F0600

E

Failure to Prevent Resident‑to‑Resident Sexual Contact, Verbal Abuse, and Repeated Elopements

Columbus, Montana Survey Completed on 02-10-2026

Penalty

Fine: $19,950

Summary

The deficiency involves the facility’s failure to protect residents from abuse and neglect, including inappropriate physical contact between residents, verbal abuse by staff, and repeated elopements. One resident with severe cognitive impairment and a history of boundary issues was documented as inappropriately touching another resident’s bottom and seeking out female residents to touch or kiss, as well as groping himself while looking into female residents’ rooms. Despite this, his care plan did not include documentation or interventions specific to sexual behaviors or lack of physical boundaries, either before or after the incident. A subsequent incident involving the same resident bumping another female resident’s thigh occurred after staff had already noted increased sexual behaviors and disruptive conduct, yet the care plan still lacked protective measures or behavior-specific interventions. Facility investigation notes indicated that both cognitively impaired residents involved could not recall the incidents, and the events were deemed “unable to substantiate,” even as staff acknowledged the resident’s sexual behaviors and instructed him to keep his hands to himself.

The deficiency also includes an incident of verbal abuse toward a resident by a staff member. During shift change, a staff member directed profane and demeaning language at a resident, telling the resident to “shut the f k up.” The facility’s investigative report substantiated that this statement was made as alleged, and interviews identified additional reports that the same staff member was rude and made residents feel small. The facility’s own findings characterized the language used toward the resident as verbal abuse, confirming that the resident was not kept free from abusive treatment.

Additionally, the facility failed to prevent neglect related to repeated elopements by another resident. Over a 43‑day period, this resident left the facility five times without staff awareness, and each time was found in the community rather than on facility grounds, including once approximately one mile away at a busy stop near an interstate. The resident had been admitted from a sister facility and had a known history of leaving to go to a park where she exchanged sex for drugs and had been exploited for sex and drugs. Despite this history and the repeated elopements, the resident was able to leave the facility multiple times without detection, demonstrating that effective plans and protections to prevent further elopements were not in place.