WRIGHTSVILLE, GA - Federal inspectors issued an immediate jeopardy citation to Wrightsville Manor Health and Rehab following a sexual assault of a female resident by a male resident on November 29, 2024. The citation, the most serious category of nursing home violations, indicates deficiencies that have caused or are likely to cause serious injury, harm, impairment, or death.
Sexual Assault Discovered During Night Shift
On November 29, 2024, at approximately 12:30 am, nursing staff discovered a female resident with significant vaginal bleeding after multiple staff members observed a male resident repeatedly entering and exiting her room. A Licensed Practical Nurse contacted the facility's Registered Nurse after discovering a large amount of bright red blood on the right side of the resident's brief, appearing to originate from the vaginal area.
Staff members reported observing the male resident leaving the victim's room and adjusting his belt in the facility lobby. Nursing staff noted visible blood on the male resident's pants near the zipper area. The female resident was immediately transported to the hospital for evaluation.
Hospital records from that morning documented findings consistent with sexual assault. Medical staff performed a sexual assault examination at 6:10 am, which revealed abrasions at multiple locations and a small vaginal tear. The hospital provided the victim with prophylactic treatment for sexually transmitted infections, a standard protocol following sexual assault.
Police Investigation and Arrest
Local law enforcement responded to the facility at 6:41 am on November 29, 2024. The responding officer's report documented that an on-duty nurse entered the female resident's room and witnessed the male resident positioned over the victim. When the male resident fled from the room, the nurse discovered blood around the victim's genital area.
Staff located the male resident with his hands positioned in front of his pants. Blood was visible on his clothing. The facility collected clothing from both residents as evidence. Four staff members provided statements confirming they had witnessed the male resident entering and exiting the female resident's room multiple times during the night shift.
After consulting with medical staff and collecting the sexual assault examination kit, law enforcement determined the female resident had been raped. The male resident was arrested but subsequently returned to the facility due to concerns about his mental capacity. The facility moved him to a locked unit pending transfer to a behavioral health facility.
Warning Signs Documented by Multiple Staff Members
Federal inspectors identified critical failures in the facility's supervision and monitoring protocols. The inspection report documented that four separate staff members had observed the male resident repeatedly entering the victim's room throughout the night shift, yet no intervention occurred until after the assault.
The Registered Nurse who responded to the emergency stated that staff observed the male resident "fiddling with his pants" and noted fresh blood on his clothing. A Certified Nursing Assistant entering the victim's room immediately after the male resident departed discovered the blood. The nurse confirmed the victim had no blood present during earlier care that shift.
Medical evaluation revealed the victim experienced physical pain during the assessment, flinching when staff cleaned the vaginal area, a response not previously observed during routine care. This physical reaction indicated acute injury consistent with the timeline of events documented by staff.
Administrator Response Raises Concerns
During interviews with federal inspectors on January 29, 2025, the facility's Director of Nursing made statements that raised additional concerns about the facility's understanding of sexual assault and resident protection obligations. The Director stated she did not know if the victim "was raped" and suggested "it depends on what you define as rape."
The Director further stated that if the male resident "did something" to the victim, it would have been with his hands because he was not capable of sexually assaulting the victim. These statements contradicted medical evidence documented in hospital records and the law enforcement investigation.
Federal regulations require nursing homes to protect residents from all forms of abuse, including sexual abuse. Sexual assault encompasses any non-consensual sexual contact, regardless of the specific nature of that contact. The medical evidence of vaginal trauma, bleeding requiring emergency treatment, and findings documented during the hospital's sexual assault examination established the severity of the incident.
Medication Management Questions
Inspectors documented that the male resident had been prescribed medroxyprogesterone, a medication sometimes used to reduce sexual impulses in individuals with behavioral concerns. The Director of Nursing revealed the resident "was starting back on" this medication, indicating it had been discontinued at some point prior to the assault.
The inspection report does not clarify when the medication was discontinued, why it was restarted, or whether appropriate behavioral assessments were conducted before making these medication changes. Proper medication management for residents with behavioral concerns requires comprehensive assessment, physician oversight, and implementation of non-pharmacological interventions to protect resident safety.
Inadequate Post-Incident Monitoring
Following the assault, the facility placed the male resident on 15-minute observation checks while he remained in the locked unit awaiting transfer to a behavioral facility. However, the Administrator confirmed during inspection interviews that the facility did not implement one-on-one supervision despite the severity of the incident.
Immediate jeopardy situations require facilities to implement the most restrictive monitoring necessary to ensure resident safety. Continuous one-on-one supervision is the standard intervention following a serious incident involving resident-to-resident harm when the alleged perpetrator remains in the facility.
Investigation Deficiencies
The Administrator, who served as the facility's abuse coordinator, stated she did not conduct follow-up interviews with staff beyond obtaining three written statements. Comprehensive abuse investigations require detailed interviews with all witnesses, review of relevant documentation, and assessment of systemic factors that may have contributed to the incident.
Federal regulations mandate that nursing homes thoroughly investigate all allegations of abuse. This includes interviewing all potential witnesses separately, reviewing staffing patterns and supervision protocols, examining any previous incidents involving the residents, and identifying corrective actions to prevent recurrence.
Required Corrective Actions
Federal inspectors documented that the facility removed the immediate jeopardy designation after implementing specific corrective actions. These included in-service training on abuse prevention for the Administrator and Director of Nursing, holding an emergency Quality Assurance and Performance Improvement meeting, and implementing enhanced monitoring procedures.
The facility installed a camera monitor in the victim's room with continuous viewing at the nurses' station. The male resident was discharged from the facility. Staff received abuse prevention education, and the facility conducted interviews with all residents to assess whether similar incidents had occurred.
The facility also implemented weekly skin assessments for all residents to identify unexplained injuries, bruises, or skin tears that might indicate unreported abuse. These assessments began on December 2, 2024, with completion documented by December 6, 2024.
The Social Services Director convened an emergency meeting on February 7, 2025, with the resident council to review abuse prevention and resident rights. The facility modified its policies to ensure new employees cannot begin work without completing abuse prevention training.
Federal Oversight and Resident Protection Standards
Immediate jeopardy citations represent the most serious category of nursing home violations under federal oversight. These citations indicate the Centers for Medicare and Medicaid Services has determined that facility practices have caused or are likely to cause serious injury, harm, impairment, or death to residents.
Federal regulations require nursing homes to ensure each resident receives care in a safe setting and is free from abuse. This includes implementing adequate supervision, conducting thorough assessments of residents with behavioral concerns, and maintaining staffing levels sufficient to prevent resident-to-resident harm.
Facilities must conduct comprehensive assessments when residents exhibit behaviors that may pose risks to themselves or others. These assessments should inform care planning, including appropriate supervision levels, environmental modifications, and behavioral interventions. When medication is used to address behavioral concerns, facilities must regularly reassess its effectiveness and necessity.
The full inspection report is available through Medicare's Nursing Home Compare website, which provides detailed information about deficiencies identified during federal surveys of all certified nursing homes nationwide.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wrightsville Manor Health and Rehab from 2025-02-14 including all violations, facility responses, and corrective action plans.
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