F0740

E

Failure to Provide Necessary Behavioral Health Services and Supervision for Inappropriate Sexual Behaviors

Choctaw, Mississippi Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents received necessary behavioral health care and services, specifically by not proactively assessing and implementing effective behavioral interventions to address inappropriate sexual behaviors between residents. Facility policy on Resident Rights states that each resident has the right to be free from mental and physical abuse and to have a safe, secure, and homelike environment, and that the facility is responsible for implementing interventions to prevent resident-to-resident altercations and to ensure supervision sufficient to protect residents from harm. The facility’s Behavioral Health Services policy further requires that all residents receive necessary behavioral health services to help them reach and maintain their highest level of mental and psychosocial functioning.

One incident involved a resident with borderline intellectual functioning and severe cognitive impairment, who approached another resident with a cognitive communication deficit while both were seated in the front lobby and touched her leg without consent. The cognitively impaired resident had a BIMS score of 07, indicating severe cognitive impairment. The resident who was touched reported the incident to staff and stated she told him to quit and he left her alone. She later reported that she only spoke once with a nurse about what happened, that there was no further follow-up discussion or additional inquiries from other staff, and that she did not receive any updates regarding the outcome of the investigation. Her health status note for the date of the incident contained no documentation of the inappropriate touching. She also reported seeing the other resident’s name still listed on the room across from hers and stated she planned to avoid him and common areas if he returned. Record review showed that another female resident later reported that the same cognitively impaired resident inappropriately touched her twice on her leg and between her thighs.

A separate incident involved a resident with vascular dementia and moderate cognitive impairment, who reported that another resident with a cognitive communication deficit and a BIMS score indicating intact cognition touched her breast without consent in the hallway in front of the nurse’s station. The resident who was touched immediately notified a CNA and clearly described that the other resident had touched her breast. Facility records showed that this same resident with intact cognition had previously been noted at the nurses’ desk touching another resident inappropriately and, when redirected, simply looked at the nurse and continued rolling in his wheelchair. In both incidents, record review revealed that the residents were in common areas without effective supervision at the time of the events. Although staff responded after the incidents occurred, the facility did not implement sufficient proactive interventions or supervision to prevent inappropriate resident-to-resident contact before these incidents took place, and affected residents did not receive consistent, documented behavioral health follow-up and support as required by facility policy.