F0600

D

Failure to Prevent Ongoing Sexual Abuse Between Cognitively Impaired Residents

Chatsworth, Georgia Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent sexual abuse between residents and to protect residents from non-consensual sexual contact as required by its Abuse, Neglect, and Exploitation policy. The policy states the facility will prohibit and prevent abuse, neglect, and exploitation, including non-consensual sexual contact of any type with a resident. Despite this, one resident (R1), who had significant cognitive impairment with a BIMS score of 08 and diagnoses including vascular dementia, bipolar disorder, anxiety disorder, and dementia with behavioral disturbances, repeatedly entered other residents’ rooms and beds. Nursing notes over several months documented R1 attempting to go into other residents’ rooms, climbing into their beds, wandering hallways, and being found lying on top of other residents, both male and female, with staff redirection attempts noted as unsuccessful.

Multiple nursing notes described specific incidents where R1 was found in bed with other residents. On one occasion, a nurse documented that R1 was found in another patient’s room lying asleep on top of another patient and was assisted off. Another note the same date documented that another patient was in R2’s room and laid down on top of her and went to sleep, and that the other patient was removed and returned to their room. Subsequent notes indicated that R1 continued to try to get into bed with residents and that he was wandering up and down hallways and going in and out of other residents’ rooms, with continued attempts to enter a specific female resident’s room despite redirection. Staff interviews confirmed that it was common and “normal” for R1 to get in and out of bed with other residents and to lie on top of them, and that CNAs routinely reported these behaviors to nursing staff.

R2 was a resident who could not complete the BIMS, indicating significant cognitive impairment. A nurse note documented that R2’s daughter was concerned after finding blood on R2’s bottom lip and that R2 was not herself. Later, a nurse note recorded that R2’s responsible party was notified that another resident had been found in bed with R2, with his pants down and his lips on hers. The facility’s investigation included a CNA’s written statement that R1 was found in R2’s bed with his pants and underwear off, on top of R2, holding her by both arms and attempting to kiss her while R2 screamed. Another CNA interview described finding R1 on top of R2 with her arms pinned down, his face very close to hers, and his pants pulled down. Staff, including the Social Services Assistant and LPNs, acknowledged that R1’s behaviors of getting into bed with other residents were ongoing, that redirection was ineffective, and that these behaviors occurred both when R1 was on a locked dementia unit and after the unit doors were removed, yet R1 continued to have access to other residents and their rooms.