F0600

J

Failure to Protect Cognitively Impaired Resident From Sexual Abuse and Inadequate Investigation

Nanticoke, Pennsylvania Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse by another resident and to follow its own abuse and sexual abuse investigation policies. Resident 1, who had dementia and a BIMS score of 7 indicating severe cognitive impairment and impaired judgment and decision-making capacity, shared a bathroom with Resident 2, who had intact cognition with a BIMS score of 14. On one evening, a nurse aide (Employee 1) observed Resident 1 in the shared bathroom unlocking and slightly opening the door to Resident 2’s room, which was described as a habitual signal that she was finished using the bathroom. Resident 2 opened his door, leaned toward Resident 1, and kissed her on the lips. Employee 1 immediately removed Resident 1 from the bathroom and notified the RN Supervisor. The facility’s investigation documented this event and noted that Resident 2 later stated, “She is my friend. Who cares if we kissed.”

Following this initial incident, staff reported ongoing concerning behaviors by Resident 2 toward Resident 1. Employee 1 stated that she and another nurse aide frequently remained in Resident 1’s room to ensure her safety because Resident 2 continued to sit outside Resident 1’s room and stare at her in common areas. Facility documentation showed that the inside door to Resident 2’s side of the shared bathroom was locked and a bedside commode was provided to limit his access to the shared bathroom, and that the facility attempted to relocate Resident 2 but he declined. The Nursing Home Administrator acknowledged that Resident 1 was not relocated after the first incident due to concern that a move would increase her confusion, and Resident 1 was not offered a room change despite her cognitive impairment. Progress notes documented that Resident 2 exited Resident 1’s room after a visit with her and her family and that he later argued with staff, felt he was being watched, and could not be redirected. Social Services met with Resident 2 and documented that he reflected on past interactions with Resident 1 and was instructed not to enter her room or allow her into his room.

A subsequent, more serious incident occurred when Employee 3 and Employee 4, both nurse aides, were conducting rounds after midnight and found Resident 1 missing from her bed, with her wheelchair empty and next to the bed. They found the shared bathroom door locked from the inside and, due to the known prior history between the residents, proceeded to Resident 2’s room. There, they observed Resident 1 lying naked in Resident 2’s bed while Resident 2 was touching her vaginal area, with her legs open. Employee 3 later clarified in interview that she observed Resident 2’s fingers inside Resident 1’s vagina and that she yelled for the supervisor, at which point Resident 1 went to the bathroom, dressed, and wiped herself. Both aides documented that Resident 1 complained of vaginal pain and was observed checking herself in the bathroom. The facility’s investigative documentation recorded that both residents stated they had been talking, that the facility determined there was no evidence of penetration, and that no further assessment was completed at that time. The Nursing Home Administrator stated Resident 1 was not sent to the emergency department for evaluation despite facility policy indicating the need for evaluation following suspected sexual abuse.

Despite these events and the facility’s own policy defining sexual abuse as non-consensual sexual conduct and requiring investigation and protection when a resident may lack capacity to consent, the facility did not fully investigate or rule out sexual abuse and did not implement timely and effective interventions to prevent further contact between the two residents. Employee 3 reported that staff were aware of multiple prior incidents, including Resident 2 being found in the bathroom with Resident 1 on multiple occasions and an additional incident where Resident 2 was found caressing Resident 1’s breast. Employee 1 reported that even after the January 11 incident, the two residents were still found unattended together multiple times, and at the time of her interview, they were alone together in the chapel, which the surveyor confirmed. Resident 2 acknowledged spending time alone with Resident 1 and described her as infatuated, while recognizing her dementia diagnosis. Resident 1’s care plan did not include 15-minute safety checks until days after the sexual abuse incident, and the safety check documentation for both residents was incomplete or delayed, with later-added entries and signatures that conflicted with the original records. The Director of Nursing could not explain why incomplete safety check records were later supplemented. Staff reported observable changes in Resident 1’s behavior after the incident, including staying awake later than usual and appearing fearful when using the bathroom, frequently looking toward the doorway previously used by Resident 2. These failures led surveyors to determine that the facility did not ensure Resident 1 was free from sexual abuse by Resident 2 and did not follow its abuse policies, resulting in Immediate Jeopardy to residents’ health and safety.

Removal Plan

• Provide staff education on facility abuse policies, including allegations of sexual abuse.
• Provide education to nurse aides and licensed nurses on documenting resident behaviors.
• Monitor documentation of resident behaviors and update resident care plans as needed.
• Continue education prior to each licensed staff member’s next shift.
• Immediately place the perpetrator and victim on 1:1 supervision in the event of sexual abuse.