Failure to Protect Cognitively Impaired Resident From Sexual Abuse and Elopement Due to Inadequate Supervision and Reporting
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse and neglect, including inadequate supervision despite known risks. One resident with Wernicke’s encephalopathy and severe cognitive impairment, reflected by a BIMS score of 99, was fully ambulatory and had a documented history of wandering, exit seeking, and intrusive behaviors into other residents’ rooms. Another resident involved in a sexual incident had mild cognitive impairment with a BIMS score of 13 and self-propelled in a wheelchair. On one occasion, documentation showed the cognitively impaired resident was found in another male resident’s room on his knees performing oral sex; the residents were separated, and the cognitively impaired resident later had no recollection of the event. A subsequent progress note documented the same cognitively impaired resident sitting on the side of a female resident’s bed with his pants off while the other resident was fully clothed under the covers; staff could not later identify this third resident for surveyors. The facility’s care planning and supervision for the cognitively impaired resident were deficient. A comprehensive care plan entry dated 2/24/26 identified a psychosocial well-being problem related to sexual/physical contact with another resident and directed staff to immediately separate and remove the resident from such situations and notify the NP and responsible party/guardian. Another care plan entry dated 3/9/26 specified that the resident had obsessive compulsive behavior and required 1:1 monitoring at all times, medication administration as ordered, and redirection and cues as needed. However, multiple nursing staff and CNAs interviewed on 3/17/26 and 3/18/26 denied knowing that the resident was to be on 1:1 supervision, and supervision was not provided. The care plan interventions focused on reacting after sexual or physical contact was found, and there was no evidence of preventative measures being implemented to protect the resident from himself or to protect others from him. None of the care plan interventions for behaviors or elopement were documented as implemented, and no behaviors were documented on the MAR during the resident’s stay. The facility also failed to adequately supervise the resident’s known wandering and elopement risk and to secure exit doors. Nursing and physician notes documented multiple episodes of wandering and exit seeking, including the resident going into other residents’ rooms during their personal care, attempting to exit through doors, and an elopement through the courtyard gate on 12/15/25, when he pushed the gate and exited to the parking lot before being redirected back inside. An elopement evaluation completed later incorrectly indicated no history of elopement and minimized the impact of the resident’s wandering on safety and privacy, despite prior documentation of elopement and intrusion into other residents’ rooms. A Wander-Guard device had been ordered on 11/13/25, but on 3/17/26 no device was found on the resident, and he had previously removed it on 3/8/26 without replacement or care plan direction until the time of survey. During survey observations, the courtyard gate alarm was found in the off position, the gate could be opened without an alarm sounding, and no staff were present in the courtyard despite residents being there. The resident’s prior elopement and the incident of him unclothed in a female resident’s room were never reported to the state agency, and the facility’s abuse reporting and investigation documentation for the 2/23/26 sexual incident was incomplete, lacked the initial report, lacked staff witness statements, and had no confirmation that required reports were timely submitted to the state agency, contrary to federal, state, and facility policy requirements.
Removal Plan
- Resident #1 was placed on 1:1 continuous supervision 24 hours/day.
- The resident provider and resident representative were notified.
- Residents who have a BIMS score of 9 or greater have been interviewed to determine if they have experienced any unwanted sexual interaction with another resident, if they have concerns about other residents wandering into their rooms, and if they feel safe residing in the facility.
- Residents who have a BIMS score of less than 9 have had a body skin assessment completed by a licensed nurse to identify any changes in skin that may have resulted from abuse.
- Any newly identified areas from skin assessments will be reported to the residents' provider and the residents' representative.
- Other residents who have a moderate or higher risk for elopement have been reviewed to determine that appropriate interventions, including use of a Wander Guard, are in place and functional.
- A staff member has been assigned to continuously monitor the facility exit door to the courtyard until another alarm system can be installed.
- The courtyard gate alarm was activated and is being monitored every 30 minutes to ensure that it remains engaged.
- All current residents will be reviewed to ensure that elopement risk assessments have been completed and that appropriate interventions are being implemented per the resident care plan and provider orders.
- All staff will be re-educated on abuse, including unwanted or non-consensual sexual activity and the capacity to consent.
- Staff who are unable to participate in the initial abuse training will be educated prior to their next scheduled shift.
- All licensed nursing staff will be re-educated on completion of the elopement risk assessment, importance of implementing safe precautions and supervising residents who may be at risk of elopement, and documenting functionality and placement of the Wander Guard.
- Licensed nursing staff who are unable to participate in the initial elopement training will be educated prior to their next scheduled shift.
- The smoke attendant will be educated on safety precautions and their responsibility for supervising the exit door to the courtyard and supervising that the alarm on the courtyard gate is engaged each shift.
- All staff will be re-educated on the importance of supervising wandering residents and approaches to re-direct residents who wander into other resident rooms.
- Staff who are unable to participate in the initial wandering supervision training will be educated prior to their next scheduled shift.
- Residents who have expressed concern of other residents wandering their rooms will be offered interventions such as a room change, use of stop sign, or other alternative, to minimize other residents from wandering into their rooms.
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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