SHAWNEE, KS - A February 2025 inspection at Shawnee Gardens Healthcare & Rehab Center revealed that facility staff failed to prevent a sexual assault on a cognitively impaired female resident and subsequently moved the male resident involved to a different unit without implementing protective measures, placing 19 additional female residents at risk.
Resident-to-Resident Sexual Assault in Memory Care Unit
On February 8, 2025, staff at Shawnee Gardens documented an incident in which R1, a male resident with known sexual behavioral issues, groped a female resident identified as R2 during meal service in the facility's locked memory care unit. According to a staff witness statement, R1 was seated next to R2 in the dining room when staff observed him inappropriately touching R2's breast and buttocks.
The witness statement described that R1 "groped R2's nipples and pulled her breast downward." R2 was visibly distressed by the incident and reported to staff that "she felt like she was being held against her will." The witness documentation noted that R2 continued to express fear following the encounter.
Following the assault, facility staff separated R1 from R2 and placed him under one-on-one supervision for the remainder of that evening. However, when state surveyors arrived at the facility on February 19, 2025, they observed R1 walking freely from his room to the second-floor dining area without staff assistance or supervision.
During the inspection, R2 was observed walking around the locked memory care unit. When asked about the February 8 incident, she was unable to recall what had occurred, highlighting her cognitive impairment and vulnerability.
Pattern of Inadequate Supervision
The inspection revealed that R1 had a documented history of sexual behaviors toward female residents, yet the facility failed to implement and maintain appropriate preventative interventions. According to staff interviews conducted during the survey, R1 had been moved from the locked memory care unit specifically due to his sexual behaviors toward females.
A Certified Nurse Aide interviewed on February 19 stated that cognitively impaired residents should be monitored closely due to the potential risk of injuries and abuse. The aide emphasized that residents with documented behavioral issues should be monitored closely around other residents and that "male residents with sexual behaviors should not be left unsupervised around female residents." The aide specifically stated that R1 should not be seated next to or be around female residents without supervision.
When interviewed, a Licensed Nurse acknowledged that R1 was recently moved from the locked unit due to sexual behaviors toward females. The nurse explained that direct care staff were expected to document behavioral monitoring in the facility's electronic medical record system and that staff were supposed to "keep an eye on R1 while he was out walking around." However, the nurse indicated he was uncertain whether monitoring protocols were properly documented for the resident.
The Licensed Nurse noted that care plans should reflect repeated behaviors toward females, monitoring requirements, coping strategies, and interventions to prevent problematic behaviors. However, the facility's documentation failed to demonstrate that such comprehensive plans were in place or being followed.
Inadequate Response After Transfer
Following the February 8 assault, facility administration made the decision to move R1 to a different hallway within the facility. However, inspection findings revealed that staff failed to implement effective preventative interventions for R1's sexual behaviors before or after the transfer, placing 19 female residents on the new unit at risk.
An Administrative Nurse interviewed during the inspection confirmed that R1 was immediately separated from R2 after the incident and placed on one-on-one supervision. The nurse stated that R1 was then moved to another hall and that medication changes were being made. The nurse claimed that R1 "was not a risk to the females in the new hallway," despite his documented history of sexual behaviors and the recent assault.
When asked about monitoring expectations, the Administrative Nurse indicated that staff were expected to monitor R1's behaviors and document them under the Psychotropic Medication Monitoring section of his Medication Administration Record. However, this documentation method would not have ensured real-time supervision or prevented inappropriate contact with other residents.
Why These Failures Matter for Resident Safety
Sexual assault in nursing homes represents one of the most serious violations of resident rights and safety. Cognitively impaired residents, particularly those with dementia or other memory disorders, face heightened vulnerability to abuse because they may not be able to report incidents, remember what occurred, or take protective action.
When residents exhibit sexually inappropriate behaviors, facilities have a responsibility to implement comprehensive interventions that protect other residents while respecting the rights and dignity of all individuals. These interventions should include supervised activities, appropriate medication management when indicated, behavioral monitoring protocols, environmental modifications, and staff training on prevention and response.
The movement of a resident with documented sexual behaviors to a new unit without implementing protective measures violates fundamental principles of abuse prevention. Each transfer requires a complete reassessment of risks and implementation of appropriate safeguards before the resident is placed in proximity to potentially vulnerable individuals.
One-on-one supervision, when medically necessary, must be continuous and documented. The observation that R1 was walking freely without staff assistance just 11 days after the assault indicates that initial protective measures were not sustained, creating ongoing risk.
Care plans serve as the roadmap for individualized resident care and must accurately reflect behavioral risks, monitoring requirements, and specific interventions. When care plans fail to document known behavioral issues or protective protocols, staff members lack the information necessary to provide safe care across all shifts and during staff changes.
Regulatory Standards and Facility Obligations
Federal regulations require nursing homes to protect residents from all forms of abuse, including resident-to-resident interactions that result in harm. Facilities must develop and implement written policies and procedures that prohibit and prevent abuse, and they must ensure all staff can appropriately respond to allegations of abuse.
The facility's own Abuse, Neglect, and Exploitation policy, revised in November 2017, stated that Shawnee Gardens would "provide safety and dignity for all residents by implementing proper procedures for enforcing resident rights." The policy specifically noted that the facility would "protect residents of suspected abuse and all potentially affected residents from incidents of abuse."
According to regulatory standards, when a facility becomes aware of behaviors that pose a risk to other residents, administrators must take immediate action to protect potential victims. This includes comprehensive assessment of the resident exhibiting problematic behaviors, development of individualized interventions, implementation of appropriate supervision, and ongoing monitoring of effectiveness.
Staff training represents a critical component of abuse prevention. All nursing home employees must receive education upon hire and annually on recognizing, preventing, and responding to abuse. This training must include specific protocols for separating alleged perpetrators from potential victims and reporting requirements.
Immediate Jeopardy Determination
State surveyors determined that the facility's failures resulted in immediate jeopardy to resident health and safety. This represents the most serious level of deficiency, indicating that the facility's noncompliance caused or was likely to cause serious injury, harm, impairment, or death to residents.
The immediate jeopardy determination was based on the facility's failure to prevent the sexual abuse of R2 and the subsequent placement of 19 female residents at risk when R1 was moved to another unit without adequate protective interventions.
On February 19, 2025, at 3:31 PM, facility administrative staff were notified of the immediate jeopardy finding. The facility submitted an acceptable plan for removal of the immediate jeopardy that same day at 4:30 PM.
The immediate removal plan included placing R1 on continuous one-on-one supervision until a psychiatric evaluation could be completed, identifying all at-risk residents on the new unit, providing staff in-service education on abuse prevention and response, and conducting safe surveys with female residents on the unit to assess for any unreported incidents.
State surveyors verified implementation of the immediate jeopardy removal plan while onsite on February 19, 2025, at 4:45 PM. However, the deficient practice remained cited at a scope and severity level indicating actual harm to residents based on the assault that had already occurred and the fear and distress experienced by R2.
Additional Issues Identified
Beyond the primary sexual assault and supervision failures, the inspection revealed additional concerns about the facility's abuse prevention systems. Documentation practices were inconsistent, with different staff members indicating that behavioral monitoring should be recorded in different locations within the electronic medical record system, creating confusion about where critical information should be documented and reviewed.
The facility's response to the initial incident, while including immediate separation, did not demonstrate the comprehensive assessment and intervention development required when residents exhibit behaviors that pose risks to others. The decision to move R1 to a different unit without first implementing and verifying effective interventions represented a significant gap in protective protocols.
Staff interviews revealed uncertainty about care plan contents and monitoring requirements, suggesting that critical safety information was not being effectively communicated to direct care workers responsible for daily supervision and care delivery.
The incident also raised questions about supervision practices in the memory care unit, where cognitively impaired residents require enhanced monitoring to ensure safety. The fact that R1 was able to engage in inappropriate contact with R2 during a supervised meal service indicated potential staffing or attentiveness concerns during a structured activity when residents should have been closely monitored.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Shawnee Gardens Healthcare & Rehab Center from 2025-02-19 including all violations, facility responses, and corrective action plans.
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