F0600

J

Failure to Prevent Resident-to-Resident Sexual Abuse by Known High-Risk Resident

New Glarus, Wisconsin Survey Completed on 02-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from sexual abuse by another resident with a known history of inappropriate sexual behavior. One resident (R1), who had a documented history of touching other male residents inappropriately, was initially placed on 1:1 supervision after incidents on 4/27/25 and 4/28/25 in which he was found with his hands in other male residents’ briefs or crotch areas, touching their genitals. Over the following months, the facility progressively reduced R1’s supervision from 1:1 to 15‑minute checks, then to one‑hour checks, then to two‑hour checks, and ultimately discontinued his supervision entirely on 12/12/25, despite his history of sexually inappropriate conduct.

R1’s medical record shows multiple medical conditions, including hemiplegia and hemiparesis following a stroke, diabetes mellitus, hypertension, and other cardiovascular conditions. His MDS documented a BIMS score of 10, indicating moderate cognitive impairment, and noted physical and verbal behaviors directed toward others. His care plan identified a behavior problem of inappropriate sexual conduct with other residents and inappropriate comments to staff, and included interventions such as providing care in pairs and, later, specific directions to intervene, remove him from other residents’ rooms, and protect the rights and safety of others. Staff interviews confirmed that R1 was known to be sexually inappropriate, particularly with male residents, and that interventions such as 1:1 supervision when up in his wheelchair, 15‑minute checks when in bed or recliner, and a door alarm were in place at the time of the survey.

On 1/18/26, after supervision had previously been discontinued and then later re‑implemented, R1 was found in another resident’s (R2’s) room inappropriately touching R2 in his private area under his clothing. R2, who had diagnoses including acute respiratory failure with hypoxia, COPD, sepsis, Alzheimer’s disease, and hypertension, was documented as cognitively intact on his MDS, able to understand and be understood, and having no behaviors. Witness accounts from staff indicated that R1’s hand was inside R2’s pants, touching R2’s penis and upper thigh, and R2 stated that the touching was not consensual. The facility’s abuse, neglect, and exploitation policy required prevention of abuse, identification and monitoring of residents with behaviors that might lead to conflict, and increased supervision to protect residents from harm, but the facility’s reduction and discontinuation of R1’s supervision, despite his known history of sexually inappropriate behavior, led to the incident of non‑consensual sexual contact. Surveyors determined that this failure to provide adequate supervision and protect residents from sexual abuse created a reasonable likelihood for serious psychosocial harm and resulted in a finding of Immediate Jeopardy beginning on 1/18/26.

Removal Plan

• Residents were separated and the incident was reported to the NHA.
• Staff provided statements; additional staff interviews were completed as needed.
• Law enforcement responded and interviewed the residents.
• Residents had mood, behavior, and appetite monitored.
• Residents received skin assessments.
• Residents’ physicians were updated; the POA was updated; the resident who is their own decision maker declined notification.
• All residents on the wing with a BIMS less than 7 received skin checks.
• All residents with a BIMS greater than 7 were interviewed.
• The resident was placed on 1:1 supervision when up in a wheelchair.
• The resident was placed on 15-minute checks when in bed or recliner.
• Alarms were implemented on the resident’s door and at ground level to alert staff.
• Residents’ psychosocial well-being care plans were updated.
• Resident relationship, intimacy, and sexuality histories were completed; both residents denied wanting a relationship.
• Staff education was initiated regarding abuse with emphasis on sexual abuse, 1:1 definition and expectations, resident-specific interventions, and 15-minute checks; charge nurse and leadership ensured staff were educated prior to the start of their shifts.
• The social worker interviewed the residents and both stated they feel safe.
• The DON and VP of Nursing interviewed the resident and the resident stated they feel safe.
• BCS services were offered to the residents and both declined.
• The resident was offered materials to help with hypersexuality and declined.
• A care plan meeting was held with the resident, the facility, and the POA to discuss behaviors, the plan moving forward, and activities of interest.
• The Medical Director was updated regarding the incident between the residents.