The facility received an immediate jeopardy citation from federal inspectors who found no evidence that staff implemented required safety measures after the sexual abuse allegation. The accused resident never received the mandatory one-on-one monitoring, and the victim continued sharing a room with his alleged abuser until late that evening.
The incident began around 2:38 a.m. when the night nurse received reports of the alleged sexual abuse between the two roommates. Both men shared the room with two other residents. The registered nurse on duty confirmed she left no staff member with the accused resident after learning of the incident, and the man did not receive one-on-one care.
By 3:00 a.m., the assistant director of nursing had been notified. When she checked on the victim later that morning, she found him coming out of the doorway while the accused resident remained in bed in the same room. The accused resident said and did nothing, she reported to inspectors.
Nobody told the administrator.
The victim had to walk to her office himself, five and a half hours after staff first learned of the allegation. The administrator confirmed to inspectors that she should have been notified immediately. She called the night nurse to get details about what had happened between the two residents.
The accused resident remained in the shared room until his discharge at 6:08 p.m. that day — nearly 16 hours after the initial report.
The director of nursing told inspectors that the accused resident should have been placed on one-on-one care immediately after the incident. Such documentation would typically appear in the resident's notes or shift reports. He could not provide any evidence that this monitoring occurred.
The assistant director of nursing, who was responsible for taking physician orders, acknowledged she had no system in place for handling verbal orders. She told inspectors she misplaced the verbal discharge order from the physician for the accused resident and could not locate any discharge documentation.
The accused resident had severe cognitive impairment, according to his mental status assessment score of 6 out of 15 on the facility's screening tool. His medical record showed diagnoses including chronic viral hepatitis C, cognitive communication deficits, and cannabis use.
During the night shift on December 27-28, the registered nurse confirmed that no additional staff remained in the residents' room when she ended her shift at 7:00 a.m. At that point, the victim had returned to the shared room and was in his bed, the accused resident was in his bed, and the two other roommates remained in their beds.
The facility's own plan of correction acknowledged multiple failures. Staff should have followed the abuse and neglect policy to protect residents immediately. Any resident accused of abuse should have been placed on one-on-one monitoring with behavior documentation until cleared by a medical provider or discharged. The administrator and director of nursing were responsible for ensuring all aspects of the abuse and neglect policy were implemented.
Federal inspectors found the facility had failed to protect residents from abuse. The immediate jeopardy citation indicated that residents faced serious harm or death from the facility's deficient practices.
The two roommates who witnessed the incident had "potential to be affected," according to the facility's own assessment. Staff began trauma assessments for these residents on January 30, 2025 — more than a month after the incident.
The facility initiated emergency staff education on January 30, 2025, requiring 100 percent of employees and contract workers to receive training on the abuse and neglect policy, including proper reporting timeframes and procedures for one-on-one monitoring. Staff members could not work until completing this education.
Regional administrators sent voice and text message communications to all staff. In-person meetings were conducted by the director of nursing, associate director of nursing, and assistant director of nursing. The facility scheduled daily education sessions until achieving 100 percent completion.
An emergency quality assurance meeting was held January 31, 2025, involving the administrator, director of nursing, management nurses, department heads, medical director, and floor staff to discuss systemic changes.
Beginning the week of February 3, 2025, the social services director planned to interview five residents weekly for four weeks about potential abuse, then continue monthly interviews for three months. Results would be reviewed by the quality assurance committee to ensure compliance with protective procedures.
The facility asserted that the likelihood for serious harm to residents no longer existed as of January 30, 2025. The accused resident had been discharged on December 27, 2024, and new policies were implemented to prevent similar failures in resident protection and abuse response procedures.
The administrator and director of nursing both acknowledged their responsibility for overseeing the facility's abuse and neglect policies, including proper reporting timeframes, one-on-one monitoring requirements, and staff education to ensure resident safety and well-being.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland Place Rehab and Nursing Center from 2025-02-04 including all violations, facility responses, and corrective action plans.
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