Failure to Protect Resident From Sexual Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident. During routine morning care on 12/30/25, a CNA was informed by a resident witness that he had observed a male resident (R1) fondling a female resident (R2) on two separate occasions approximately four weeks earlier, two days apart. The witness reported that the first incident occurred at a puzzle table, where R1 squeezed R2’s breast over her clothes and then rubbed her thigh. The second incident reportedly occurred in a hallway near the therapy gym, where R1 again squeezed R2’s breast over her clothes, then lifted her shirt and bounced her breast. R1 later admitted in an interview with the NHA and DON that he had lifted R2’s top and touched her breasts, describing the incident as very quick. R1’s EMR showed he was cognitively intact, responsible for his own medical and financial decisions, and had been admitted with diagnoses including hydronephrosis. R2’s EMR documented that she had cerebral palsy, developmental disorders of speech and language, was non-communicative, and had a legal guardian/conservator for medical and financial decisions. A personal protection order was issued on behalf of R2, citing that she had a reasonable apprehension of sexual assault because R1 had sexually assaulted or threatened her with sexual assault. The facility had an Abuse, Neglect and Exploitation policy intended to prohibit and prevent abuse, neglect, and exploitation, but the events described show that R2 was subjected to inappropriate sexual touching by R1, resulting in mental trauma based on the reasonable person concept.
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