Failure to Protect Cognitively Impaired Residents From Repeated Resident-to-Resident Sexual Abuse
Summary
The deficiency involves the facility’s failure to protect cognitively impaired residents from sexual abuse by another resident with a known pattern of sexually inappropriate behaviors. One resident (R4), who had moderately impaired cognition, a history of hypersexual behavior, and was able to self-propel in a wheelchair, repeatedly engaged in sexual contact with other residents who were severely cognitively impaired and dependent on staff for ADLs. On 11/22/25, R4 took a glove from a nurse’s cart while in a hallway on B wing and placed her gloved hand on another resident’s (R7) vaginal area, fondling her labia. Staff separated the residents, but R4’s care plan was not updated to address this sexual behavior, and no interventions were added to prevent further sexual abuse. R7’s care plan, which identified her as low risk for abuse despite dementia with depression and anxiety, was also not updated with interventions to protect her from sexual abuse. On 2/10/26, while in the dementia unit, R4 again engaged in sexual abuse, this time toward a male resident (R5) who had severe cognitive impairment and required assistance with ADLs. During the evening medication pass, staff observed R4 wheeling herself quickly toward R5, then placing her whole hand inside his pants and undergarments, touching his penile area. Staff immediately separated the residents, and R4 became upset and yelled that she wanted to return to R5. The incident was reported to the ADON, and R4 was reportedly placed on 1:1 supervision. However, R4’s care plan was not revised to address this sexual behavior, and R5’s care plan, which later documented him as moderate risk for abuse due to poor cognition, did not include interventions related to the sexual abuse incident or measures to protect him from further sexual abuse. On 3/11/26, R4 again sexually abused another male resident (R6), who had severe cognitive impairment, Alzheimer’s dementia, bipolar disorder, and was identified in his care plan as high risk for abuse due to dementia and mental health diagnoses. During an activity in the common area, R4 and R6 were seated side by side in wheelchairs when staff observed R4’s hand in R6’s groin area, moving toward his private area in an up-and-down tapping motion. R4 loudly expressed sexual intent, stating she wanted to have sex with R6 and would do whatever she wanted. Staff immediately separated them, and R6 appeared wide-eyed and looking around as if for help. Despite this incident and R4’s known pattern of hypersexual behavior, R4’s care plan still did not include interventions addressing her sexual behaviors, and R6’s care plan, although identifying him as high risk for abuse, had no interventions to address the sexual abuse or to protect him from further sexual abuse. Across these incidents, staff interviews confirmed that R4 had been hypersexual, touching other residents in their private areas and making sexually explicit statements to other residents. The DON acknowledged awareness that R4 had inappropriately touched residents in the dementia unit. The Dementia Director/Social Services stated that when abuse occurs, a trauma assessment should be done immediately to assess emotional and psychological impact and provide supportive interventions, but no trauma assessments were completed for R7, R5, or R6 at the time of their respective incidents. The physician reported he was not made aware of the sexual abuse incidents involving R4 and the other residents until 3/13/26. The Regional Director of Operations stated that the care plans for R4, R7, R5, and R6 should have been updated when the incidents occurred to ensure proper interventions were in place. The facility’s own Abuse, Neglect and Exploitation policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required protection of residents’ health, welfare, and rights, but the facility failed to implement timely care plan updates and protective interventions following repeated episodes of resident-to-resident sexual abuse. These failures resulted in an Immediate Jeopardy situation beginning on 11/22/25 when R4 first sexually abused R7 and continuing through subsequent incidents involving R5 and R6. The surveyors determined that the facility did not protect residents from sexual abuse, did not promptly assess for trauma, did not notify the physician in a timely manner, and did not revise care plans or implement effective interventions despite clear evidence of ongoing sexually aggressive behavior by R4 toward severely cognitively impaired residents.
Removal Plan
- R4 was separated from other residents and placed under continuous 1:1 supervision to prevent further inappropriate contact until discharge from facility or her condition warrants immobility.
- R5, R6 and R7 were assessed by nursing staff for physical injury and psychosocial distress.
- SSD/Memory Care Director verified all memory care residents have had a risk for abuse assessment completed per policy.
- The physicians and parties responsible for all residents involved were notified.
- R4, R5, R6 and R7 had an Abuse/Neglect/Trauma assessment.
- R5, R6, and R7 had the Trauma Informed Care Assessment completed.
- Abuse policies were reviewed and no revisions were required.
- DON and ADON educated all staff on facility Abuse, Neglect and Exploitation policy with an emphasis on identifying abuse, reporting abuse, appropriate interventions, following resident care plans, and monitoring of residents with a history of aggressive or sexual behaviors.
- Any staff who did not receive education will be educated prior to next shift.
- The DON or designee reviewed facility abuse policies and procedures with any agency staff prior to their shift.
- Regional Nurse Director in-serviced Administrator and DON on identifying abuse (including sexual abuse) and reporting abuse.
- Regional Nurse Director in-serviced Administrator and DON on the process to relay information to staff regarding the resident's care plans or changes to a resident's care plans pertaining to interventions/strategies to redirect resident when exhibiting either aggressive or sexual behaviors.
- Emergency QAPI was held with Medical Director to discuss citation and develop interventions to ensure safety of other residents.
- Root Cause Analysis was completed.
- R5, R6, and R7 had their care plan updated with safety interventions to protect from abuse.
- R4's care plan was updated to reflect interventions put in place to safeguard other residents on the unit, including but not limited to: one-to-one supervision and providing residents with sensory items to help keep residents occupied and hands busy.
- Administrator will audit weekly for 6 weeks and then monthly for 3 months to monitor residents with history of sexual behaviors/resident abuse and verify appropriate interventions are in place and care plans updated accordingly.
- All abuse findings will be reviewed by the QAPI team to ensure appropriate measures have been put in place.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A CNA aggressively slapped and grabbed a resident’s wrist during lunch feeding assistance, then roughly pulled the resident’s hand off his shirt sleeve after she had grabbed it. The CNA had prior disciplinary actions, including a previous feeding incident in which a resident choked and required the Heimlich maneuver. A nurse later assessed the resident and found no bruises or cuts.
A facility failed to protect two residents from resident-to-resident physical abuse. In one incident, a resident with dementia and cognitive impairment was struck during a dispute over TV volume and responded by scratching the other resident. In another, a resident with dementia and physically aggressive behaviors scratched a roommate’s face, leaving superficial marks. Staff interviews and clinical records confirmed both altercations and the resulting injuries.
A resident with a left ankle fracture, muscle weakness, and total-assist transfer needs was supposed to receive 2-person assistance and remain NWB on the left leg. Instead, a nurse aide transferred the resident with only one staff member during a toilet-to-wheelchair transfer, and the resident heard a pop and developed increased pain. X-ray and hospital imaging confirmed fractures of the distal R tibia and fibula, and the facility substantiated neglect for not following the care plan.
Failure to Protect Resident from Repeated Room Intrusions: A cognitively intact resident with depression and hip OA was repeatedly frightened when another resident with dementia and wandering behaviors entered her room, took belongings, and could not be reliably redirected. Staff used a stop sign banner and other barriers, but the other resident continued to enter the room, and the resident became so fearful that she requested discharge before completing her therapy goals.
Failure to protect a resident from alleged physical abuse: A resident with COPD, speech disturbances, and dysphagia reported that an LPN pushed them in the chest during med pass after they refused meds, causing them to fall. The resident had no visible injuries, but the report was documented by nursing staff and the NP, and the resident later reiterated by writing/gestures that the LPN pushed them. The LPN denied pushing the resident and described the contact as accidental, while the facility concluded there was no evidence of abuse.
A resident-to-resident sexual abuse allegation was not thoroughly investigated, and the resident was not promptly protected or monitored after the allegation. In a separate issue, a handwritten sign with personal care instructions was posted above another resident's bed, and an RT, LPN, RN, and CNA all acknowledged it was a privacy and dignity concern and against facility policy.
Failure to Protect Resident from Abuse During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident’s right to be free from abuse during lunch assistive feeding. While standing about 3 feet from the lunch table, the surveyor heard a CNA aggressively slap Resident #56’s left wrist and observed the CNA grab the resident’s left wrist and roughly pull her hand off of his shirt sleeve after she had grabbed it. The surveyor then continued observing the meal and later reported the incident to the DON and Administrator. Resident #56 was assessed by a licensed nurse after the incident, and no bruises or cuts were found on her wrists. The CNA involved had been hired by the facility in 2024, had signed the facility’s Resident Abuse Procedural Summary, and had attended behavior training in 2026. The CNA also had three prior disciplinary actions, including a prior incident in which a resident choked after being given too large a bite during assistive feeding and required a Heimlich maneuver.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure two sampled residents were free from physical abuse by other residents. One resident with dementia, anxiety, chronic pain, visual hallucinations, and moderate cognitive impairment was involved in an altercation with a roommate after a disagreement about TV volume. The incident escalated when the roommate attempted to take the TV remote and struck the resident with an open hand, and the resident responded by scratching the roommate. The record also documented a new scratch on the resident’s left hand and later noted that the resident no longer wanted to share a room with the other resident. The other incident involved a resident with dementia and significant cognitive impairment who had a behavior care plan for impaired safety awareness and physically aggressive behaviors. The record stated that the resident clawed a roommate in the face, leaving superficial scratches and red marks on the roommate’s chin and cheek. The roommate’s record reflected ongoing monitoring for scratches to the chin and neck, and the roommate stated that the other resident reached up and ran fingernails across her face while they were getting up for breakfast. Facility documentation and staff interviews confirmed both resident-to-resident incidents. Staff described the first event as a physical altercation triggered by conflict over TV volume, and the second as an incident in which one resident scratched another resident’s face. The DON stated the facility investigated and reported the incidents, and also acknowledged that the documentation surrounding the second event was inconsistent and did not meet expectations or policy. The cited deficiency was based on the facility’s failure to ensure the residents were protected from physical abuse by other residents.
Failure to Follow Two-Person Transfer Plan Resulted in Resident Fractures
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not follow the resident’s individualized transfer plan requiring assistance from two staff members. The resident was admitted with a left lower leg trimalleolar fracture, polyosteoarthritis, and muscle weakness, and the MDS indicated the resident was cognitively intact but required total assistance for transfers and toileting. The comprehensive care plan and physician orders both directed staff to provide two-person assistance for transfers and to maintain non-weight-bearing status on the left lower extremity. During a transfer from the toilet to a wheelchair, one nurse aide assisted the resident without a second staff member. According to the documentation, the resident stood without difficulty, but during the pivot transfer the resident’s right foot turned inward and both the resident and the aide heard a loud pop. The resident immediately reported increased pain. Later that day, x-ray findings identified an acute fracture of the right tibia, and the resident was transferred to the hospital emergency department for further evaluation and treatment. Hospital imaging confirmed fractures of the distal right tibia and fibula, and the resident was scheduled for surgical repair. The facility’s investigation determined that the aide transferred the resident with only one staff member despite the care plan and physician order requiring two staff members, and that this failure directly resulted in the resident sustaining the fractures. The facility substantiated caregiver neglect and terminated the employee following the investigation.
Failure to Protect Resident from Repeated Room Intrusions
Penalty
Summary
The facility failed to protect a cognitively intact resident with osteoarthritis of the right hip and major depressive disorder from mental abuse by another resident. The resident was admitted as a vulnerable adult and her care plan identified a goal of being free from abuse, neglect, or financial exploitation, but it did not include interventions to protect her from abuse. The resident later reported that another resident repeatedly entered her room, scared her, and took belongings, and she asked staff to contact her lawyer. She also began using a stop sign banner across her door and later barricaded her room with a walker, closet door, and bedside table because she was afraid of the other resident. The other resident had moderate cognitive impairment, vascular dementia with agitation, and Alzheimer’s disease, and his care plan documented restlessness, agitation, sundowning, wandering into other residents’ rooms, and urinating in public. Progress notes showed repeated episodes of wandering into other residents’ rooms, difficulty with redirection, aggression toward staff, and disruptive behavior in resident rooms. Notes also documented that he entered the affected resident’s room on multiple occasions, and staff observed that he could move barriers out of the way and continue entering the room despite attempts to block access. Staff interviews confirmed that the resident was very scared of the other resident and that the repeated room intrusions continued over several days. Staff stated that stop sign banners did not stop him, closed doors did not stop him, and that it often took two or more staff to remove him from rooms. The resident requested discharge from the facility and left before reaching her maximal level with therapy services. Therapy documentation stated she was improving but still needed higher-level therapy before discharge, and the therapy director stated her early discharge was because she could not remain in the facility due to the other resident coming into her room. Facility records also showed staffing levels that were below the facility assessment on several shifts, and the assignment sheets did not identify a staff member assigned to 1:1 observation for the wandering resident.
Failure to Protect Resident from Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when a nurse allegedly made physical contact with the resident during medication administration. Resident #7, who had diagnoses including COPD, speech disturbances, and dysphagia, had intact cognition on the MDS dated 03/18/2026 and was care planned as at risk for misappropriation, neglect, abuse, and/or exploitation. On 04/08/2026, the resident reported to the RN supervisor that an LPN pushed them in the chest after they refused medications, causing them to fall to the floor. The resident was assessed and no visible injuries were noted. The resident’s report was documented in nursing and medical progress notes, and the facility’s investigation recorded that the resident was visibly upset while describing the incident. The LPN denied the allegation and stated that any contact was accidental, describing that the resident was close behind them as they left the room and that the resident’s chest contacted their back or shoulder. The RN supervisor, DON, and NP each documented interviews and assessments in which no bruising, swelling, or visible injury was found, and the resident later communicated by writing and gestures that they had told the LPN to leave the room and that the LPN pushed them in the chest and they fell. The facility concluded there was no evidence of abuse, neglect, exploitation, or mistreatment, despite the resident’s allegation and the conflicting accounts from the LPN and resident. The RN supervisor stated law enforcement was notified and police interviewed the resident and the LPN, but no report was filed. The DON later stated the contact was accidental and that the resident’s reporting was inconsistent regarding whether a fall occurred.
Failure to Protect Resident from Abuse and Maintain Privacy
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a resident-to-resident sexual abuse allegation was not thoroughly investigated and the resident was not promptly protected or monitored after the allegation. The report states this involved 1 of 52 sampled residents, Resident 45, and that the deficient practice had the potential to place the resident at risk for continued abuse, emotional distress, fear, anxiety, a diminished sense of safety, and delayed implementation of interventions necessary to protect the resident from further abuse. The facility also failed to protect the privacy and confidentiality of Resident 58. Resident 58 was admitted with diagnoses including chronic obstructive pulmonary disease. During observation, a handwritten sign reading, "Attention please no briefs chucks only!!" was posted above the resident's bed and remained there on a later observation. Staff members including a Respiratory Therapist, LPN, RN, and CNA each acknowledged the sign was visible above the bed and stated it was a privacy, dignity, and policy issue. A facility Residents Rights policy stated residents have the right to privacy and confidentiality with personal care and medical records, and that resident medical and personal care information is private and staff are required to respect and uphold resident privacy at all times.
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