F0609

D

Failure to Report and Protect After Alleged Resident-to-Resident Sexual Abuse

Oroville, California Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The facility failed to timely report an allegation of sexual abuse and to protect a resident after staff observed inappropriate physical contact between two residents. Facility policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required reporting all alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, including immediately but not later than two hours when abuse is involved. The policy also required immediate protective measures for alleged victims, such as increased supervision and emotional support. Despite this, an RN documented on 12/20/25 that staff reported a cognitively intact male resident sitting next to a severely cognitively impaired female resident, touching her side and grunting, and only noted to monitor behavior.

Resident 1, the alleged victim, had diagnoses including toxic encephalopathy, dementia with psychotic disturbance, and schizophrenia, with a recent MDS showing severely impaired cognition (BIMS score of 5). Resident 2, the alleged perpetrator, had diagnoses including COPD, major depressive disorder, and difficulty in walking, with an intact cognition (BIMS score of 14). On 12/20/25, RN A documented in Resident 2’s progress notes and the facility communication report that staff saw Resident 2 rubbing Resident 1’s side while grunting, and that the residents were separated. However, RN A did not complete a nursing evaluation, did not document in Resident 1’s record, did not initiate a change in condition assessment, and did not report the allegation as abuse per facility policy, stating she did not feel compelled to report because she had not personally witnessed the interaction and that she only entered a progress note as directed.

On 12/22/25, a subsequent incident occurred in which staff witnessed Resident 2 touching Resident 1’s chest area, as documented in an IDT note dated 12/23/25. During observation on 12/23/25, Resident 1, in bed, could not recall the incidents but stated that something had happened that was not good. Resident 2 was observed ambulating independently in his wheelchair without direct staff supervision, including to the area outside Resident 1’s room. In an interview, the Administrator stated he was unaware of the 12/20/25 incident because nursing staff failed to notify him, confirmed the incident was not reported per facility policy, and acknowledged that no solid plan or specific interventions were implemented to supervise Resident 2 or keep him away from Resident 1, despite knowing that Resident 2 moved throughout the facility in his wheelchair without supervision. The Administrator also confirmed that the 12/20/25 incident could have led to the escalation and the 12/22/25 incident.