F0600

K

Failure to Protect Residents From Repeated Sexual Abuse by Another Resident

Waverly, New York Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect multiple residents from sexual abuse by another resident with Alzheimer’s disease, resulting in Immediate Jeopardy and actual harm. Facility policy required staff training on abuse prevention, recognition of abuse, and ongoing assessment, care planning, and monitoring of residents with behaviors that might lead to conflict or sexually aggressive conduct. Despite this, the resident with Alzheimer’s disease (Resident #2), who had moderate cognitive impairment and ambulated independently, was repeatedly involved in sexually inappropriate situations with six other residents, most of whom had severe cognitive impairment and were dependent on staff for mobility and care. The facility did not consistently assess, care plan, or monitor at-risk residents or the aggressor in a way that prevented repeated incidents.

In the first incident, a nurse documented that Resident #2 was found in another cognitively impaired resident’s bed with a hand moving inside that resident’s brief. Resident #2 was removed and moved to another unit, but the incident report lacked staff statements and did not document Resident #2’s activities prior to discovery or when either resident was last observed. There was no documented social work follow-up or updated interventions for the victim resident, despite a care plan noting trauma and anxiety related to prior traumatic events. The only documented care plan change for Resident #2 was a temporary unit move, medication review, and behavioral monitoring, and there was no documentation of care plan updates when Resident #2 was later moved back to the original floor or of specific interventions addressing sexually inappropriate behavior.

Subsequent incidents showed a pattern of inadequate protection and follow-up. In one event, a severely cognitively impaired resident was found in Resident #2’s bed, naked from the waist down, while Resident #2 was completely unclothed; staff noted apparent fluid on the sheet, but there was no care plan update or new interventions for the victim, and Resident #2’s care plan was only revised to note that another resident had been found in the bed, with no new protective measures. In another incident, Resident #2 was observed in a dining room kissing a severely cognitively impaired resident and removing a hand from the resident’s thigh area; although staff separated them and documented the event, there was no care plan revision for the victim. In a further incident, a cognitively intact resident reported that it was not acceptable for Resident #2 to touch their breast when Resident #2 attempted to kiss and rub the resident’s breast; the only documented intervention was to keep the residents apart in the activity room, and there was no care plan revision or psychosocial follow-up for the victim.

Additional incidents continued despite knowledge of Resident #2’s history. In one case, staff found Resident #2 at the bedside of a severely cognitively impaired resident with both hands under the sheet; the victim’s brief was almost completely unsecured, and the resident stated, “it hurts,” though no open skin areas were found. In another case, Resident #2 was found lying in the bed of a severely cognitively impaired resident who was yelling for help, and later sitting on the same resident’s bed holding their hand; staff noted that Resident #2 wandered frequently at night and that there were no safety measures in place to protect female residents aside from general monitoring. Interviews with social services staff and the DON confirmed prior knowledge of Resident #2’s sexually inappropriate behaviors with multiple female residents, acknowledged that there were no safety measures in place for several of the victim residents, and revealed that no psychosocial follow-ups or psychological evaluations were completed for the victims. The Medical Director reported being notified only recently about the pattern of inappropriate sexual behaviors, despite expecting to be informed of such incidents. These actions and omissions demonstrate that the facility failed to implement effective assessments, care plan revisions, monitoring, and protective interventions to prevent ongoing sexual abuse of residents.