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F0600
K

Failure to Protect Cognitively Impaired Resident from Sexual Abuse

Junction City, Kansas Survey Completed on 11-13-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A cognitively impaired female resident with severe cognitive impairment, a history of wandering, and inability to consent to sexual relations was not protected from sexual abuse by another resident. The male resident involved was cognitively intact, had a history of inappropriate sexual behaviors, and was known to make sexually explicit comments, gestures, and attempts at contact. Despite being aware of his inappropriate behaviors and receiving counseling and medication for hypersexuality, he continued to pursue and interact with the cognitively impaired resident. Multiple documented incidents occurred prior to the abuse event, including the male resident making inappropriate gestures, blowing kisses, and inviting the female resident to his room. Staff and social services were aware of these behaviors and had taken steps such as moving the male resident to a different room and providing education about consent and legal implications. However, the female resident continued to access the male resident's room, and staff interventions were insufficient to prevent further contact between the two residents. The deficiency culminated when staff found both residents in the male resident's room, both unclothed from the waist down, with the male resident performing oral sex on the cognitively impaired female resident. Interviews with staff and the male resident confirmed the incident and the ongoing pattern of inappropriate sexual behavior. The facility's failure to adequately supervise and prevent contact between the residents resulted in the female resident being subjected to sexual abuse.

Removal Plan

  • Staff immediately separated R1 and R2, and placed R2 under one-on-one supervision, pending assessment
  • R1 was placed on continuous monitoring, and R2 was restricted from unsupervised access to rooms
  • Administrative Staff A and Administrative Nurse D initiated an internal investigation per the abuse policy upon knowledge of the incident, and after R1 and R2 were separated
  • Staff re-education on abuse prevention, reporting, and sexual consent with cognitively impaired residents training initiated and continued for all staff to be re-educated prior to working the next scheduled shift until all staff had been re-educated
See complete original report
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