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:
An agency NA forcefully pushed a wheelchair-bound resident through a doorway while the resident was caught in the frame, causing the resident’s foot to strike both shins and resulting in bruising, swelling, pain, and an acute right tibia fracture. The resident had dementia, muscle weakness, and required assistance with mobility and transfers. CCTV and the facility’s investigation showed the NA did not follow safety measures during the transfer.
A resident with dementia and a history of aggression assaulted another resident in a hallway, pushing him from a chair onto the floor and then attempting to strike him with a chair while a third resident was nearby. Staff on constant observation and another observer did not intervene until after the resident had already been pushed down, despite the resident being on enhanced supervision for prior resident-to-resident altercations. Both residents had severe cognitive impairment, and interviews showed the assigned aide did not understand the urgency of the constant observation role.
Delayed reporting of resident-on-resident sexual abuse allowed continued nonconsensual sexual contact. A resident with schizophrenia and moderate cognitive impairment reported that his roommate kissed, touched, and sexually assaulted him without consent, while the roommate admitted to sexual contact. A nurse aide heard the allegation but did not report it right away, and the unit manager later confirmed the delay.
Failure to respond appropriately to an alleged sexual abuse incident: a resident with intact cognition alleged a CNA raped them during incontinence care, but the resident remained in the facility for hours without a documented medical or psychosocial assessment. The CNA said they provided care and applied ointment to the resident’s groin and vaginal area, while video showed the CNA in the room for 36 minutes. The resident was later tearful, fearful, and distrustful of staff, and the DON and admin did not report the allegation to DOH because the resident later described rough handling.
Failure to Maintain Separation Between Residents With Known Aggression: A resident with a known hx of resident-to-resident physical aggression struck another resident in the head with a cane in the dining room, causing a bump, laceration, and bruising. The assaulted resident was non-ambulatory, dependent on staff for transfers, and had dementia, while the aggressive resident had intact cognition, used a cane, and had a care plan for prior physical altercations. Staff placed the residents in the same area with limited supervision, and the aggressive resident stated the other resident deserved it and that he would hit him again.
A resident with stroke-related diagnoses and cognitive intact status was transferred to the hospital for weakness, dizziness, pallor, and low K+. After the resident was stable for return, the DON and administrator went to the hospital and, along with the owner and corporate administrator on speaker phone, were reported by the resident and hospital staff to have yelled, been rude and aggressive, and told the resident the facility would not take the resident back because of behaviors and money owed. The resident stated feeling pressured, outnumbered, and insignificant.
Failure to Protect Resident During Transfer Resulted in Right Tibia Fracture
Penalty
Summary
The facility failed to protect a resident from abuse and neglect when an agency nurse aide forcefully handled Resident R86 during wheelchair transport. CCTV review showed the aide pulling the resident as she was caught in a doorway, then attempting to push her through the doorway forcefully. During this event, the resident’s right foot became caught on the doorframe and struck her right shin, then her left shin, before she was pushed through the doorway. Resident R86 was admitted to the facility with diagnoses including hypertension, vascular dementia, muscle weakness, and cognitive communication deficit. The resident’s MDS indicated dependence for multiple mobility-related activities and use of a wheelchair. The care plan noted that the resident could move around the facility without supervision but could not exit without supervision, and later documented bruising to both lower extremities, swelling of the lower right extremity, and a right tibia fracture, with bed rest and Hoyer transfers for all transfers. After the incident, bruising was documented on the resident’s lower extremities, including dark purple/green bruising to the right shin and swelling and pain in the right leg. The resident was unable to tolerate range-of-motion assessment because of pain and agitation. X-rays later showed an acute mildly displaced spiral fracture below the level of the tibial prosthetic stem in the right tibia. The facility’s investigation concluded that the nursing aide neglected to follow facility safety measures.
Failure to Prevent Resident-to-Resident Abuse During Constant Observation
Penalty
Summary
The facility failed to protect a resident from abuse when a resident with severe cognitive impairment and a history of aggressive behavior assaulted another resident in the hallway. Resident #1 had diagnoses including unspecified dementia with behavioral disturbance, COPD, muscle weakness, and major depressive disorder, and his MDS coded him with a BIMS score of 3 out of 15. Resident #2 also had severe cognitive impairment, with diagnoses including Alzheimer’s disease with early onset, unspecified dementia without behavioral disturbance, hypertension, and muscle wasting and atrophy, and his MDS also coded a BIMS score of 3 out of 15. During the incident, staff heard a chair flip over and a thud, then found Resident #2 on the floor. A video reviewed by the facility showed Resident #1 standing in front of Resident #2 and pushing him out of a chair and onto the floor. The video also showed Resident #1 picking up a chair and attempting to strike Resident #2 with it while Resident #3 was in close proximity. An OSM sitting nearby observed the incident and did not intervene until after Resident #2 had been pushed to the floor, and the chair was only stopped when the OSM placed a hand on it. The record and interviews showed that Resident #1 had been on constant supervision because of prior aggressive behavior and resident-to-resident altercations. The care plan documented behaviors related to aggression during care and a history of pushing another resident. Staff interviews indicated that the Activities Aide assigned to constant observation was watching the incident but did not intervene quickly, and the aide stated she did not think the situation would become physical and did not know what the constant observation was for. The facility’s policy required staff on constant observation to remain within close proximity to intervene immediately if necessary, but that did not occur during the altercation.
Delayed Reporting of Resident-on-Resident Sexual Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from abuse when continued nonconsensual sexual contact occurred between two roommates. Resident 1 had diagnoses including schizophrenia and a BIMS score of 9, indicating moderate cognitive impairment. Resident 2 had a BIMS score of 15, indicating normal cognitive function. According to the resident’s statement, Resident 2 kissed his body and engaged in sexual contact that Resident 1 did not consent to, including manual genital manipulation, kissing and licking of his body, and anal penetration. A nurse aide heard Resident 1 say that Resident 2 liked to kiss his body and later questioned him about whether Resident 2 asked him to do things he did not want to do. Resident 1 responded that Resident 2 “jerks me off” and said it happened often. The nurse aide stated that he or she was unsure what to do and did not feel comfortable talking to anyone except the unit manager. The unit manager’s statement indicated that the nurse aide reported the allegation four days after the initial disclosure. Resident 2 also acknowledged sexual contact, stating that he had kissed Resident 1 all over his body and touched his private area, and said the last contact occurred two nights before the interview. The resident was evaluated in the ED for sexual assault, and the facility later substantiated sexual abuse based on the delayed reporting by the nurse aide. The report identified that the delay in reporting allowed further nonconsensual sexual contact to occur before the allegation was acted upon.
Failure to Respond to Alleged Sexual Abuse and Assess Resident Distress
Penalty
Summary
The facility failed to protect a resident from abuse, psychosocial harm, and to respond appropriately after an allegation of staff-to-resident sexual abuse. The resident had diagnoses including obstructive and reflux uropathy and hemiplegia and hemiparesis following cerebral infarction. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and the care plan included psychosocial well-being interventions such as orienting the resident to the environment, introducing compatible peers, and addressing concerns. During incontinence care, the resident alleged that a CNA raped them. The incident report documented that the resident told an LPN they were raped, and the LPN notified a supervisor. The supervisor assessed the resident and noted redness in the perineal area. A nursing progress note later documented that the resident complained of burning in the sacral and vaginal area after incontinence care and that the DON was aware. Video review showed the CNA in the resident’s room for 36 minutes. The CNA stated they provided incontinence care, applied A and D ointment to the resident’s pubis, groin crease, and vagina, and remained in the room because the resident had multiple bowel movements, although the bowel record did not document multiple bowel movements. The resident remained in the facility for about five and a half hours after the allegation without documentation of a medical or psychosocial assessment. Family members reported the resident was hysterically crying, contacted law enforcement, and requested hospital transfer. The resident later stated they felt something enter their anus and vagina, that they told the CNA to stop, and that they became distressed, tearful, fearful, and distrustful of facility staff. The facility concluded abuse did not occur because of conflicting statements, and the DON and administrator stated the allegation was not reported to the state because the resident later described rough handling. The PCP stated the facility should have called law enforcement and the Department of Health if the allegation was rape, and stated a psychosocial assessment should have been completed. The social worker stated they were aware of the incident after it occurred and did not know what interventions should be put in place.
Failure to Maintain Separation Between Residents With Known History of Aggression
Penalty
Summary
The facility failed to protect a resident from resident-to-resident abuse when one resident struck another resident in the head with a cane in the main dining room. The assaulted resident was non-ambulatory, dependent on staff for bed-to-chair transfers, used a Broda wheelchair, and had diagnoses including non-Alzheimer’s dementia and depression. He had a BIMS score of 12 out of 15 and was documented as having potential verbally aggressive behaviors toward other residents related to dementia. After the assault, he was found with a 5 cm bump and a 1 cm laceration to the left forehead, along with facial bruising, and he stated he felt unsafe around the other resident. The resident who struck him had a BIMS score of 13 out of 15, walked with a cane, transferred independently, and had diagnoses including stroke and depression. His care plan identified a history of resident-to-resident physical aggression and directed staff to monitor for agitation, assist him to a quiet area, and maintain separation from the other resident. Despite that history, he independently approached the other resident in the dining room and struck him multiple times with the cane. During the interview, he stated the other resident deserved it and said he would hit him again if he saw him, indicating the assault was intentional and unprovoked. The investigation also documented a prior resident-to-resident altercation between the same two residents in which the aggressive resident had struck the other resident in the face with his cane several times, causing bruising to the eye and cheek. Staff statements showed the two residents were placed in the same dining area with limited supervision, and staff were occupied with other residents when the assault occurred. Several staff members stated they believed the aggressive resident was simply walking back to his room and did not realize he would attack the other resident. The facility’s investigation concluded that previously identified supervision and separation interventions were not consistently maintained, allowing the aggressive resident to reach and assault the other resident again.
Verbal Abuse During Hospital Discharge Discussions
Penalty
Summary
The facility failed to ensure a resident was free from verbal abuse by facility staff. The resident had diagnoses including frontal lobe and executive function deficit, stroke, atrial fibrillation, cerebrovascular accident, and hemiparesis, and the record also documented the resident as cognitively intact. The resident had been admitted on 01/17/2025 and was transferred to the emergency department on 6/18/2026 for further evaluation and treatment related to possible infection, weakness, dizziness, pallor, and low potassium. After the hospital transfer, the resident stated that facility leaders told the resident the facility would not allow the resident to return because there were no available beds. The resident reported that the administrator and DON came to the hospital, that the administrator, DON, company owner, and corporate administrator were on speaker phone, and that the administrator and DON were verbally abusive, yelled at the resident, and said the resident had behavioral issues, owed the facility a lot of money, and was a bad person. The resident stated feeling pressured, outnumbered, and extremely insignificant, and said the resident never told staff not to return until being told the facility did not want the resident back. Hospital staff corroborated the resident’s account. The hospital social worker stated the facility refused to accept the resident back, that the DON was rude, unpleasant, and harassed the resident in the emergency department waiting room, and that the administrator and DON were aggressive and yelled at the resident during the discussion about returning to the facility. The hospital case manager stated the administrator and DON told the resident about problems the resident had caused for the facility and said the resident could return if the resident paid on the bill. The administrator later stated that staff had to yell because the resident was hard of hearing and acknowledged that the conversation involved reviewing the letter and bullet points about what led to the situation.
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