F0610

D

Failure to Investigate Alleged Sexual Abuse Between Cognitively Intact and Severely Impaired Residents

Cincinnati, Ohio Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to investigate an allegation of sexual abuse between two residents in the secured Memory Care Unit (MCU). Resident #01, who was cognitively intact with diagnoses including major depressive disorder, morbid obesity, pulmonary embolism, intellectual disability, essential primary hypotension, and diabetes mellitus, was ordered to reside in the secured unit for safety of self and others. Resident #12, who had diagnoses including dementia, insomnia, essential primary hypertension, major depressive disorder, and diabetes mellitus, was care planned as having impaired cognition with short- and long-term memory impairment and severely impaired cognition on the MDS, requiring assistance with decision-making. The facility’s 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 and thoroughly investigated.

On 01/28/26, CNA #222 was alerted by OTA #177 and PT #189, who observed Resident #01 seated next to Resident #12 on a couch in the men’s secured unit. OTA #177 reported seeing Resident #01’s hand around Resident #12’s penis, squeezing and rubbing it through clothing, and PT #189 similarly observed Resident #01’s hand on Resident #12’s genital area. CNA #222 reported the incident to ADON #258. Nurse progress notes for both residents documented that Resident #01 had hand contact with Resident #12’s genital area while both were seated in the common area, that staff intervened and redirected Resident #01 away from Resident #12, and that guardians and other parties were notified. NP #501 documented, as a late entry, that staff reported Resident #01 was witnessed attempting to ejaculate Resident #12, that Resident #12 did not appear to understand what had happened, and that Resident #12 was the receiver of another resident’s high-risk sexual behavior.

Despite these observations and documentation, the facility did not conduct a thorough investigation of the alleged sexual abuse as required by its abuse policy. The Administrator stated he did not consider the incident to be sexual abuse and did not report it externally because both residents were fully clothed and he believed “nothing happened” to Resident #12, even while acknowledging that Resident #01 was cognitively intact, had a history of sexually inappropriate behavior, and that Resident #12 was severely cognitively impaired and unable to consent to being touched in that manner. The medical records for both residents lacked documented evidence that either resident was evaluated by psychiatric services after the 01/28/26 incident, despite NP documentation indicating high-risk sexual behavior and severe cognitive impairment of the involved residents. The Administrator later verified that the facility did not complete a thorough investigation related to the incident, in contradiction to the facility’s written abuse policy requiring prompt and thorough investigation and immediate reporting of such allegations.