F0600

J

Failure to Prevent Resident-to-Resident Sexual Abuse by Known Sexually Disinhibited Resident

Bethel Park, Pennsylvania Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from resident-to-resident sexual abuse despite having policies defining abuse, neglect, and sexual abuse as non-consensual sexual contact of any type with a resident. The facility’s own policy states that abuse includes the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and that neglect is the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility had residents with known psychiatric and behavioral conditions, including one resident with a history of sexually inappropriate behavior, but did not have an adequate care plan in place addressing sexual expression and safety until after an incident occurred.

One resident (R1) had diagnoses including parkinsonism, bipolar disorder, and anxiety disorder, and a BIMS score of 15, indicating cognitive intactness. Another resident (R2) had schizoaffective disorder, anxiety, and depression, and a BIMS score of 6, indicating severe cognitive impairment. R2’s care plan identified risk for attention-seeking/manipulative behavior related to psychiatric disease. On a documented date, staff reported that R1 was observed in the dining room alone with R2, acting inappropriately and exposing himself. The residents were separated, and the note stated that the other resident appeared to be consenting, but R2’s low BIMS score and psychiatric diagnoses were known to the facility.

The clinical record showed that R1 had exhibited sexually inappropriate behavior on multiple prior dates (7/21/25, 7/23/25, 8/16/25, and 1/3/26). A psychiatric evaluation note for R1 documented that he had been exhibiting inappropriate sexual behaviors with female residents and that staff had observed these behaviors. Staff interviews revealed that some employees had witnessed the incident between R1 and R2 and that at least two staff members had heard rumors or observed changes in R1’s behavior, including sexual behaviors, beginning around the summer of 2025. Despite this history and staff awareness, R1’s care plan addressing sexual expression and protection from unconsented sexual expression was not initiated until after the incident with R2, and the facility failed to prevent R1, a resident with known sexually inappropriate behavior, from having sexual contact with a resident who was not capable of consent, resulting in an Immediate Jeopardy situation.

Removal Plan

• Place Resident R1 on 1:1 supervision and maintain 1:1 supervision.
• Ensure Resident R2 remains safe from resident-initiated sexual abuse by providing 1:1 supervision to Resident R1.
• Update Resident R1's care plan to reflect 1:1 supervision.
• Interview current female residents who are cognitively intact to identify any other residents potentially affected.
• Complete skin assessments for current female residents who are cognitively impaired to identify any other residents potentially affected.
• Provide education to all staff on Abuse/Neglect and Reporting of Incident and Accidents by the Director of Nursing or designee.
• Complete audits for new admissions and current residents for sexual behaviors to ensure resident safety.
• Hold an Ad Hoc Quality Assurance and Process Improvement (QAPI) meeting.
• Monitor the plan of correction at QAPI meetings until consistent substantial compliance is met.