F0600

D

Failure to Supervise Residents to Prevent Sexual Abuse

Saint Petersburg, Florida Survey Completed on 03-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to adequately supervise residents to prevent resident-to-resident sexual abuse, resulting in an incident between two residents. A CNA reported that during a breakfast tray pass she noticed that one resident’s door, which was usually open, was closed and the room was dark. Upon entering, she observed one resident in a wheelchair at the bedside of another resident, who was lying in bed in a fetal position with her brief pulled down. The CNA saw the wheelchair-bound resident with a clenched fist against the other resident’s vagina and the other hand on his exposed penis. The CNA immediately separated the residents and removed the alleged perpetrator from the room.

The resident who was the alleged victim had a history of dementia and significantly impaired cognition, with a BIMS score of 5, and was care planned for impaired cognitive function, dementia, and memory loss. Her care plan included interventions such as cueing, reorientation, supervision as necessary, and maintaining a consistent routine to decrease confusion. A facility assessment of capacity for sexual consent documented that this resident lacked capacity to consent to sexual activity. Progress notes documented that she was found lying in bed with her gown raised in a fetal position, that a head-to-toe skin check revealed no injuries, and that she denied knowing anything had occurred. Psychiatry and medical assessments noted no signs or symptoms of abuse-related distress and that she was confused but at baseline.

Prior to the incident, there were indications of ongoing boundary and behavioral concerns that were not effectively addressed. The CNA stated she had worked with both residents many times and knew that the alleged perpetrator frequently went into the alleged victim’s room, appeared very friendly, and needed redirection, but she was unaware of any behavioral diagnoses until after the incident. She also described a previous inappropriate interaction in the dining room months earlier, where the male resident was at the female resident’s table smiling, and the female resident opened her legs and began to open her incontinence brief; the CNA redirected the resident but did not report the incident because she did not know about the male resident’s behaviors and did not think it was serious. The resident’s representative reported having seen the male resident in the female resident’s room with the door shut on three separate occasions, including times when he had his hand on her arm, and stated that each time they informed staff at the entrance, who said they would separate the residents and watch them more closely. Facility leadership and nursing staff reported that they were not aware of the male resident’s hypersexual behavior diagnosis or any significant behavioral issues prior to the incident, despite knowledge that he frequently masturbated in his shared room. These actions and inactions demonstrate a failure to identify, assess, care plan, and monitor residents with behaviors that might lead to conflict or abuse, as required by the facility’s abuse, neglect, and exploitation policy.