Failure to Protect Minor Resident From Sexual Abuse and Misclassification of Incident as Consensual
Summary
The deficiency involves the facility’s failure to protect a minor resident from sexual abuse by an adult resident and to correctly identify and report the incident as sexual abuse. The minor resident had a history of traumatic brain injury (TBI) with subarachnoid hemorrhage, diffuse axonal injury, psychosis, insomnia, ADHD, anxiety, and depression, and required that decisions and consents be made by a legal guardian/parent. Care plans documented that the minor was at risk for impaired cognitive function or impaired thought processes due to recent hospitalization and TBI-induced psychosis, with interventions stating the resident needed supervision/assistance with all decision making and behavioral monitoring. Despite this, the resident was allowed to ambulate freely around the facility without direct supervision prior to the incident, and there was no care-planned intervention addressing supervision or discouraging the minor from spending time with other residents. In the days leading up to the incident, multiple staff and the minor’s legal guardian were aware that the minor and an adult resident were spending significant time together. Staff reported that the two residents were often seen together, including eating meals together and walking the halls, and that staff had warned the adult resident that the minor was underage. The unit manager reported that, prior to the incident, there was fear among staff that something inappropriate might occur between the two residents, and she called the minor’s legal guardian to report that the minor was spending time with another resident and that the facility did not want anything inappropriate to happen. The legal guardian stated that she was asked by facility staff to speak to the minor about the relationship but was unable to come to the facility, and she believed it was the facility’s responsibility to ensure the minor’s safety. There was also staff report that the minor had demonstrated sexually inappropriate behavior toward staff, yet there was no documented care plan addressing supervision or specific interventions to manage these behaviors or to prevent unsupervised interactions with other residents. On the night of the incident, an LPN entered another resident’s room and observed the adult resident on her knees in the bathroom in front of the minor, who was standing with his pants down, which the LPN interpreted as the adult performing oral sex on the minor. The residents were separated and the incident was reported to the DON. The police report later documented that both residents stated that oral sex occurred in the bathroom after the minor asked for it, and that the adult resident knew the minor’s age. The facility’s 5-day investigation report characterized the encounter as consensual between two cognitively intact residents with BIMS scores of 15 and concluded that abuse could not be substantiated, reporting to the State Agency that the incident was consensual. The clinical record for the minor did not contain documentation that the resident had been sexually abused, did not describe the incident as sexual abuse, and did not document the specific event that led to psychosocial monitoring and transfer for pediatric psychiatric evaluation. Additionally, the facility did not notify the Department of Child Services; DCS only became involved after the hospital reported the incident. Adult Protective Services later verified neglect of the adult resident as a vulnerable adult and verified that a sexual assault occurred. The surveyors found no evidence that, prior to the incident, the facility implemented supervision or preventive measures to separate or monitor the two residents despite staff concerns and knowledge of the minor’s age and vulnerabilities. The deficiency also includes the facility’s failure to implement immediate protective interventions for the minor on the date the incident occurred. Although documentation shows that the minor was placed on change-of-condition monitoring and assigned a one-to-one sitter starting the night after the incident and continuing until discharge, there was no evidence that protective interventions were put in place on the date of the incident itself. Staff interviews indicated that prior to the incident the minor was not directly supervised and had freedom to roam the facility, and that one-to-one supervision was only initiated after the event. The facility’s own investigation and reporting documents did not identify the sexual contact between an adult and a minor as sexual abuse, instead framing it as a consensual encounter, despite internal staff, APS, and DCS statements that a minor could not legally consent. The surveyors concluded that the facility failed to address the minor’s inappropriate interactions with staff, failed to provide supervision when the minor was noted to spend time with a cognitively impaired adult resident, and failed to identify and report the sexual contact between a minor and an adult as sexual abuse, resulting in a finding of Immediate Jeopardy and Substandard Quality of Care. Additional documentation in the clinical record and staff interviews further demonstrate gaps in assessment and follow-through related to the incident. Although multiple provider notes referenced plans for psychiatric consultation for both residents, there was no evidence that the minor ever received a psychiatric consult while at the facility, and the clinical record lacked clear documentation of the incident as the reason for psychosocial monitoring or hospital transfer for pediatric psychiatric evaluation. For the adult resident, psychiatric evaluation occurred after the incident and focused on anxiety and worrying about a recent event, without detailing the nature of the event in the clinical record. The facility’s care plans for both residents referenced a “reported event” and potential psychosocial well-being problems but did not specify the sexual incident or outline concrete supervision strategies to prevent recurrence. Staff interviews consistently indicated that the two residents had been spending time together, that staff were informally “keeping an eye” on the minor, and that there was concern something might happen, yet these concerns were not translated into documented, formalized interventions or timely recognition and reporting of the incident as sexual abuse of a minor by an adult resident.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A CNA aggressively slapped and grabbed a resident’s wrist during lunch feeding assistance, then roughly pulled the resident’s hand off his shirt sleeve after she had grabbed it. The CNA had prior disciplinary actions, including a previous feeding incident in which a resident choked and required the Heimlich maneuver. A nurse later assessed the resident and found no bruises or cuts.
A facility failed to protect two residents from resident-to-resident physical abuse. In one incident, a resident with dementia and cognitive impairment was struck during a dispute over TV volume and responded by scratching the other resident. In another, a resident with dementia and physically aggressive behaviors scratched a roommate’s face, leaving superficial marks. Staff interviews and clinical records confirmed both altercations and the resulting injuries.
A resident with a left ankle fracture, muscle weakness, and total-assist transfer needs was supposed to receive 2-person assistance and remain NWB on the left leg. Instead, a nurse aide transferred the resident with only one staff member during a toilet-to-wheelchair transfer, and the resident heard a pop and developed increased pain. X-ray and hospital imaging confirmed fractures of the distal R tibia and fibula, and the facility substantiated neglect for not following the care plan.
Failure to Protect Resident from Repeated Room Intrusions: A cognitively intact resident with depression and hip OA was repeatedly frightened when another resident with dementia and wandering behaviors entered her room, took belongings, and could not be reliably redirected. Staff used a stop sign banner and other barriers, but the other resident continued to enter the room, and the resident became so fearful that she requested discharge before completing her therapy goals.
Failure to protect a resident from alleged physical abuse: A resident with COPD, speech disturbances, and dysphagia reported that an LPN pushed them in the chest during med pass after they refused meds, causing them to fall. The resident had no visible injuries, but the report was documented by nursing staff and the NP, and the resident later reiterated by writing/gestures that the LPN pushed them. The LPN denied pushing the resident and described the contact as accidental, while the facility concluded there was no evidence of abuse.
A resident-to-resident sexual abuse allegation was not thoroughly investigated, and the resident was not promptly protected or monitored after the allegation. In a separate issue, a handwritten sign with personal care instructions was posted above another resident's bed, and an RT, LPN, RN, and CNA all acknowledged it was a privacy and dignity concern and against facility policy.
Failure to Protect Resident from Abuse During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident’s right to be free from abuse during lunch assistive feeding. While standing about 3 feet from the lunch table, the surveyor heard a CNA aggressively slap Resident #56’s left wrist and observed the CNA grab the resident’s left wrist and roughly pull her hand off of his shirt sleeve after she had grabbed it. The surveyor then continued observing the meal and later reported the incident to the DON and Administrator. Resident #56 was assessed by a licensed nurse after the incident, and no bruises or cuts were found on her wrists. The CNA involved had been hired by the facility in 2024, had signed the facility’s Resident Abuse Procedural Summary, and had attended behavior training in 2026. The CNA also had three prior disciplinary actions, including a prior incident in which a resident choked after being given too large a bite during assistive feeding and required a Heimlich maneuver.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure two sampled residents were free from physical abuse by other residents. One resident with dementia, anxiety, chronic pain, visual hallucinations, and moderate cognitive impairment was involved in an altercation with a roommate after a disagreement about TV volume. The incident escalated when the roommate attempted to take the TV remote and struck the resident with an open hand, and the resident responded by scratching the roommate. The record also documented a new scratch on the resident’s left hand and later noted that the resident no longer wanted to share a room with the other resident. The other incident involved a resident with dementia and significant cognitive impairment who had a behavior care plan for impaired safety awareness and physically aggressive behaviors. The record stated that the resident clawed a roommate in the face, leaving superficial scratches and red marks on the roommate’s chin and cheek. The roommate’s record reflected ongoing monitoring for scratches to the chin and neck, and the roommate stated that the other resident reached up and ran fingernails across her face while they were getting up for breakfast. Facility documentation and staff interviews confirmed both resident-to-resident incidents. Staff described the first event as a physical altercation triggered by conflict over TV volume, and the second as an incident in which one resident scratched another resident’s face. The DON stated the facility investigated and reported the incidents, and also acknowledged that the documentation surrounding the second event was inconsistent and did not meet expectations or policy. The cited deficiency was based on the facility’s failure to ensure the residents were protected from physical abuse by other residents.
Failure to Follow Two-Person Transfer Plan Resulted in Resident Fractures
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not follow the resident’s individualized transfer plan requiring assistance from two staff members. The resident was admitted with a left lower leg trimalleolar fracture, polyosteoarthritis, and muscle weakness, and the MDS indicated the resident was cognitively intact but required total assistance for transfers and toileting. The comprehensive care plan and physician orders both directed staff to provide two-person assistance for transfers and to maintain non-weight-bearing status on the left lower extremity. During a transfer from the toilet to a wheelchair, one nurse aide assisted the resident without a second staff member. According to the documentation, the resident stood without difficulty, but during the pivot transfer the resident’s right foot turned inward and both the resident and the aide heard a loud pop. The resident immediately reported increased pain. Later that day, x-ray findings identified an acute fracture of the right tibia, and the resident was transferred to the hospital emergency department for further evaluation and treatment. Hospital imaging confirmed fractures of the distal right tibia and fibula, and the resident was scheduled for surgical repair. The facility’s investigation determined that the aide transferred the resident with only one staff member despite the care plan and physician order requiring two staff members, and that this failure directly resulted in the resident sustaining the fractures. The facility substantiated caregiver neglect and terminated the employee following the investigation.
Failure to Protect Resident from Repeated Room Intrusions
Penalty
Summary
The facility failed to protect a cognitively intact resident with osteoarthritis of the right hip and major depressive disorder from mental abuse by another resident. The resident was admitted as a vulnerable adult and her care plan identified a goal of being free from abuse, neglect, or financial exploitation, but it did not include interventions to protect her from abuse. The resident later reported that another resident repeatedly entered her room, scared her, and took belongings, and she asked staff to contact her lawyer. She also began using a stop sign banner across her door and later barricaded her room with a walker, closet door, and bedside table because she was afraid of the other resident. The other resident had moderate cognitive impairment, vascular dementia with agitation, and Alzheimer’s disease, and his care plan documented restlessness, agitation, sundowning, wandering into other residents’ rooms, and urinating in public. Progress notes showed repeated episodes of wandering into other residents’ rooms, difficulty with redirection, aggression toward staff, and disruptive behavior in resident rooms. Notes also documented that he entered the affected resident’s room on multiple occasions, and staff observed that he could move barriers out of the way and continue entering the room despite attempts to block access. Staff interviews confirmed that the resident was very scared of the other resident and that the repeated room intrusions continued over several days. Staff stated that stop sign banners did not stop him, closed doors did not stop him, and that it often took two or more staff to remove him from rooms. The resident requested discharge from the facility and left before reaching her maximal level with therapy services. Therapy documentation stated she was improving but still needed higher-level therapy before discharge, and the therapy director stated her early discharge was because she could not remain in the facility due to the other resident coming into her room. Facility records also showed staffing levels that were below the facility assessment on several shifts, and the assignment sheets did not identify a staff member assigned to 1:1 observation for the wandering resident.
Failure to Protect Resident from Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when a nurse allegedly made physical contact with the resident during medication administration. Resident #7, who had diagnoses including COPD, speech disturbances, and dysphagia, had intact cognition on the MDS dated 03/18/2026 and was care planned as at risk for misappropriation, neglect, abuse, and/or exploitation. On 04/08/2026, the resident reported to the RN supervisor that an LPN pushed them in the chest after they refused medications, causing them to fall to the floor. The resident was assessed and no visible injuries were noted. The resident’s report was documented in nursing and medical progress notes, and the facility’s investigation recorded that the resident was visibly upset while describing the incident. The LPN denied the allegation and stated that any contact was accidental, describing that the resident was close behind them as they left the room and that the resident’s chest contacted their back or shoulder. The RN supervisor, DON, and NP each documented interviews and assessments in which no bruising, swelling, or visible injury was found, and the resident later communicated by writing and gestures that they had told the LPN to leave the room and that the LPN pushed them in the chest and they fell. The facility concluded there was no evidence of abuse, neglect, exploitation, or mistreatment, despite the resident’s allegation and the conflicting accounts from the LPN and resident. The RN supervisor stated law enforcement was notified and police interviewed the resident and the LPN, but no report was filed. The DON later stated the contact was accidental and that the resident’s reporting was inconsistent regarding whether a fall occurred.
Failure to Protect Resident from Abuse and Maintain Privacy
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a resident-to-resident sexual abuse allegation was not thoroughly investigated and the resident was not promptly protected or monitored after the allegation. The report states this involved 1 of 52 sampled residents, Resident 45, and that the deficient practice had the potential to place the resident at risk for continued abuse, emotional distress, fear, anxiety, a diminished sense of safety, and delayed implementation of interventions necessary to protect the resident from further abuse. The facility also failed to protect the privacy and confidentiality of Resident 58. Resident 58 was admitted with diagnoses including chronic obstructive pulmonary disease. During observation, a handwritten sign reading, "Attention please no briefs chucks only!!" was posted above the resident's bed and remained there on a later observation. Staff members including a Respiratory Therapist, LPN, RN, and CNA each acknowledged the sign was visible above the bed and stated it was a privacy, dignity, and policy issue. A facility Residents Rights policy stated residents have the right to privacy and confidentiality with personal care and medical records, and that resident medical and personal care information is private and staff are required to respect and uphold resident privacy at all times.
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