§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
§483.12(a) The facility must-
§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
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Observations:
Based on review of the facility's abuse policy, clinical records, investigation reports, and interviews with residents and staff, it was determined that the facility failed to assure that one resident (Resident 1) out of six sampled residents was free from sexual abuse perpetrated by another resident (Resident 2).
Findings included:
A review of the current facility policy titled "Abuse, Neglect and Exploitation", last reviewed by the facility on February 19, 2025, revealed it is the policy of the facility to provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Sexual abuse is defined as non-consensual sexual contact of any type with a resident.
A review of Resident 2's clinical record revealed admission to the facility May 20, 2025, with diagnoses to include dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), and high risk heterosexual behavior (multiple partners, unprotected sexual activity, and/or substance use during sexual activity).
A quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 27, 2025, revealed that Resident 2 was severely cognitively impaired with a BIMS score of 6 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment), and was independently ambulatory.is able to ambulate independently.
A review of nursing documentation dated August 22, 2025, at 2:44 PM revealed Resident 2 was observed wandering into peers' rooms and using other residents' bathrooms. Additional documentation dated September 6, 2025, at 9:24 PM revealed Resident 2 was found wandering the halls entering multiple female resident rooms and making sexual remarks toward staff members. The resident was redirected easily however, documentation indicated behaviors continued despite redirection. Documentation also indicated supervision was provided by staff.
Nursing documentation dated September 8, 2025, at 3:00 PM revealed Resident 2 continued with frequent wandering into peer rooms.
A review of Resident 2's care plan dated September 20, 2025, identified the resident exhibited inappropriate sexual behaviors, making sexual comments and touching. Interventions planned were to immediately respond to sexually inappropriate comments or behavior by telling him he is being inappropriate and it will not be tolerated, medicate as ordered with Depakote (divalproex sodium- a prescription medication used to treat seizure disorders and mood disorders such as bipolar disorder, and to help reduce aggressive or impulsive behaviors by stabilizing electrical activity in the brain), redirect if necessary from female staff and peers by offering diversional activity, snack, or conversation, redirect to room is visibly aroused to respect dignity and privacy, respect resident's privacy if he is found masturbating, ensure he is in his room and the curtain is closed to maintain dignity, and to seat the resident next to male peers at activities to decrease chances of sexual stimulation. Resident 2's care plan was revised on October 6, 2025, with an added intervention to redirect from the doorways of female peers as needed.
Nursing documentation dated October 4, 2025, at 8:11 PM indicated Resident 2 was placed on one-to-one supervision (a level of supervision in which one staff member provides continuous direct observation to one resident) due to wandering into female residents' rooms.
A review of Resident 1's clinical record revealed admission to the facility on August 27, 2025, with diagnoses to include dementia, anxiety, and depression. An admission Minimum Data Set assessment dated September 3, 2025, revealed that Resident 1 was severely cognitively impaired with a BIMS score of 3.
Nursing documentation dated October 4, 2025, at 9:00 PM revealed Resident 3's daughter called the facility stating that a male resident entered her mother's room and sat on her roommate's bed, staring at her and causing her to cry. She stated her mother said there was no contact made, he just stared at her. The facility was informed to maintain one-to-one supervision of the male resident (Resident 2) until further notice.
A witness statement provided by Employee 4 (Registered Nurse) dated October 5, 2025, revealed that she initiated an investigation after being informed by Resident 3's daughter that Resident 2 had entered Resident 1 and 3's room on October 4, 2025, at approximately 8:00 PM and touched Resident 1's breasts. Resident 3 stated she yelled at him to leave; after several minutes he did. Resident 3 also reported that as Resident 2 exited, he said, "You're next." Law enforcement and protective services were notified and responded. Resident 1's daughter confirmed that her mother stated a man entered her room while she was sleeping and touched her breast.
A review of a written witness statement provided by Employee 4 (Registered Nurse) dated October 5, 2025, (no time indicated) revealed that the incident occurred on October 4, 2025. Employee 4 documented that at approximately 1:05 PM on October 5, 2025, she was called to the room shared by Resident 1 and Resident 3. At that time, Resident 3's daughter was present and reported that during a conversation with her mother earlier that day, Resident 3 had disclosed that a male resident (Resident 2) had entered their room the previous evening at approximately 8:00 PM and touched her roommate's breasts (Resident 1). Resident 3 stated that she yelled at him repeatedly to leave, and after several minutes, he left the room.
Resident 3's daughter expressed concern for her mother's safety, reporting that when she arrived at the facility, she did not observe a nurse aide providing supervision to Resident 2, and that Resident 2 was standing in his doorway staring toward their room. Employee 4 noted that, at the time of her arrival, a nurse aide was seated with Resident 2 providing one-to-one supervision.
Employee 4 initiated an internal investigation immediately. She began collecting staff statements and performed a full body audit of Resident 1, which revealed no signs of trauma. Employee 4 attempted to contact Resident 1's daughter by telephone to notify her of the situation but was unable to reach her.
While Employee 4 was preparing to contact law enforcement to report the incident, a police officer arrived at the facility. Employee 4 escorted the officer to the room of Residents 1 and 3. The officer met with Resident 3 and her daughter to obtain statements. During that discussion, Resident 3 added new information, stating that as Resident 2 was leaving the room, he turned to me and said, 'you're next '." This additional statement had not been previously reported to Employee 4.
The officer then attempted to interview Resident 1, however, due to her cognitive impairment, the interview was limited. The officer declined to interview Resident 2. A Protective Services Worker arrived shortly thereafter and interviewed Resident 1 regarding the event.
Employee 4 again attempted to contact Resident 1's daughter to provide an update on the ongoing investigation. Resident 1's daughter later reported that she had spoken with her mother the night of October 4, 2025, when her mother stated she had been sleeping when she felt someone sit on her bed and touch her breast. Resident 1's daughter stated she asked to speak to Resident 3, and then ended the call, intending to follow up with the facility the following Monday. The attending physician (MD) was notified of the situation and the ongoing investigation, no new medical orders were received at that time.
A review of a written witness statement provided by Resident 3, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, dated October 5, 2025 (no time indicated), revealed that the incident occurred on October 4, 2025. Resident 3 reported that a male resident from room 203 (Resident 2) entered her room, sat on the bed of her roommate, Resident 1, who was lying in bed, and placed his hand on her breast. Resident 3 stated that she yelled at him to leave. After several minutes, Resident 2 got up and exited the room.
A review of a written witness statement provided by Employee 1 (Nurse Aide), undated and without a recorded time, revealed that she was providing care in room 204 when Resident 1 appeared in the doorway and stated there was a man in her room. Employee 1 immediately went to Resident 1's room and observed Resident 2 exiting the doorway while Resident 3 was yelling for him to leave. Employee 1 stated that she removed Resident 2 from the room, calmed both residents, and notified the nurse. Employee 1 reported that she did not personally witness Resident 2 touch Resident 1, but Resident 1 told her that he had tried to touch her.
A review of a written witness statement provided by Employee 2 (Licensed Practical Nurse) dated October 5, 2025 (no time indicated) revealed that the incident occurred on October 4, 2025. Employee 2 reported that while she was administering medication at approximately 9:00 PM to Resident 3, the resident told her that Resident 2 had entered her room and sat on her roommate's bed. Resident 3 stated she yelled at him to get out. Employee 2 reported that she informed her supervisor immediately and that Resident 2 was then placed on one-to-one supervision.
A review of a written witness statement provided by Employee 3 (Registered Nurse Supervisor) dated October 5, 2025 (no time indicated) revealed that the incident occurred on October 4, 2025. Employee 3 reported that at approximately 9:00 PM she entered the second floor and staff informed her that Resident 2 had wandered into Resident 1's room and sat on her bed. Employee 3 stated that, simultaneously, she received a phone call from the Director of Nursing and the Assistant Director of Nursing instructing her to initiate one-to-one supervision for Resident 2. Documentation confirmed Resident 2 was immediately placed on one-to-one supervision at that time.
An interview conducted with Resident 3 on October 8, 2025, at 10:30 AM revealed that Resident 2 was known to wander frequently and had previously entered their room on multiple occasions. Resident 3 reported that on the evening of October 4, 2025, Resident 2 again entered the room, sat on her roommate's bed, and touched her roommate's breast. She stated she witnessed him grab her breast and began yelling for him to leave, using loud language to get his attention. After repeated yelling, he got up and, as he walked toward the door, turned back and said, "Don't worry, you're next." Resident 3 reported that she immediately telephoned her daughter to report what had happened. She stated that Resident 1 was crying, shaking, and hyperventilating after the event, and said, "I felt so bad for her."
An interview with Resident 1 on October 8, 2025, at 10:48 AM revealed that she was lying in bed asleep when a man sat on her bed and placed his hand on her breast. Resident 1 stated she was frightened, got out of bed, and left the room to seek help.
An interview with Employee 1 on October 8, 2025, at 11:30 AM confirmed that she had been providing nighttime care in room 204 when she heard Resident 3 yelling, "Get out of here!" As Employee 1 stepped into the hallway, she saw Resident 1 at the doorway of room 204 calling out, "Nurse, nurse, there's a man in my room!" Resident 1 told Employee 1 that the man had tried to touch her. Employee 1 stated she immediately escorted Resident 2 out of the room, reported the incident to the nurse and supervisor, and noted that Resident 1 appeared visibly upset and shaken.
An interview with Resident 3's two daughters conducted by telephone on October 8, 2025, at 11:45 AM confirmed that Resident 3 had contacted Daughter 1 on the evening of October 4, 2025, at 8:52 PM to report that a man had entered her room and was sitting on her roommate's bed. Daughter 1 reported that she immediately called the facility after speaking with her mother and later called the Director of Nursing's cell phone at approximately 9:00 PM to report the same concern. Daughter 1 stated that at that time, her mother had not mentioned that Resident 2 touched Resident 1.
Daughter 2 reported that while visiting her mother on October 5, 2025, at approximately 1:30 PM, she observed Resident 2 in the hallway unattended and staring into her mother's room. During that visit, Resident 3 told her that Resident 2 had entered their room the previous evening, sat on her roommate's bed, and touched Resident 1's breast. Daughter 2 stated she became concerned about the safety of her mother and other residents, as Resident 2 was unsupervised despite his history of wandering and inappropriate behavior. Daughter 2 reported that she informed nursing staff of her concerns and of the touching incident that occurred on October 4, 2025.
An interview with the Director of Nursing (DON) on October 8, 2025, at 1:30 PM revealed she had received a call from Resident 3's daughter on October 4, 2025, reporting that Resident 2 had entered Resident 1's room and was sitting on her bed. The DON stated she contacted the Registered Nurse Supervisor and instructed her to place Resident 2 on one-to-one supervision. The DON reported she did not become aware of the allegation of sexual contact until the following day, October 5, 2025, at approximately 1:00 PM. Documentation provided by the DON confirmed that Resident 2 was placed on one-to-one supervision on October 4, 2025, and remained under that supervision thereafter.
An interview with Employee 5 (Nurse Aide) on October 8, 2025, at 1:55 PM confirmed she provided one-to-one supervision to Resident 2 on October 5, 2025, during the 7:00 AM to 3:00 PM shift. She stated that during her break, Employee 6 (Licensed Practical Nurse) covered her assignment to maintain continuous supervision.
An interview with Employee 6 on October 8, 2025, at 2:05 PM confirmed she assumed one-to-one supervision while Employee 5 was on break. She reported hearing Resident 3 yelling because Resident 2 had approached the doorway of room 202 and stated she redirected him back to his room.
An interview with the Nursing Home Administrator (NHA) conducted on October 8, 2025, at 2:20 PM confirmed that the facility failed to ensure that Resident 1 was free from sexual abuse perpetrated by Resident 2.
28 Pa. Code 201.29 (a)(c) Resident rights
28 Pa. Code 201.18 (e)(1) Management.
28 Pa. Code 211.10(d) Resident care policies.
| | Plan of Correction - To be completed: 12/04/2025
Perpetrator immediately placed on 1:1 after report of entering resident room and sitting on her bed. On 10.06.25 perpetrator was moved to 3rd floor and continues with 1:1.
Residents with a BIMS of >7 were interviewed to identify any concerns. Any concerns or allegations will be reported and investigated immediately.
"During ambassador rounds, random residents will be interviewed to ensure they feel safe and have no concerns related to abuse.
Perpetrator will be evaluated by psychiatry services to evaluated medications and provide recommendations.
Staff including agency will be re-educated on abuse policy to include reporting, resident to resident incidents, and investigations.
"Random resident interviews will be reviewed at IDT meetings weekly for 4 weeks and then monthly for 3 months to ensure any concerns have been addressed appropriately. Concerns will be addressed immediately.
Reported concerns will be submitted to the QAPI committee monthly for 3 months for further review and recommendations."
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