MARLINTON, WV - Federal inspectors placed Pocahontas Center under immediate jeopardy status after discovering the facility failed to protect residents from a male resident who sexually assaulted multiple female residents over more than 15 months.
The August 1, 2024 inspection revealed a pattern of sexual, physical, and verbal misconduct by a male resident with dementia and Alzheimer's disease that facility staff documented but failed to properly investigate or report to authorities.
Pattern of Sexual Assaults Documented But Ignored
The most recent incident occurred on July 2, 2024, when nursing aides witnessed the male resident grabbing a female resident's breast. However, federal inspectors discovered this was just the latest in a disturbing pattern of documented assaults dating back to April 2023.
Medical records revealed multiple instances where staff documented the male resident's inappropriate behavior but failed to follow the facility's own policies for reporting and investigating alleged misconduct. One female resident told inspectors: "I am afraid of Resident #20. Resident #20 had a reputation of touching women."
The resident described how the male resident had entered her room at night, touched her leg, and attempted to get into bed with her. When she asked him to leave, he refused, forcing her to call for nursing staff assistance.
Facility Failed to Follow Safety Protocols
Federal regulations require nursing homes to protect residents from potential harm and immediately investigate any allegations of misconduct. The inspection found Pocahontas Center violated these fundamental safety requirements in multiple ways.
Staff members acknowledged being aware of the male resident's behavioral issues but failed to implement adequate supervision. One registered nurse told inspectors: "It is absolutely best to keep eyes on him" when referring to the male resident.
Despite this knowledge, the facility's investigation into the July incident was inadequate. When inspectors questioned the nurse who conducted the investigation about why licensed staff claimed no awareness of sexual misconduct when multiple nurses had acknowledged knowing about the behavior, she responded: "I can't answer why they would each tell us something different."
Extensive Documentation of Escalating Behavior
Medical records contained detailed documentation of increasingly concerning behavior patterns spanning over 15 months:
- April 2023: Staff documented the resident making explicit sexual comments to female residents in the dining room - August 2023: Multiple incidents of the resident groping female residents' private areas and physically restraining them - October 2023: Staff observed escalating inappropriate behavior including public masturbation - 2024: Continued incidents of chasing female residents and making inappropriate contact
In one particularly disturbing incident from August 2023, kitchen staff reported hearing a female resident yelling "help, help" and witnessed the male resident groping her while she was "pinned where she could not get away from him."
Medical and Safety Implications
Sexual misconduct in nursing home settings poses serious psychological and physical risks to vulnerable residents. Residents with dementia and cognitive impairments are particularly susceptible to trauma from such experiences, which can worsen existing conditions and create new behavioral problems.
The failure to properly address aggressive behavior also creates an unsafe environment for all residents. Federal guidelines require facilities to assess residents who exhibit potentially harmful behaviors and implement appropriate interventions to protect other residents.
Proper protocols should include immediate protective measures, comprehensive behavioral assessments, medication evaluations, and environmental modifications to prevent future incidents. The facility also should have notified physicians and family members about each incident as required by policy.
Investigation Reveals System-Wide Failures
The inspection uncovered multiple system failures beyond the immediate misconduct:
- No proper investigations were conducted for documented incidents - Family members were not notified as required by facility policy - Physicians were not informed of behavioral escalations - Quality improvement processes were not utilized to address patterns - Staff training was inadequate for recognizing and responding to misconduct
The facility's corporate clinical lead nurse acknowledged to inspectors that no investigations had been performed related to the documented incidents and that the facility had failed to identify the specific residents mentioned in progress notes.
Additional Violations Found
Beyond the immediate jeopardy citation for resident protection failures, inspectors identified multiple other deficiencies:
- Inadequate social services for residents needing discharge planning assistance - Incomplete medical record documentation for residents with mental health conditions - Staffing violations including failure to maintain required registered nurse coverage - Fire safety hazards from overflowing dryer lint traps - Infection control problems from improper storage of clean resident clothing
Immediate Corrective Actions Required
Upon discovering the violations, the facility immediately placed the male resident under one-on-one supervision and conducted staff re-education on recognizing and reporting misconduct. However, the immediate jeopardy status remained in effect until August 1, 2024, when inspectors confirmed implementation of corrective measures.
Federal regulations require nursing homes to ensure resident safety through proper screening, staff training, incident prevention, thorough investigations, and appropriate reporting to authorities. Facilities must also protect residents during investigations and respond appropriately to investigation findings.
Regulatory Oversight and Accountability
The immediate jeopardy citation represents the most serious level of violation federal inspectors can assess, indicating conditions that pose immediate risk to resident health or safety. Such citations require facilities to implement immediate corrective actions and demonstrate sustained compliance.
This case highlights the critical importance of proper oversight systems in nursing homes, particularly for residents with behavioral challenges related to dementia and other cognitive conditions. Effective management requires comprehensive assessment, appropriate medication management, environmental modifications, and continuous monitoring to ensure all residents remain safe and protected.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pocahontas Center from 2024-08-01 including all violations, facility responses, and corrective action plans.
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