Failure to Prevent Resident-to-Resident Sexual Abuse of a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to prevent abuse when a cognitively intact resident engaged in inappropriate sexual contact with a severely cognitively impaired resident. Facility policy dated 8/25/2025 states that all residents have the right to be free from verbal, sexual, physical, and mental abuse, and defines sexual abuse as non-consensual sexual contact, including unwanted intimate touching of the breasts. The Final Facility Incident Report for 01/02/2026 documents a resident-to-resident interaction in the TV lounge in which one resident was observed with his hand on another resident’s chest and admitted he had a moment of weakness and placed his hand on the other resident’s breast over clothing. The resident who initiated the contact had diagnoses including a displaced right acetabulum fracture, COPD, heart failure, atrial fibrillation, peripheral vascular disease, and hypertension, and was documented as cognitively intact with a BIMS score of 15/15 and able to understand and be understood. The resident who was touched had diagnoses including dementia, depression, hypertension, and hyperlipidemia and was documented as severely cognitively impaired. This resident also had an existing physician’s order for 15-minute observation checks due to wandering. A CNA later reported visualizing another resident making inappropriate contact with this severely cognitively impaired resident. The administrator reported that after an incident on 12/28/2025, the cognitively intact resident was placed on 15-minute checks for three days and, when no concerns were identified, those checks were discontinued. Subsequently, staff observed this same resident touching the back of the cognitively impaired resident’s head, and a CNA reported observing him pacing the hallways looking for her. These events, in the context of the facility’s stated abuse-prevention policy, demonstrate that the facility did not effectively prevent sexual abuse of a vulnerable resident by another resident.
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