F0600

D

Failure to Protect Resident From Repeated Sexual Contact and to Follow Abuse Policy

Oroville, California Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The facility failed to protect a resident from sexual abuse and to follow its own abuse, neglect, and exploitation policy after two separate incidents of non-consensual touching by another resident. The policy defined abuse to include certain resident-to-resident altercations and required immediate protection of the alleged victim, examination for injury or psychosocial harm, increased supervision, and emotional support. Despite this, after staff observed one resident sitting next to another and rubbing her side while grunting, the nurse documented the event only in the alleged perpetrator’s chart and did not report it as abuse, did not complete a nursing evaluation or change-in-condition assessment for the alleged victim, and did not initiate protective interventions as outlined in the policy.

The alleged victim, Resident 1, had diagnoses including toxic encephalopathy, dementia with psychotic disturbance, and schizophrenia, and her most recent MDS showed severely impaired cognition with a BIMS score of 5. The alleged perpetrator, Resident 2, had diagnoses including COPD, major depressive disorder, and difficulty in walking, with intact cognition and a BIMS score of 14. Staff documented that on one date Resident 2 was seen touching Resident 1’s side and grunting, and on a later date staff witnessed Resident 2 touching Resident 1’s chest area. The second incident was recorded in an IDT note, but nursing staff confirmed that Resident 1 was not given a full nursing evaluation after this incident, and the Infection Preventionist also confirmed that Resident 1 was not evaluated by nursing staff after the second event.

Multiple staff interviews confirmed that the facility did not implement its abuse policy to protect Resident 1 after either incident. The LVN and RN involved acknowledged that no full evaluation of Resident 1 was completed after the second incident, and one RN stated he was unaware he should have done so per policy. Another RN stated she did not feel compelled to report the first incident as abuse because she had not personally witnessed it and only wrote a progress note in Resident 2’s chart after being told to do so, with no documentation for Resident 1. The Administrator reported he was not informed of the first incident, confirmed there was no solid plan to keep Resident 2 away from Resident 1, and acknowledged that Resident 2 continued to move throughout the facility in his wheelchair without direct supervision, including to the area outside Resident 1’s room, while no specific protective measures were in place for Resident 1.