F0600

D

Failure to Prevent Resident-to-Resident Sexual Abuse After Prior Inappropriate Contact

San Gabriel, California Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident after a prior incident of inappropriate sexual behavior. One resident (Resident 1) had a history of cerebrovascular disease with cerebral infarction, aphasia, anxiety disorder, and was assessed as moderately impaired in cognitive skills for daily decision-making. Resident 1 was dependent on staff for multiple activities of daily living, including personal hygiene, transfers, and toileting. Another resident (Resident 2) had diagnoses including COPD, psychosis, anxiety disorder, and dementia, but was assessed as cognitively intact and required only supervision or limited assistance with mobility and self-care tasks.

On 12/17/2025, a change of condition note documented that Resident 2, while propelling his wheelchair toward his room, stopped in the hallway and attempted to get up and kiss Resident 1 on the cheek while both were in their wheelchairs. LVN 2 intervened and was able to stop Resident 2 from kissing Resident 1 and immediately separated the two residents. Despite this documented attempt at inappropriate physical contact, Resident 2’s care plan was not updated to address this behavior. During a later review, the MDS Coordinator confirmed that Resident 2 did not have a care plan for inappropriate behavior related to the attempted kiss and stated that a care plan with interventions such as close monitoring and activities to keep Resident 2 occupied should have been developed.

On 3/7/2026, CNA 1 observed Resident 1 lying on her bed in her room while Resident 2 was on top of her, touching her breast and kissing her on the lips. CNA 1 reported that Resident 1 was trying to move her face away from Resident 2. LVN 1, summoned to the room, saw CNA 1 wheeling Resident 2 out and was told that Resident 2 had been on top of Resident 1, kissing her lips and touching her breasts; LVN 1 identified this as sexual abuse. In a subsequent interview, Resident 1 nonverbally confirmed that a male resident had entered her room and touched her breasts and the top of her vaginal area, demonstrating the areas touched. Resident 2 denied inappropriate behavior when questioned, stating he only intended a greeting. The Director of Nursing acknowledged that the facility failed to prevent the abuse because another incident occurred between the two residents after the earlier event.