F0600

J

Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Known Sexually Inappropriate Resident

Worthington, Minnesota Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a severely cognitively impaired female resident from sexual abuse by a male resident with a known history of sexually inappropriate behaviors. Prior to admission, referral documents from a previous facility clearly identified that the male resident had engaged in public urination, following female residents, rubbing their shoulders and arms, and an incident involving touching a woman’s breast, which had been serious enough to be reported to the State Agency. That prior facility had revised his care plan to include 1:1 supervision to prevent further sexually inappropriate behavior, and progress notes documented that while on 1:1 supervision he had no further incidents of touching female residents. Despite receiving these records, the admitting facility did not initially incorporate this history of sexually inappropriate behaviors into his vulnerability assessment or care plan.

After admission, the male resident’s behaviors toward female residents, particularly one female resident with severe cognitive impairment, escalated over several months. Progress notes documented repeated episodes of him holding and rubbing female residents’ hands, rubbing or attempting to touch their arms and chest, standing over or very close to them, staring at them, and attempting to touch their breasts. Staff repeatedly redirected him, but the behaviors persisted and often required frequent or constant redirection. Although the care plan was eventually updated to address “touching of other residents” and directed staff not to allow physical contact, progress notes showed that staff did not consistently prevent physical contact, and the male resident continued to approach and touch female residents, including the cognitively impaired female resident who became the primary focus of his attention.

On the day of the abuse incident, a nursing assistant observed the male resident standing over the cognitively impaired female resident, who was resting in a recliner, with his hand under her shirt touching her breast. Another resident pointed toward them, prompting the assistant to intervene, tell him to stop, and direct him away. The female resident, who had severe cognitive impairment and required extensive assistance with ADLs, awoke and questioned what he was doing, indicating she was unable to independently protect herself from the unwanted sexual contact. This event occurred in the context of documented ongoing and escalating sexually inappropriate behaviors by the male resident toward female residents, including this particular resident, and despite prior knowledge from referral records, guardian reports, and internal documentation that he had a pattern of progressing from seeking proximity and handholding to touching women’s breasts.