F0600

J

Failure to Address Known Sexual and Aggressive Behaviors Resulting in Resident Abuse

Corbin, Kentucky Survey Completed on 01-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a severely cognitively impaired resident from abuse by another resident despite months of documented sexually inappropriate and aggressive behaviors. The resident identified as the aggressor had schizophrenia, anxiety, depression, and dementia, and psychiatric evaluations as early as mid‑August documented a known history of sexually inappropriate behavior, aggression, psychosis, delusions, paranoia, irritability, and agitation. Staff and psychiatric notes repeatedly described ongoing sexually inappropriate behavior, increased aggression toward staff and other residents, physical contact with other residents, and attempts to enter other residents’ rooms, with redirection often ineffective. Despite this, the facility’s MDS assessments in August and October documented no behavioral symptoms, the behavior care area did not trigger, and the comprehensive care plan did not include a behavioral problem or interventions for these behaviors.

Additional facility documentation showed that staff were aware of repeated incidents involving the aggressive resident’s sexually inappropriate contact with staff and targeting of others. Behavioral nursing notes described the resident pushing a female resident down the hallway toward her room, grabbing a CNA’s arm and trying to put his arms around her, and later grabbing CNAs’ legs and buttocks during care. A speech therapist reported that the resident leaned over her and kissed her face in his room. Behavior Review Committee notes in November recorded episodes of touching female caregivers inappropriately and identified triggers, but recommended only reminders, redirection, and encouragement of activities, without evidence of increased supervision, modified staff assignments, or other protective interventions. These behaviors and risks were not incorporated into the resident’s care plan or CNA Kardex, and the DON later acknowledged that behavioral care plans and Kardex entries were not updated and that she had assumed, without verification, that the Unit Manager was doing so.

The resident who was abused was severely cognitively impaired with dementia and anxiety disorder and had not been assessed or documented as able to consent to sexual contact, contrary to facility policy. Nursing notes shortly before the incident recorded that this resident and her family were fearful of the aggressive resident, with the resident crying, expressing fear that men were outside her door to harm her, and specifically identifying the aggressive resident as someone who made her feel uncomfortable and scared. On the day of the incident, staff and a family member observed the aggressive resident pacing the hallway, repeatedly standing in his doorway and looking into the cognitively impaired resident’s room. An LPN was alerted that he was attempting to enter the room and then observed him inside, positioned over the resident in bed, holding her hands down with one hand and pushing her shoulder back into the bed with the other while attempting to get on top of her. Afterward, the cognitively impaired resident exhibited ongoing emotional distress, crying, fear of that man coming into her room again, and a desire to leave the facility, with repeated social services and nursing documentation of anxiety, fear of individuals entering her room, and need for frequent reassurance.

Despite these events and the facility’s own abuse policy defining sexual abuse as nonconsensual sexual contact and requiring assessment of capacity to consent, the administrative team did not initially treat the incident as abuse. The SSD/Assistant ED and ED stated they believed the severely cognitively impaired resident could consent to being touched and to the male resident entering her room, but they could provide no supporting assessment or documentation. The SSD/Assistant ED described the facility’s practice as gathering information and then deciding as a team whether to report to the state, and reported that the ED, SSD, and DON decided this incident did not need to be reported because they did not feel it met the definition of abuse. The ED, who served as abuse coordinator, stated there had not been recent incidents requiring reporting because the leadership team had not determined that abuse had occurred. The DON similarly stated she had not identified the incident as abuse based on her belief that the severely cognitively impaired resident could consent to being touched. The surveyors determined that the facility failed to promptly recognize, assess, and intervene to address known behaviors and failed to develop and implement a comprehensive behavioral care plan to protect other residents, resulting in abuse and psychosocial harm.