F0600

D

Failure to Protect Cognitively Impaired Resident From Sexual Contact in Memory Care Unit

Clyde, Ohio Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The facility failed to ensure adequate supervision to protect a resident on the secured memory care unit from sexual abuse. A resident with vascular dementia, severe cognitive impairment (BIMS score 0/15), dependence for ambulation, and a history of sexual behaviors and poor impulse control was seated in a wheelchair in the common area of the memory care unit. Another resident with severe cognitive impairment (BIMS score 6/15), independent ambulation, and a similar history of sexual behaviors and poor impulse control was observed standing over her, holding her shirt open with one hand and placing his other hand down the front of her shirt. Both residents had guardians and resided on the secured memory care unit at the time of the incident.

The incident was witnessed by a CNA returning to the unit, who immediately reported that the male resident’s hand was inside the female resident’s shirt while both were in the common area. The CNA stated she did not feel the interaction was consensual, although she could not recall whether the female resident displayed her usual combative or rejecting behaviors when she did not want someone in her space. The DON and Administrator confirmed that the male resident’s hand was inside the front of the female resident’s shirt. The DON stated that the interaction was considered consensual based on the female resident’s baseline hypersexual behavior, lack of combative response, and lack of distress or memory of the event shortly afterward. The facility’s abuse policy defined sexual abuse as non-consensual sexual contact of any type with a resident, and the facility determined the allegation of sexual abuse to be unsubstantiated and inconclusive, despite both residents having severe cognitive impairment and documented histories of sexual behaviors and poor impulse control.