Failure to Prevent Sexual and Physical Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, including sexual and physical abuse, as evidenced by multiple incidents involving residents with severe cognitive impairment. One resident with dementia and a BIMS score indicating severe cognitive impairment was observed manipulating another resident's genital area over her clothing while both were in the closed Alzheimer's Unit. Both residents were unable to answer questions appropriately, and the facility recognized this as an instance of sexual abuse. Additionally, two other residents, both with dementia and other significant medical conditions, were involved in a physical altercation in the secure Memory Care Unit. One resident entered another's room, resulting in a struggle where one attempted to choke the other, who responded by striking back. Both sustained minor injuries, including red marks around the neck, a cut lip, and facial scratches. Staff and CNAs witnessed the incident, and documentation confirmed the altercation as resident-to-resident abuse.