The incident involving Resident C and Resident G was one of multiple unreported sexual abuse allegations that federal inspectors discovered during an October complaint investigation at the 47331 facility.
Resident G told inspectors that a couple weeks before their October 27 interview, she was wheeling herself down the hallway when Resident C came up behind her and started pushing her wheelchair. "Resident C took his hand and started sliding it down the front of her chest," according to the inspection report. "Resident G indicated she swiped his hand away and told him to cut it out."
She had reported the incident to staff members but couldn't remember their names. The Director of Nursing had never spoken with her about what happened.
Resident G said these sexual behaviors kept happening outside when residents returned from the smoking area. "No one ever sees it," she told inspectors.
The facility's own safety check records showed Resident C was placed on 15-minute monitoring from October 5 through October 9 for "sexually acting out." But there was no documentation in his clinical record explaining why the enhanced supervision began.
Resident C's quarterly assessment from August 22 indicated he was severely cognitively impaired for daily decision making. His diagnoses included vascular dementia, depression, anxiety, hypertension, heart failure and epilepsy. He was independent with walking.
The Director of Nursing told inspectors that on October 5, someone reported to her that Resident C "may have been doing something he should not have been doing." Another resident had reported that Resident C was being inappropriate with female residents. Resident G might have been one of them.
The incident was not reported to the Indiana Department of Health.
The Regional President of Operations, who was serving as the facility's administrator on October 5, said the Director of Nursing had texted him about Resident C touching a female resident. He was unsure who the female resident was. The allegation was not reported to state health officials.
When inspectors interviewed Registered Nurse 1 on October 27, she said she was working on October 6 and knew Resident C was on 15-minute checks but was unsure why. She couldn't find any documentation beyond the 15-minute check sheet.
The next day, the same nurse's memory had apparently improved. She told inspectors she remembered that on October 5, Resident C was placed on 15-minute checks because he was sexually acting out toward female residents. She was unsure who the female residents were.
By October 28, the Director of Nursing told inspectors she was unsure why there was no documentation in Resident C's clinical record about the October 5 incident.
The facility's abuse policy, provided by the Director of Nursing, clearly stated that if there was an allegation of abuse, the administrator would notify the Indiana Department of Health.
Resident G's quarterly assessment from September 19 indicated she was moderately cognitively impaired. Her diagnoses included type 2 diabetes, generalized anxiety disorder and depression.
Federal regulations require nursing homes to immediately report suspected abuse, neglect or theft to state health departments and report investigation results to proper authorities. The failure to report can result in fines and increased oversight.
The inspection found the facility failed to report sexual abuse allegations for two of six residents reviewed during the investigation. The violations were classified as causing minimal harm or potential for actual harm, affecting few residents.
The lack of documentation about why Resident C was placed on enhanced monitoring suggests the facility recognized problematic behavior but failed to properly investigate or document the incidents. Safety checks every 15 minutes indicate staff believed Resident C posed an ongoing risk to other residents.
Resident G's account that the sexual behaviors "keep happening" outside the smoking area suggests the incidents were not isolated events. Her statement that "no one ever sees it" indicates the facility's supervision may have been inadequate in areas where vulnerable residents gathered.
The facility's failure to interview Resident G about her allegations, despite her reporting them to staff, represents another breakdown in the investigation process. The Director of Nursing's admission that she had never spoken with Resident G about the incident shows the facility did not follow its own abuse policies.
The Regional President of Operations' uncertainty about which female resident was involved demonstrates poor communication between nursing staff and administration about serious safety incidents. His failure to report the allegation to state authorities violated both facility policy and federal regulations.
The registered nurse's changing account of what she knew and when she knew it raises questions about the facility's handling of the incident. Her initial claim that she was unsure why Resident C was on 15-minute checks, followed by her later detailed recollection of sexual acting out, suggests either poor initial investigation or reluctance to disclose information to inspectors.
The absence of clinical record documentation about the October 5 incident that triggered enhanced monitoring violates standard nursing home practices for documenting behavioral incidents and care plan changes. Such documentation is essential for tracking patterns of behavior and ensuring appropriate interventions.
Majestic Care of Connersville's failure to report these sexual abuse allegations deprived state health officials of the opportunity to conduct their own investigation and potentially protect other vulnerable residents. The facility's own policies required such reporting, making the violations even more serious.
The inspection was conducted in response to a complaint and focused specifically on sexual abuse allegations. The findings suggest systemic problems with incident reporting and investigation at the facility.
Resident G continues to live at the facility where the alleged sexual abuse occurred, with no indication from the inspection report that additional protective measures were implemented beyond the temporary 15-minute checks for Resident C.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Majestic Care of Connersville from 2025-10-29 including all violations, facility responses, and corrective action plans.
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