F0600

E

Failure to Protect Residents From Ongoing Sexual and Physical Aggression by a Cognitively Impaired Resident

Oakland, California Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect three cognitively intact or communicative residents from ongoing aggressive and inappropriate sexual behaviors by another resident with known mental and behavioral disorders and cognitive impairment. Resident 4, a female resident admitted in 2020 with a BIMS score of 7/15, was known by staff, including the DON and RN 1, to have a hot temper, become easily angry, and exhibit hyper-sexualized behaviors toward male staff and residents. Despite this knowledge, Resident 4 continued to have access to other residents in common areas and hallways, where she engaged in sexually inappropriate and aggressive conduct.

Resident 1, a male resident admitted in 2019 with a disability-related diagnosis and able to make himself understood, reported that while in the activity room a few weeks prior, Resident 4 wheeled herself to him, licked her lips, stuck out her tongue, rubbed his thighs, grabbed his scrotum, and made explicit sexual comments without his consent. He reported feeling embarrassed, angry, and unsafe. The Activity Director confirmed awareness that interactions between Resident 1 and Resident 4 had become more explicit over time, with Resident 4 physically touching Resident 1, and stated he had to keep them separated in the activity room, but he did not recall specific dates.

Resident 2, who was usually able to understand others and make himself understood, stated that Resident 4 frequently caused problems with staff and residents, tried to touch and grab his genitals, and became violent when she did not get what she wanted. He described an incident in the activity room where Resident 4 became angry, hit an activity assistant, pulled her hair, and threw hot coffee at both the assistant and him. Resident 3, cognitively intact with a BIMS score of 14/15, reported that Resident 4 grabbed his buttocks from behind, startling him, and that he had seen her yelling angrily at others in hallways and activities areas, making him feel uncomfortable when she was near. The DON acknowledged that Resident 4 had grabbed him on the buttocks and made explicit sexual comments, and that she often tried to touch residents inappropriately and became mad if they tried to stop her. Although the Activity Director reported Resident 4’s inappropriate and aggressive behavior to facility management, he stated he was told only to separate her from other residents when such behaviors were observed, indicating the facility did not effectively implement its abuse prevention policy to provide a safe environment and prevent further abuse.