F0600

J

Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Co-Resident

Temple, Texas Survey Completed on 01-03-2026

Penalty

Fine: $15,940

Summary

The deficiency involves the facility’s failure to protect a severely cognitively impaired, nonverbal female resident from sexual assault by a male co-resident and to ensure adequate supervision and monitoring on the memory care unit. The female resident had dementia, anxiety and depressive disorders, gait and mobility abnormalities, and required supervision or touching assistance with transfers, bed mobility, and lower body dressing. Her MDS showed she was unable to complete a BIMS interview, had short- and long-term memory problems, and was moderately impaired in daily decision-making. Her care plan identified wandering into other residents’ rooms and sometimes lying in other residents’ beds, with interventions directing staff to anticipate and meet needs, protect other residents’ rights and safety, divert and remove her from situations, and redirect her to her room or common areas when she entered other residents’ rooms.

On the day of the incident, a medication aide reported that while passing medications she knocked, heard moaning, and entered the male resident’s room, where she observed him on top of the female resident in his bed. She stated both residents’ pants were down, the female resident’s brief was still on, the female resident was making noises and had a flushed face, and the male resident was thrusting against her. She told him to stop, after which he rolled off, and she separated the residents and called for assistance. Nursing documentation described the female resident as being found in bed with another resident, with staff intervening and separating them, and later noted that she was observed in a male resident’s room in bed with a male on top of her gyrating his hips. A subsequent skin check documented dried feces on the female resident’s pubic hair. The female resident was nonverbal, unable to meaningfully participate in BIMS, and could not be interviewed about the event.

The male resident involved had vascular dementia, schizophrenia with auditory and visual hallucinations, and a BIMS score of 15 on his most recent MDS, indicating he was cognitively intact at that time. His care plan noted he resided on the secure unit due to wandering and poor safety awareness. On the day of the incident, nursing documentation for him stated he was observed lying in bed next to a female resident when staff intervened. An incident note (later struck out) described him as confused and disorganized with impaired judgment and poor personal boundaries at the time of redirection. The facility’s self-report narrative, matching the administrator’s note, stated that the medication aide found the male resident in bed with the female resident, his pants down with genitalia exposed, and the female resident’s pants down but brief intact, and that the male resident rolled to his side when told to stop. The administrator documented that no penetration was noted by the witness and no evidence of penetration was seen on physical examination, but the family of the female resident reported being told that a male resident was found on top of her with clothes off and her brief loosened, and that she was not sent to the hospital until they requested it two days later.

The deficiency is further supported by inconsistent and incomplete monitoring and staff accounts regarding supervision and rounding on the memory care unit. Fifteen-minute check forms for both residents on the day of the incident contained only limited entries, with no documentation beyond early evening times. Staff interviews revealed conflicting statements about whether the female resident wandered, whether she was on 1:1 supervision, how often residents were rounded on (ranging from every 30 minutes to less than every two hours), and who the abuse coordinator was. Some CNAs denied knowledge of any resident-to-resident sexual abuse incidents, despite the documented event. The assistant DON acknowledged being told that a staff member walked in on the male resident on top of another resident having sexual intercourse but did not know if 1:1 monitoring was implemented. The social worker stated she did not conduct psychosocial assessments or safety surveys for the involved residents after the allegation. These actions and inactions demonstrate that the facility did not ensure adequate supervision, timely assessment, and protection of the female resident’s right to be free from abuse and neglect.

Additional information from interviews with the residents’ representatives underscores the nature of the event and the facility’s response at the time of the deficiency. The female resident’s MPOA stated she was unable to get up on her own and was not a wanderer, and that they were notified by phone that a male resident was found on top of her with clothes off and her brief loosened. They reported learning two days later that she had not been sent to the hospital on the day of the incident and that they had to request hospital evaluation. The male resident’s responsible party reported being told that staff caught him sexually assaulting another female resident and that he was sent to the ER because he was distraught, and also stated staff told them this was not the first incident involving him. These documented accounts, combined with the clinical records and staff statements, show that the facility failed to protect the female resident from sexual abuse by another resident and failed to provide consistent supervision and timely, thorough assessment in accordance with the residents’ conditions and care plans.

The survey findings also note discrepancies in documentation of the male resident’s cognitive status and behavior. While his quarterly MDS showed a BIMS of 15 and no behavioral symptoms, nursing notes around the time of the incident described him as having a BIMS of 6 with severe cognitive impairment, confusion, disorganized behavior, and poor personal boundaries. The administrator’s note and the facility’s self-report both referenced his low BIMS score and cognitive impairment, yet staff interviews varied on whether he wandered or could give consent. The lack of clear, consistent assessment and monitoring of his behaviors and risks, combined with the failure to prevent or promptly and comprehensively respond to the observed sexual contact with a vulnerable, nonverbal resident, constitutes the core of the deficiency identified by surveyors.