F0600

D

Failure to Prevent Sexual Abuse and Timely Address Escalating Sexually Inappropriate Behaviors

Gig Harbor, Washington Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse and to timely implement appropriate interventions for a resident with escalating sexually inappropriate behaviors. Facility policy on abuse required immediate assessment and protection of residents following any allegation or observation of abuse, as well as prompt revision of the care plan with interventions to minimize recurrence. Despite this, the facility did not act in accordance with its policy when confronted with repeated sexually inappropriate behaviors by one resident toward staff, which preceded an incident of sexual contact with another resident.

Resident 1 was admitted with dementia and anxiety disorder, was moderately cognitively impaired per the MDS, and resided on a locked unit due to wandering and exit seeking. Resident 1 was able to ambulate independently without assistive devices. On the date of the incident, Resident 1 was found in another resident’s room and reported that the other resident had taken them by the hand into the room and touched their breasts inappropriately. Resident 1 later stated they did not want to be touched and could not understand why the other resident had touched them. Staff interviews confirmed that Resident 1 had been led into the other resident’s room and touched on the breasts.

Resident 2, who had dementia, aphasia, and a cognitive communication deficit and was severely cognitively impaired per the MDS, had documented sexually inappropriate behaviors toward staff on multiple days, including touching a CNA inappropriately, motioning a CNA to get into bed, rubbing a social worker’s arm and directing them toward the bed, and exposing their genitals to a CNA. Despite these documented behaviors, Resident 2’s behavior care plan did not include interventions for sexually inappropriate behaviors until after the incident involving Resident 1. One-to-one supervision was initiated the following day, and observations showed that even after this was ordered, staff did not consistently maintain line-of-sight supervision, allowing Resident 2 to move out of visual range and into their room with the door closed. Staff interviews indicated that some staff were aware of Resident 2’s sexually inappropriate behaviors but did not have clear guidance or care plan interventions to manage these behaviors prior to the substantiated incident of sexual abuse involving Resident 1.