The worker sat on Resident 33's bed between Christmas and New Year's Day, rubbed her back and arms, kissed her cheek and neck, and told her he wanted to see her "beautiful cat" again after seeing her naked in the hallway. The resident has moderate cognitive impairment and legal blindness following a stroke.
Her roommate watched it happen. A certified nursing assistant saw the worker sitting on the bed, talking to the resident and kissing her cheek. Another aide heard about the incident from colleagues.
None of them reported it immediately.
The roommate finally told staff about the sexual abuse on January 5, a week after witnessing it. By then, the male worker had continued his regular duties, with unrestricted access to residents throughout the facility.
"She would not want an unknown male kissing and touching her," the victim's sister told inspectors. "If Resident 33 had all her cognitive abilities, the resident would have suffered serious psychosocial harm from the male staff kissing and touching her while in her bed."
The sister said her cognitively intact sister "would have been fearful" and "wouldn't want that person near her."
Federal inspectors found the facility failed to protect residents from sexual abuse and immediately cited Lakeshore Manor for violations that posed immediate jeopardy to resident health and safety.
The roommate, identified as R1, was cognitively intact and provided detailed testimony about what she witnessed. She told inspectors the male worker came into their shared room approximately a week before January 5, walked to Resident 33's bed, and tried to wake her by whispering and rubbing her back and arm.
"S5MAIN kissed Resident 33's left cheek, sat down next to Resident 33 on her bed, began to rub Resident 33's back and arm, and again kissed her on the cheek and the neck," according to the inspection report.
R1 heard the worker tell Resident 33 "he wanted to see her beautiful cat again, and that he had seen her beautiful cat while she was naked in the hall." She said other staff members also witnessed the worker sitting on Resident 33's bed.
But R1 waited days before reporting what she saw. She finally told certified nursing assistant S6CNA about the incident on January 5.
The delay wasn't unique. Certified nursing assistant S8CNA also witnessed inappropriate behavior but never reported it to administration. She told inspectors she saw the male worker sitting on Resident 33's bed sometime between Christmas and New Year's Day, talking to her, rubbing her shoulder, and kissing her cheek.
"The observation made her feel uncomfortable and she thought it was inappropriate," inspectors noted. "She stated she did not report the incident to administration and stated she would have if it happened again."
S8CNA communicated what she saw with two other nursing assistants, S6CNA and S7CNA, but none of them elevated the concerns to supervisors.
S7CNA told inspectors that both S8CNA and R1 had told him about witnessing the male worker "sitting on Resident 33's bed, talking to her and making inappropriate sexual statements." He never reported it either.
The director of nursing, S2DON, didn't learn about the incident until January 5 around 6:00 p.m., when S3RN reported what R1 had witnessed. S2DON immediately contacted the administrator and Regional Director of Clinical.
"She was not aware a staff member had witnessed the incident and confirmed the staff that witnessed it should have immediately reported it so Resident 33 could have been protected," the inspection report states.
Administrator S1ADMIN learned about the allegations around 7:00 p.m. on January 5. The male worker had told him "a few weeks ago" that he kissed Resident 33 on the forehead while leaving her room after speaking with residents, but the administrator was unaware that multiple staff had witnessed more extensive inappropriate behavior.
The administrator hadn't reported the incident to police as of January 10, when inspectors interviewed him.
The male worker, identified as S5MAIN, had not worked at the facility since January 2 and was placed on indefinite suspension pending review. But the facility's delayed response meant he continued working with unrestricted access to vulnerable residents for days after the sexual abuse occurred.
Resident 33 was admitted to the facility with multiple serious conditions including hemiplegia following a stroke, dementia, difficulty walking, and legal blindness. Her cognitive assessment score of 8 indicated moderate impairment, making her particularly vulnerable to abuse.
The facility's own policy defined sexual abuse as "non-consensual sexual contact of any type with a resident" and required immediate reporting of suspected abuse. Staff responsibilities included reporting allegations to the administrator and other officials as required.
The inspection revealed a systemic failure in the facility's abuse prevention and reporting systems. Multiple staff members recognized inappropriate behavior but failed to follow established protocols for protecting residents.
By the time inspectors arrived, the facility had implemented corrective measures including staff retraining on abuse recognition and reporting procedures, psychological evaluations for the victim, and daily safety monitoring. The administrator reported the incident to police on January 10.
The facility also interviewed other residents to determine if they had experienced abuse and observed non-verbal residents for signs of trauma, finding no additional victims.
Federal inspectors also cited the facility for assessment errors, inadequate care planning, food safety violations, and infection control failures during the same inspection. These included improperly stored and expired food items, and staff failing to follow enhanced barrier precautions for residents with medical devices and wounds.
The sexual abuse case highlighted the vulnerability of cognitively impaired residents and the critical importance of immediate reporting when staff witness inappropriate behavior. The victim's sister emphasized that her sister would have been traumatized and fearful if she had full cognitive abilities to understand what happened to her.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lakeshore Manor Nursing & Rehab from 2025-01-12 including all violations, facility responses, and corrective action plans.
Additional Resources
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