexual behavior toward Resident 1, manifested by inappropriate touching, and that Resident 2 was being monitored for inappropriate behavior manifested by touching Resident 1. The Administrator later stated that Residents 1 and 2 did not have consent to touch, especially in the private area or for any sexual interaction with another resident, and that if sexual inappropriate touching was not consensual, it was considered sexual abuse.

The events leading to the deficiency were corroborated by witness interviews and video review. Visitor 1 reported seeing two wheelchairs side by side in the hallway, with Resident 1 closest to the wall and Resident 2 next to Resident 1, and observed Resident 2’s hand down the front inside of Resident 1’s pants, moving. Visitor 1 reported this to LVN 1 at the nurse’s station. The Administrator and DON reviewed surveillance footage from the hallway, which showed the two residents sitting side by side in wheelchairs, Resident 2 attempting to place a hand under and in front of Resident 1’s pants, and Resident 1 swaying Resident 2’s hand away; the exact hand location was not visible on the video. Housekeeping staff (HK1) stated that Visitor 1 told him something about Resident 2 touching Resident 1 and pointed toward the residents, but HK1 did not fully understand and did not report it to nursing or other staff. The Administrator acknowledged that the facility was not able to prevent Resident 2’s sexually inappropriate touching and stated that everyone is a mandated reporter required to report even alleged abuse. The facility’s abuse and neglect policy stated that the facility does not condone any form of resident abuse and that its purpose is to address the health, safety, welfare, dignity, and respect of residents.