The December 17 incident left the female resident crying when she described it to staff the next morning. Multiple nurses identified the unwanted touching as sexual abuse and escalated their concerns through the facility's chain of command. But when the report reached the administrator, who also serves as the facility's abuse coordinator, she made a unilateral decision that contradicted her own staff's professional judgment.
"She did not think that the tickling of Resident 1's foot by Resident 2 was sexual in nature," state inspectors wrote after interviewing the administrator on December 23. The administrator told investigators that "if the facility knew it was sexual in nature she would have reported the allegation of sexual abuse."
Her staff disagreed.
Certified Nursing Assistant 1 was the first to learn about the incident on December 18 around 8 a.m. The female resident approached her and "was about to cry when Resident 1 was talking about the incident," the CNA told inspectors. The nursing assistant immediately recognized the behavior as inappropriate, telling investigators that "residents should not be touching other residents without permission."
Licensed Vocational Nurse 1 received the CNA's report and went directly to interview the affected resident. The woman confirmed that the male resident "came into Resident 1's room and tickled Resident 1's foot" the previous evening. When the LVN asked if he had touched her anywhere else, the resident said no.
But the resident's next statement alarmed the nurse: "she thought Resident 2 wanted to have sex with her."
The LVN immediately escalated the report to Registered Nurse 1, explaining that "the incident between Resident 1 and Resident 2 is possible sexual abuse because Resident 2 touched Resident 1 without Resident 1's consent."
RN 1 agreed with that assessment. During her December 22 interview with inspectors, she stated definitively that "Resident 2 does not have the right to tickle or touch anyone without their consent, that's a type of sexual abuse." She told investigators that "in RN 1's professional opinion, the alleged tickling was an alleged sexual abuse which is why RN 1 reported the incident to the Administrator who is the abuse coordinator."
The registered nurse followed proper protocol, reporting the incident to the administrator around 8:45 a.m. on December 18. She provided the administrator with the same details that had convinced her the incident constituted sexual abuse: the male resident had tickled the female resident's foot without consent, and the victim believed he wanted to have sex with her.
But the administrator, despite serving as the facility's designated abuse coordinator, reached a different conclusion.
The facility's own policy, last reviewed on January 8, 2025, requires immediate reporting of suspected abuse to multiple agencies. The policy states that "all reports of resident abuse are reported to local, state, and federal agencies and thoroughly investigated by facility management." It mandates that suspected abuse "must be reported immediately to the administrator and to other officials according to state law."
The policy requires reports to seven different entities: the state licensing agency, the local ombudsman, the resident's representative, adult protective services, law enforcement officials, the resident's attending physician, and the facility medical director.
None of those reports were made.
The administrator's decision to override her nursing staff's professional judgment left the incident uninvestigated by outside authorities. State inspectors discovered the failure during a complaint investigation that began December 23, nearly a week after the alleged abuse occurred.
The affected resident had communicated clearly that the touching was unwanted. She cried when describing it to staff. She expressed fear about the other resident's sexual intentions. Three separate staff members, from nursing assistant to registered nurse, identified the behavior as inappropriate and potentially abusive.
The male resident had entered the female resident's room uninvited and touched her body without permission while she was vulnerable in bed. The victim's immediate emotional distress and her statement about his perceived sexual intentions provided additional context that concerned the nursing staff.
Federal regulations require nursing homes to protect residents from abuse and to report suspected incidents immediately. The facility's own policy acknowledges these requirements, mandating reports to multiple agencies whenever abuse is suspected.
But policies only work when administrators follow them.
The administrator's role as abuse coordinator gave her significant authority over how the facility responded to allegations. Her decision that the incident wasn't "sexual in nature" effectively ended the facility's investigation and prevented outside agencies from conducting their own reviews.
Her reasoning contradicted the professional opinions of three staff members who had direct contact with both residents and understood the incident's context. The registered nurse, with advanced training in patient care and abuse recognition, had specifically identified the behavior as sexual abuse based on the lack of consent and the victim's interpretation of the perpetrator's intentions.
The administrator's failure to report also violated the resident's right to protection from abuse. Federal nursing home regulations require facilities to ensure resident safety and to take immediate action when abuse is suspected. By refusing to file required reports, the administrator prevented outside agencies from investigating, potentially leaving both residents at risk.
The incident remained hidden from state authorities until inspectors arrived for an unrelated complaint investigation. Only then did the administrator's decision come to light, when investigators interviewed staff members who had tried to follow proper procedures.
The female resident spent nearly a week without the protection that state oversight might have provided. The male resident received no intervention or evaluation that might prevent future incidents. The facility's other residents remained unaware that their abuse coordinator had failed to follow mandatory reporting requirements.
The administrator told inspectors she would have reported the incident "if the facility knew it was sexual in nature." But her facility did know. Three staff members had identified it as sexual abuse and followed the proper chain of command to bring their concerns to her attention.
She chose not to listen.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for West Hills Health and Rehabilitation Center from 2025-12-23 including all violations, facility responses, and corrective action plans.
Additional Resources
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