Other·April 27, 2026

REGULATION VIOLATION(S) §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 denied 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; DEFINITIONS "Sexual abuse," is denied at §483.5 as "non-consensual sexual contact of any type with a resident." The facility failed to ensure Resident 1 was free from abuse, when a Licensed Nurse witnessed and Unlicensed Staff touching his exposed penis against Resident 1's naked body during care. This made Resident 1 feel uncomfortable, and would risk making a reasonable person, who suffered from a similar sexual assault by a facility staff member, to experience fear, guilt, shame, isolation, dehumanization and humiliation as a result. Findings: Resident 1 was admitted to the Skilled Nursing Facility on 7/20/20, with diagnoses including Parkinson's Disease (A chronic, progressive brain disorder affecting chemicals in the brain, leading to impaired muscle control) with Dyskinesia (involuntary movements), with fluctuations of Dyskinesia, Dysphonia (a voice disorder characterized by hoarseness, raspiness, breathiness, or strain), and muscle weakness. Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/11/25, indicated Resident 1 had no memory impairment and had unclear speech. The MDS indicated Resident 1 had a BIMS (Brief Interview for Mental Status) score of 13 (13-15 indicates intact cognition, 8-12 suggests moderate impairment, and 0-7 signifies severe impairment). During an interview with the Administrator on 1/27/26 at 9:15 a.m., he stated he was informed by his Business Officer Manager (BOM) that Licensed Nurse B walked into Resident's 1's room on 12/29/25 and witnessed Unlicensed Staff A standing behind Resident 1 with his own penis in his hand. The Administrator stated Licensed Nurse B immediately escorted Unlicensed Staff A to meet with the Business Officer Manager. During an interview with Resident 1 on 1/27/26 at 10:30 a.m., in the Administrator's office, Resident 1 was observed sitting in a specialty wheelchair, with her arms and legs contracted up to her chest. Her voice was very quiet. She answered in few words. Resident 1 stated she remembered Unlicensed Staff A. When she was asked if he was inappropriate, she responded, "Yes." When asked if he did things she did not want him to, she stated, "It did happen." When asked if he put two - three fingers in her body when he was cleaning her, she stated, "It did happen." When asked if he put his penis in her vagina she stated, "More than once." She stated she would say, "No" to him. During an interview on 1/27/26 at 11:48 a.m. the Business Operation Manager stated on 12/29/25 around 4 p.m., Licensed Nurse B came into the office with Unlicensed Staff A and stated she had observed Unlicensed Staff A in Resident 1's bedroom, standing beside Resident 1 with his penis exposed, in his hand. The Business Operation Manager stated he asked Unlicensed Staff A if it was true if he had his penis exposed in Resident 1's room and Unlicensed Staff A responded, "I don't know" and stated, "Whatever she [Licensed Nurse B] said." The Business Operation Manager stated Unlicensed Staff A never denied the allegation. The Business Operation Manager stated he interviewed Licensed Staff B, and she stated, when she walked into Resident 1's room, she observed Resident 1 lying on her back, in her bed, with her limbs contracted towards her leaning to her right side. During an interview on 1/27/26 at 1:35 p.m., Licensed Staff B stated, on 12/29/25 between 4 p.m. and 5 p.m., she walked into Resident 1's room and saw Resident 1 lying on her bed with her legs contracted and, "Unlicensed Staff A had his penis out and touching her [Resident 1's] butt area." She stated Resident 1 was positioned on the right side of the bed, facing the door, with her buttocks on the edge of the left side of the bed, where Unlicensed Staff A was standing. She stated she observed Unlicensed Staff A with his pants pulled down in the front. She stated, "He was holding his penis in his left hand, and his right hand was on Resident 1's left buttock, and his penis was pressed against her left buttock at the gluteal fold (the horizontal skin crease separating the lower buttock from the upper thigh)." During an interview on 1/27/26 at 1:50 p.m., Charge Nurse C stated, on 12/29/25 after 5 p.m., Licensed Nurse B told her she had seen Unlicensed Staff A touch Resident 1 with his exposed penis. Charge Nurse C went with Licensed Nurse B to Resident 1's room and asked her if she was okay. Charge Nurse C indicated Resident 1 stated, "Boundaries were crossed," with the unlicensed staff who had been with her. She stated she spoke with Resident 1 later during the shift, and she stated Unlicensed Staff A had crossed boundaries when he changed her brief. She indicated Resident 1 stated sometimes he would push his fingers on her anus and he was rough. She stated Resident 1 felt he lingered too long in her room during personal care. During an interview with the Police Detective on 1/29/26 at 2:32 p.m., he stated Resident 1 indicated during his interviews with her on 12/29/25 and 12/30/25, that Unlicensed Staff A had touched her with his penis, had inserted his penis into her vagina, and had inserted two or three fingers into her vagina on multiple occasions. He stated when he interviewed Unlicensed Staff A, he admitted he touched Resident 1 on multiple occasions. During a review of a facility Policy and Procedure titled, "Resident Abuse Prevention Policy," revised 9/19/25, it stipulated, "The purpose of this policy is to affirm the facility's commitment to preventing...any form of resident abuse...The facility maintains a zero-tolerance stance toward any form of resident abuse..." Therefore, the facility failed to ensure Resident 1 was free from abuse when a Licensed Nurse witnessed an Unlicensed Staff touching his exposed penis against Resident 1's naked body during care. This made Resident 1 feel uncomfortable, and would make a reasonable person, who suffered from sexual assault by a facility staff member, to experience fear, guilt, shame, isolation, dehumanization and humiliation because of the sexual abuse. The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.