Failure to Protect Cognitively Impaired Residents From Non-Consensual Physical Contact
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents with severe cognitive impairment were treated with dignity and respect and protected from unwanted physical contact. Facility policy on Resident Rights, revised 1/2024, states that residents have the right to a dignified existence and to be treated with respect and dignity. Resident #1, admitted in October 2025 with diagnoses including psychotic disorder and Alzheimer’s disease, had a Quarterly MDS dated 1/23/26 indicating severely impaired cognitive patterns, and his/her health care proxy was activated on 1/19/26. Resident #2, admitted in December 2022 with unspecified dementia and psychotic disturbance, had an Annual MDS dated 11/14/25 showing severely impaired cognition and a court-appointed guardian as of 1/31/23. Resident #3, admitted in April 2025 with cerebral infarction and adjustment disorder with anxiety, had a Quarterly MDS dated 10/10/25 indicating severely impaired cognition and a court-appointed guardian as of 7/29/25. According to the Health Care Facility Reporting System, the facility reported multiple incidents in which Resident #1 initiated physical contact with Residents #2 and #3 without their consent. On 1/09/26, Resident #1 kissed Resident #3 and hugged Resident #2 without their consent. On 1/16/26, Resident #1 massaged Resident #3’s shoulders without consent. On 2/01/26, Resident #1 touched or groped Resident #2’s breast and groin area over clothing without consent. Social Workers #1 and #2 reported that they met with Resident #1 on 1/12/26 and 1/16/26 to discuss personal boundaries among residents; although Resident #1 verbalized understanding during these conversations, he/she appeared to forget the discussions and their content almost immediately afterward. During a telephone interview on 2/17/26, the Director of Nursing stated that Resident #2 was visibly upset and shaken following the incident in which Resident #1 touched his/her breast and groin area over clothing. These events demonstrate that the facility did not effectively prevent repeated, non-consensual physical contact between residents with severe cognitive impairment, resulting in a failure to uphold residents’ rights to dignity and respectful treatment.
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