Failure to Protect Cognitively Impaired Resident From Sexual Abuse by High-Risk Peer
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse by another resident with a known history of sexually inappropriate behavior and battery. The abused resident was admitted with diagnoses including bipolar disorder, autistic disorder, and drug-induced subacute dyskinesia, and had a BIMS score of 9, indicating moderately impaired cognition. Her care plan identified a difficult past related to severe mental illness and risk factors for being a recipient or perpetrator of mistreatment, with an expectation that she would remain safe and free of mistreatment. The alleged perpetrator had diagnoses including schizoaffective disorder bipolar type and generalized anxiety disorder, and a BIMS score of 15, indicating intact cognition. His care plan documented sexually oriented behavior, including making crude, sexually oriented, profane, or suggestive remarks, and directed staff to implement limit setting and intervene if he attempted inappropriate touching. On the day of the incident, the newly admitted resident reported that the male resident approached her, asked if she was new, and obtained her room number. Later that night, video surveillance showed him entering her bedroom and remaining there for approximately 30 minutes before she went to the nurse’s station and he exited the room. The resident stated that while she was lying in bed, he entered her room, initially stood and talked, then sat on her bed, rubbed her leg, and asked for sexual favors. She reported that she told him to stop and said no, but he continued to rub her leg, unzipped his pants, exposed himself, masturbated while rubbing her leg, and ejaculated on her bed. She stated she did not scream because she feared he would harm her, and after he finished, she ran to the nurse’s station and informed staff of what had occurred. During interview, she was visibly shaken and crying, reported being afraid it would happen again, and said she cried every time she entered her room. A roommate reported observing the male resident enter the room, go to the abused resident’s side of the room, and ask for sexual favors, then hearing “wet noise” and sexual sounds before telling him to leave; she stated he asked for a minute, later adjusted his pants, and left. Nursing staff documented that the resident came to the nurse’s station and reported that a male resident had entered her room and behaved inappropriately. An LPN assessed her and found her crying and in emotional distress; the resident told the LPN that the male resident exposed himself, pleasured himself while rubbing her leg, and ejaculated on her sheets, which the LPN removed and bagged. Social services staff and another resident reported that, prior to this incident, the male resident had been sexually inappropriate with another resident and had repeatedly asked another female resident for sexual favors, including offering marijuana in exchange, leading social services to instruct nursing staff to monitor him more closely and keep him in his room at night. The psychiatrist stated he was not informed by the facility that the male resident was making inappropriate sexual advances toward other residents, despite his known sexual preoccupation and comments about women. The facility’s own criminal history analysis for the male resident identified him as a moderate risk requiring closer supervision and more frequent observation than routine, with regular monitoring for behavioral changes and periodic assessment of supervision sufficiency, yet he was able to access and remain in another resident’s room at night, resulting in the sexual abuse. The facility’s abuse policy defined sexual abuse as non-consensual sexual contact of any type with a resident, including forced observation of masturbation and coerced or extorted sexual activity, and stated that even if there is capacity to give consent, consent obtained through intimidation, coercion, or fear is considered sexual abuse. The policy also stated that sexual abuse includes non-consensual sexual relationships between residents or a consensual relationship involving a resident who lacks cognitive ability to consent. Social services staff stated that the facility uses BIMS scores to assess sexual appropriateness and that a sexual relationship is not consensual if residents’ BIMS scores are not on the same cognitive level, noting that the abused resident and the male resident were not on the same cognitive level. Despite the male resident’s documented sexually inappropriate behaviors, prior complaints from other residents, and a risk assessment recommending closer supervision, he was not effectively restricted from entering other residents’ rooms at night, and the psychiatrist was not made aware of his escalating sexual advances. These actions and inactions led to the incident in which the cognitively impaired resident experienced non-consensual sexual contact and exposure, constituting the cited abuse deficiency.
Removal Plan
- Resident R4 was discharged and is no longer a resident in the facility.
- Resident R1 was assessed for abuse risk identifying resident as high risk for abuse and an abuse care plan was initiated; R1 was reassessed for abuse risk and the care plan was reviewed.
- All current residents were reassessed for abuse risk using Screen for Abuse & Neglect UDA and each resident's abuse care plan was reviewed; Abuse UDA is completed on all new admissions within 72 hours of admission as well as quarterly, annually, and as needed by Social Services.
- A list was created of residents with a history of sexually inappropriate behaviors; the list is provided to the floors in a binder at the nursing station for identification/reference; the list will be updated as needed and reviewed at least weekly by Social Services; sources used include background check process, CHIRP, and Social Services assessment.
- Nursing staff including Social Services were in-serviced regarding the list of residents with sexually inappropriate behaviors to aid identification and ensure immediate reporting to the nurse supervisor and/or social service supervisor on call.
- Residents identified as exhibiting sexually inappropriate behaviors will be monitored every 2 hours by Nursing, Social Services and other designee with documentation on a monitoring tracker in the Residents Exhibiting Sexual Abuse Binder located at each nursing station.
- All newly hired nurses, CNAs, and Social Service workers will be in-serviced on the processes pertaining to the list of residents identified with sexually inappropriate behaviors prior to start date by the HR Director.
- All contracted workers will be in-serviced on abuse including reporting by the Administrator/designee.
- A protocol was created to provide various avenues to determine a resident's consent.
- All current residents were reassessed for cognitive ability to consent using the Brief Interview for Mental Status UDA by Social Services.
- An audit was completed to identify residents currently taking part in an intimate relationship; residents were identified and assessed by Social Services as able to consent based on BIMS score; their intimate relationship care plans were reviewed and updated.
- Residents identified as consenting to intimate relationships will be monitored weekly by Social Services to ensure continued consent; the list will be updated weekly and as necessary.
- Facility employees were in-serviced on the abuse policy with emphasis on sexual abuse.
- An additional all-in-house in-service was conducted on the abuse policy with emphasis on identifying and reporting inappropriate sexual behaviors.
- A QA audit tool was developed to monitor residents identified with sexually inappropriate behaviors to ensure identification and reporting is done immediately; to be completed 3 times per week for 12 weeks by Social Services/designee.
- A QA audit tool was developed to monitor residents identified as consenting to intimate relationships to ensure they continue to consent and are care planned; to be completed 3 times per week for 12 weeks by Social Services/designee.
- Results and trends from the QA audits will be discussed by the Assistant Administrator in the monthly QAPI meeting until resolution.
- The Medical Director was made aware of the abatement plan and agreed.
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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