PLYMOUTH, WI - Federal inspectors cited Rocky Knoll Health Care for failing to report an alleged sexual incident between residents with cognitive impairments and conducting an incomplete investigation, according to a July 2024 inspection report.
Failure to Report Serious Incident to State Authorities
Rocky Knoll Health Care faced significant violations after an April 21, 2024 incident involving two residents with severe cognitive impairments. According to the inspection report, one resident (R5) approached another resident (R2) in the facility lobby, kissed them on the mouth, and R2 responded by touching R5's breast. R5 immediately stopped the interaction, saying "No, no. We can't do that."
Despite federal requirements mandating immediate reporting of potential abuse situations, facility administrators chose not to report the incident to state authorities. The nursing home administrator and assistant administrator told inspectors they determined the incident was not abuse and no physical harm occurred based on a skin assessment of R5.
This decision violated federal regulations requiring nursing homes to report allegations of abuse within 24 hours. The incident involved residents with severely compromised decision-making abilities - R5 had a cognitive assessment score of 4 out of 15, indicating severe impairment, while R2 scored 8 out of 15, showing moderate impairment.
Medical records showed both residents had diagnoses including various forms of dementia, anxiety disorders, and depression. Both residents had activated Powers of Attorney for Healthcare, indicating their families were responsible for complex medical decisions.
Inadequate Investigation Process
Federal regulations require thorough investigations of potential abuse situations, but Rocky Knoll's response fell short of established protocols. The facility's own policies mandated comprehensive investigations including interviews with alleged victims, witnesses, other residents, and staff members from multiple shifts.
However, the facility failed to conduct proper interviews with the residents involved or other residents who might have witnessed similar behavior. When inspectors requested documentation of the investigation, the facility provided only a basic risk management report and delayed staff statements.
The facility's investigation also failed to properly assess whether the residents had the capacity to consent to intimate contact. A social services assessment for R5 was not completed until April 24, 2024 - more than 24 hours after the incident and after the initial report should have been submitted to state authorities. The assessment confirmed R5's severely impaired decision-making abilities and indicated no interest in pursuing relationships at the facility.
Capacity to consent is a critical factor in situations involving residents with cognitive impairments. Individuals with dementia may lose the ability to understand the nature and consequences of intimate contact, making any such interaction potentially problematic regardless of apparent cooperation.
Supervision Breakdown Led to Preventable Incident
The incident occurred because staff failed to follow existing care plan requirements designed to prevent exactly this type of situation. R2's care plan, implemented on March 18, 2024, specifically required staff to escort the resident to and from their room and maintain direct supervision at all times when outside the room. The plan also mandated keeping R2 separate from female residents.
On April 21, R2 was finishing lunch at a table with male residents near the dining room exit when the resident independently left for their room. Multiple staff members confirmed they were aware of the escort requirement but were busy assisting other residents during mealtime.
A certified nursing assistant told inspectors R2 was "often impatient" and didn't want to wait for staff escort. The staff member saw R2 leave the dining room and called out that they would "be right there" but continued helping other residents and forgot to follow through.
This supervision failure directly contradicted the care plan designed to protect both residents. Medical protocols require consistent implementation of safety measures for residents with behavioral issues or cognitive impairments that could lead to inappropriate interactions.
Medical Context and Risk Factors
Residents with dementia often experience changes in behavior, including inappropriate sexual conduct, as the disease progresses. These behaviors typically result from the brain changes caused by dementia rather than deliberate actions. However, nursing homes must still protect all residents from unwanted contact while managing these challenging behaviors appropriately.
The cognitive assessment scores for both residents indicated significant impairment in judgment and decision-making. R5's score of 4 out of 15 represents severe cognitive impairment, while R2's score of 8 out of 15 indicates moderate impairment. At these levels, residents typically cannot understand complex situations or make informed decisions about intimate contact.
Proper dementia care requires individualized interventions based on each resident's specific behaviors and triggers. Staff must maintain constant awareness of residents who may seek inappropriate contact and implement prevention strategies consistently.
Industry Standards and Required Protocols
Federal regulations require nursing homes to protect residents from abuse and investigate all allegations thoroughly. The reporting requirement exists because facilities may not initially recognize the full scope of a problem, and outside oversight helps ensure resident safety.
Standard investigation protocols include interviewing all potentially involved parties, assessing mental capacity, reviewing security footage when available, and consulting with regulatory authorities. These steps help determine whether an incident represents isolated behavior or part of a pattern requiring additional interventions.
Professional care planning for residents with behavioral issues must include specific, measurable interventions with clear accountability measures. When plans require constant supervision or escorts, facilities must ensure adequate staffing and training to implement these requirements consistently.
Additional Issues Identified
The inspection revealed other concerning aspects of the facility's response. Staff members acknowledged being aware of care plan requirements but admitted to inconsistent implementation. The facility provided staff education only after the incident occurred, rather than ensuring proper training beforehand.
Documentation issues included delayed progress notes and incomplete capacity assessments. The facility also failed to consider whether similar incidents might have occurred with other residents, despite their own policies requiring such evaluation.
The incident highlighted broader concerns about staffing adequacy during busy periods like mealtimes, when multiple residents require assistance simultaneously. Proper staffing models must account for residents requiring individual supervision while maintaining care for others.
This case demonstrates the critical importance of consistent care plan implementation, proper incident reporting, and thorough investigations when resident safety is compromised. The violations occurred despite existing policies and procedures, indicating failures in execution rather than planning.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rocky Knoll Health Care from 2024-07-03 including all violations, facility responses, and corrective action plans.
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