F0609

D

Failure to Report and Investigate Alleged Sexual Abuse Between Residents

Cincinnati, Ohio Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to recognize and report an allegation of sexual abuse between two residents, and to conduct a thorough investigation, as required by facility policy and state reporting requirements. One resident, who was cognitively intact and had a history of sexually inappropriate behavior, was housed on a secured men’s memory care unit under an order for placement there for safety of self and others related to major depressive disorder. Another resident on the same secured unit had severe dementia, impaired cognition, and required assistance with decision-making. On the date of the incident, staff, including therapy personnel and a CNA, observed the cognitively intact resident with his hand on the genital area of the severely cognitively impaired resident, rubbing and squeezing through clothing while both were seated in a common area.

Multiple staff members provided consistent accounts of the event. A CNA reported that two therapists had seen the cognitively intact resident with hand contact to the other resident’s genital area, caressing and rubbing through his pants. The Occupational Therapy Assistant stated she observed the resident’s hand around the other resident’s penis, squeezing and rubbing it, and reported this to the CNA. The Physical Therapist similarly reported seeing the resident’s hand on the other resident’s genital area. Nursing documentation for both residents recorded that the incident involved hand contact to the genital area in the common area, that staff intervened and separated the residents, and that guardians were notified. A Nurse Practitioner documented, as a late entry, that she was called about the incident, assessed both residents, and was told by staff that the cognitively intact resident was attempting to ejaculate the severely demented resident, who did not appear to understand what was happening.

Despite these observations and documentation, the Administrator did not report the incident to the state agency via the Self-Report Incident (SRI) system and acknowledged that no thorough investigation was completed. The Administrator stated he did not consider the event to be sexual abuse and believed it was not reportable because both residents were fully clothed and he felt that “nothing happened” to the cognitively impaired resident. This position was taken even though the Administrator verified that one resident was cognitively intact, had a history of sexually inappropriate behavior, and the other resident was severely cognitively impaired and unable to consent to being touched in that manner. The facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type, including unwanted intimate touching of the perineal area, and required that any allegation involving a resident who may not have capacity to consent be treated as alleged sexual abuse and promptly reported and investigated. The Administrator confirmed that, under this policy, the incident should have been reported and thoroughly investigated, but it was not.

Additional documentation showed that after the incident, the cognitively intact resident was given an order for medroxyprogesterone for high-risk sexual behavior and a behavioral care plan for sexually inappropriate behaviors with other residents was created. An IDT note later described another observation of the same resident placing his hand on another resident’s perineal area, after which he was moved to a private room and seen by a psychiatric provider. However, for the original incident involving the severely cognitively impaired resident, there was no documented evidence that either resident was evaluated by psychiatric services at that time. The failure identified by surveyors centered on the facility’s noncompliance with its abuse policy and regulatory requirements: specifically, not reporting the allegation of sexual abuse to the proper authorities and not conducting a prompt and thorough investigation of the incident between the two residents.

The facility’s written policy on Abuse, Neglect, Misappropriation of Resident Property, and injury of unknown origin, dated August 2024, assigned the Administrator responsibility for implementing the abuse/neglect program and required that any reports of abuse be promptly and thoroughly investigated and immediately reported to the Administrator/designee and to the Department of Health and social services. The policy explicitly stated that sexual abuse includes unwanted intimate touching of the perineal area and that if there is an allegation that a resident did not consent or may not have capacity to consent to sexual activity, the facility must respond as an alleged violation of sexual abuse and provide immediate safety measures. In this case, despite staff observations and documentation consistent with non-consensual sexual contact involving a resident lacking capacity to consent, the Administrator did not follow the policy’s reporting and investigation requirements, resulting in the cited deficiency.