F0607

D

Failure to Recognize, Investigate, and Report Resident’s Allegation of Abuse by Therapist

Whittier, California Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its abuse prevention and reporting policy when a cognitively impaired resident reported feeling uncomfortable and scared during therapy provided by an unidentified male therapist. The resident had diagnoses including metabolic encephalopathy, gait and mobility abnormalities, and muscle weakness, and an MDS showing severely impaired cognition, with the ability to usually understand others. Therapy records showed multiple male PTs and OTAs provided services to the resident in the weeks prior to the allegation. During an interview, the resident stated that while lying in bed in a gown and diaper, a male therapist held her leg and moved it from side to side without counting repetitions, and that his movements made it seem like he was having an erection and seemed sexual. The resident reported feeling nervous, scared, and confused about why she felt that way, and said she had told the Social Services Director about the incident about two weeks earlier and had also mentioned it to several other staff.

The Director of Staff Development reported that the resident’s family member had told her the previous week that the resident felt uncomfortable with a male therapist and the way he moved during therapy, and that the resident preferred another therapist. The DSD acknowledged she did not ask the resident for additional details, did not identify which male therapist was involved, and did not investigate the incident, instead only telling the rehab scheduler not to assign the previously assigned male therapist. The Social Services Director similarly stated that the resident had told her the previous week that she felt uncomfortable with a male therapist and did not want any male therapist except one specific OTA. The SSD did not clarify details of the incident at that time, did not determine which therapist was involved, did not document the report, and did not initiate an investigation. She later stated that when she asked the resident why she was uncomfortable, the resident said she did not like that the therapist did not do anything therapy-wise and did not count, but the SSD still did not treat this as an allegation of abuse and did not report it to the abuse coordinator or outside agencies.

The Director of Rehabilitation stated he had been informed that the resident felt uncomfortable with male therapists but believed it was a preference rather than a problem, and therefore did not interview the resident, did not attempt to identify the specific therapist, and did not initiate an investigation. He acknowledged that several male therapists had worked with the resident and that it “could be anybody,” but no one in the rehabilitation department was suspended because the concern was treated as a preference. The Administrator similarly stated that the incident was not reported because the information relayed by the DSD and SSD was only that the resident was uncomfortable and preferred a certain therapist, and that this did not constitute an allegation in their view. In contrast, the resident’s family member reported that she had told the SSD that a male therapist had been at the bedside, grabbed the resident by the ankle/heel, repeatedly pushed her legs up and down in a circular way without counting, and that the resident felt very nervous and scared and did not want to see or be near him. Despite the facility’s written policy requiring that all allegations of abuse be promptly reported to the Administrator, thoroughly investigated, and reported to State or Federal agencies within required timeframes, the staff did not recognize the resident’s and family member’s reports as an allegation of possible mental or sexual abuse, did not conduct an investigation, and did not make required external reports.