F0610

D

Failure to Investigate Resident’s Allegation of Sexual Abuse Gesture

Norwalk, California Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its Abuse Prevention and Prohibition Program by not investigating an allegation of sexual abuse made by a resident. The resident, who had diagnoses including amyotrophic lateral sclerosis (ALS) and major depressive disorder, had intact cognition per a recent MDS and was dependent for ADLs. During an interview, the resident reported that a CNA made an inappropriate sexual thrusting gesture with his pelvic area on a stool in the resident’s room, which the resident found offensive and perceived as mocking his sexual orientation as a gay man. The resident stated he reported this incident to the Director of Staff Development (DSD) and believed, as a mandated reporter, the DSD should have reported the allegation.

The DSD confirmed in an interview that the resident had informed her about the CNA’s inappropriate gesture and that the resident felt the CNA was mocking his lifestyle, but she did not report the allegation. The DSD acknowledged she is a mandated reporter and that the allegation should have been reported. Another CNA stated that any inappropriate sexual thrusting gesture is considered a form of abuse and should be reported for resident safety. The DON stated the DSD should have reported the allegation immediately, that the conduct described was a form of abuse, and that it could have made the resident feel offended and embarrassed. Review of the facility’s abuse-related P&Ps showed that verbal abuse includes gestured language with disparaging or derogatory terms and that the facility is required to promptly and thoroughly investigate reports of resident abuse, including suspending accused staff until the investigation is complete. These required investigative steps were not initiated in response to the resident’s allegation.