Federal inspectors found immediate jeopardy violations at Signature Healthcare at Colonial Rehab & Wellness after discovering the facility failed to protect residents from sexual abuse and medication errors that could cause serious injury or death.
The sexual assault occurred on September 4, 2023, when the Activities Director witnessed R63's hand down the front of R34's shirt, appearing to touch her breast. R34 yelled out and R63 removed his hand. The Activities Director immediately separated the residents and reported the incident to the Director of Nursing.
R34 had severe cognitive impairment with a Brief Interview for Mental Status score of six out of fifteen. She had been admitted in 2021 with encephalopathy, seizures, and epilepsy. The facility never assessed her capacity to consent to sexual relations.
R63 admitted to touching R34's breast but could not recall why. He was placed on one-to-one observation, then escorted to local law enforcement and charged with sexual abuse.
This was not R63's first inappropriate incident. Since 2022, he had a documented pattern of sexual behavior that the facility repeatedly failed to address effectively.
On February 24, 2022, R63 and another female resident kissed each other on the lips while sitting at a dining room table. On August 14, 2022, R63 and the same resident kissed during an activity. On May 17, 2023, R63 allegedly exposed himself to a female resident. On August 9, 2023, staff found R63 had entered a female resident's room and exposed himself after she yelled for help.
The facility unsubstantiated all these previous incidents while acknowledging they occurred.
Despite this pattern, the facility's care plan for R63 remained inadequate. A February 20, 2023 care plan noted he demonstrated "inappropriate behaviors with other residents" but failed to specify the sexual nature of these behaviors or alert staff to his potential for sexual misconduct.
R63 had been diagnosed with vascular dementia, psychotic disturbance, mood disturbance, and anxiety. His cognitive assessment showed moderate impairment with a score of eleven out of fifteen. Staff noted his behaviors escalated after a stroke, yet the facility never conducted a formal assessment of his capacity to consent to sexual activity.
In July 2023, R63 requested condoms and staff provided them without any documented evaluation of his ability to engage in consensual relationships.
The psychiatric nurse practitioner told inspectors that determining consent for sexual activity was beyond her scope of practice. "The term consent was actually a legal term and two physicians were required to determine capacity," she said. The facility had never asked her to evaluate residents' capacity for consent.
A Licensed Practical Nurse told inspectors she believed there were opportunities for R63 to interact with female residents without supervision and inappropriately touch them.
The MDS Nurse Coordinator said R63 had "potential for reoccurrence of inappropriate behaviors" and was being discussed in team meetings to determine his ability to be involved in relationships. She knew R63 before and after his stroke and said "the resident had definitely changed after the stroke."
The Director of Nursing said three of the four previous incidents involving R63 occurred in the dining room, which also served as the activities area. She claimed all dining and group activities were monitored by staff, yet the witnessed assault still occurred during a supervised activity.
Only after the July 2024 inspection did the facility adopt an assessment tool to determine residents' capacity to consent to sexual relationships. The Social Services Coordinator said staff had received education on this assessment "over the past few days."
The medication error posed equally serious risks. On May 3, 2022, R58 developed altered mental status and was sent to the emergency room. During assessment, the ER nurse discovered a 75-microgram fentanyl patch on R58's left upper arm.
Fentanyl was not among R58's prescribed medications. The patch belonged to R58's roommate, R2, who had an active order for the powerful narcotic. When the Director of Nursing assessed R2, she could not find the resident's prescribed fentanyl patch.
The facility had no documentation explaining how R58 received R2's fentanyl patch, a medication error that could have caused respiratory depression, coma, or death in a patient not prescribed the narcotic.
Federal regulations require nursing homes to have systems ensuring residents are free from significant medication errors. Fentanyl is among the most potent opioids available, used only for severe pain management under careful medical supervision.
The Administrator said his expectation was that residents would be safe from sexual abuse and that care plans should be updated when there were changes in residents. The Medical Director said R63's care was reviewed in morning meetings and quality assurance meetings, with psychiatric evaluations after each allegation.
Despite these claimed safeguards, the facility failed to prevent the witnessed sexual assault or the dangerous medication error.
The psychiatric provider had started R63 on medication to control sexual impulsivity and increased the dosage after another incident, but he continued to exhibit inappropriate sexual behaviors.
The Director of Nursing said staff were educated about all abuse allegations and residents' care plans were updated. She claimed three previous incidents occurred in the dining room during monitored activities, yet supervision failed to prevent the September assault.
A State Registered Nursing Assistant said she provided one-to-one observation of R63 in February or March 2023 because he had kissed another resident, indicating the facility knew he required constant supervision.
The inspection found the facility lacked policies for determining residents' capacity to consent to sexual activity, despite housing residents with severe cognitive impairments who could not protect themselves from unwanted sexual contact.
R34 remains at the facility with severe cognitive impairment and a history of seizures. Her clinical record showed no mental distress after the assault, but also revealed no comprehensive evaluation of the incident's impact on her wellbeing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Signature Healthcare At Colonial Rehab & Wellness from 2024-07-11 including all violations, facility responses, and corrective action plans.
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