Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse by a staff member. The resident had diagnoses including non‑traumatic brain dysfunction, non‑Alzheimer dementia, depression, and early onset Alzheimer dementia, with documented short‑ and long‑term memory problems and severely impaired cognitive skills for daily decision making. Care plans identified impaired communication and cognition with an increased risk for abuse, and directed staff to monitor for changes in mood, behavior, and unexplained injuries. Despite these identified vulnerabilities and care plan directives, the resident was subjected to an alleged sexual assault by a long‑term housekeeping employee. On the morning of 02/21/2026 at approximately 6:53 AM, a CNA conducting rounds heard sounds from the resident’s room, noticed the privacy curtain closed (which they reported they had not closed), and entered the room. The CNA observed a housekeeper lying in a prone position on top of the resident in the resident’s bed, with the housekeeper’s pants lowered to mid‑thigh. The CNA questioned the housekeeper, who immediately jumped off the bed and pulled up their pants, and then begged the CNA not to say anything. The CNA instructed the housekeeper to leave the unit and then reported the incident to the nurse. The roommate’s curtain was closed and the roommate was asleep at the time. Subsequent internal interviews documented that another housekeeper reported the implicated housekeeper came to the locker room shortly thereafter stating, “I did something bad,” and left, and a dietary cook observed the housekeeper running out of the building. The facility’s internal documentation and hospital records identified the event as an alleged sexual assault, with the hospital emergency department listing the visit diagnosis as sexual assault of an adult and administering multiple antimicrobial and antiviral medications. Facility staff, including the RN supervisor, DON, social work, and the physician, documented that the resident appeared calm, at baseline, and without signs of distress following the incident, and the spouse and physician both noted that due to the resident’s severe cognitive impairment, the resident likely did not understand what had occurred. The surveyors determined that the resident experienced actual psychosocial harm using the reasonable person concept from the CMS Psychosocial Outcome Severity Guide.
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