Failure to Protect Resident From Repeated Sexual Abuse by Peer
Penalty
Summary
The facility failed to protect a resident from sexual abuse when another resident grabbed her breast, waist, and buttock without permission on multiple occasions. Resident 1, who had a history of substance abuse and a personal history of unspecified childhood abuse, was cognitively intact with a BIMS score of 15/15. On 2/27/26, Resident 3 reported to staff, via a SOC 341 form, that he saw Resident 2 grabbing Resident 1’s buttock and breasts and that Resident 1 did not like it. Resident 1 later stated that a tall Black male resident had touched her breast, waist, and buttock three times, that she did not like it, and that she felt disrespected by the inappropriate touching. Resident 2, who had schizoaffective disorder and stimulant dependence and was also cognitively intact with a BIMS score of 15/15, admitted during interview that he used his right hand to grab the chest, waist, and buttock of a female resident and that the incident occurred again the next day until staff intervened. Resident 3, who had schizoaffective disorder and depression and was cognitively intact, confirmed witnessing Resident 2 grabbing Resident 1’s breast and buttock three to four times and physically demonstrated the grabbing motion during interview. Licensed Nurse 1 and the Director of Nursing both confirmed that Resident 3 had seen Resident 2 touching Resident 1’s breast and buttock inappropriately. Progress notes documented that on 3/2/26 Resident 1 reported a male resident had touched her waist, pulled her close, and touched her breasts and buttocks, and that she wanted staff to tell Resident 2 not to bother her anymore. Additional progress notes dated 2/28/26 indicated a nurse again witnessed Resident 2 using his right hand to brush Resident 1’s left buttock. Resident 2’s progress notes on 3/2/26 showed that the interdisciplinary team discussed his ongoing behaviors of initiating physical contact with peers without invitation. Despite the facility’s written policy stating residents have the right to be free from abuse, including sexual abuse, these documented incidents show that Resident 1 experienced sexual abuse by Resident 2 on more than one occasion before effective protection was in place.
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