Federal inspectors found that Forestville Healthcare Center failed to investigate and prevent abuse by a male resident who had been attempting to touch female staff and residents since at least November 2022. The facility only assigned round-the-clock supervision after the September 29 incident involving two residents.
Resident 2's medical records showed a care plan dating to November 3, 2022, that documented his "history of attempting to touch female staff and resident, attempting to go to female residents room and touching female residents inappropriately." The plan called for staff to monitor the resident while in rooms, redirect him at all times, and educate him to keep his hands to himself.
Despite these documented interventions, the resident continued his behavior for nearly three years.
On September 29, 2025, staff witnessed Resident 2 inappropriately touching Resident 1. Only then did the facility place a caregiver with Resident 2 around the clock and move him to another room.
The Director of Nursing told inspectors on October 30 that the facility had substantiated the abuse allegation and was seeking to discharge Resident 2 to another facility. Until his discharge, he would continue with 24-hour supervision.
Staff member 26 described the resident's unchecked behavior before the caregiver assignment. "Resident 2 until he/she had a caregiver watching him/her had been going into other female resident rooms without supervision, touching residents and it was good that he/she had a caregiver now."
Another staff member confirmed the pattern extended well before September. Staff member 9 stated that "Resident 2 has had past behaviors of attempting to inappropriately touch, going into other residents' rooms of female residents prior to 09/29/2025."
The resident's medical records contained extensive documentation of the ongoing problem. Social worker progress notes from December 5, 2022, through January 28, 2025, repeatedly indicated that Resident 2 had behavior problems including "attempting to go into female rooms, and attempting to touch female staff and female residents."
The facility's response revealed the inadequacy of their earlier interventions. Rather than implementing effective supervision or other protective measures when the pattern first emerged in 2022, managers allowed the behavior to continue for nearly three years.
The care plan's interventions proved insufficient to protect other residents and staff. Telling the resident to keep his hands to himself and providing general monitoring failed to prevent him from entering female residents' rooms and engaging in inappropriate touching.
Federal inspectors cited the facility for failing to protect residents from abuse, specifically noting the inadequate investigation and response to the documented pattern of sexual misconduct. The violation affected few residents but posed minimal harm or potential for actual harm.
The September incident that finally triggered intensive supervision represented the culmination of a documented pattern that facility managers had failed to address effectively since 2022. The facility's decision to seek discharge rather than develop adequate in-house protections suggested their recognition that previous interventions had been insufficient.
The inspection occurred following a complaint and revealed systemic failures in the facility's abuse prevention protocols. While managers had documented the resident's inappropriate behavior extensively, they failed to implement effective safeguards to protect vulnerable female residents and staff.
The round-the-clock supervision implemented after September demonstrated the facility's capability to provide adequate protection when motivated to do so. The delay in implementing such measures left other residents vulnerable to inappropriate contact for nearly three years.
Staff members' comments revealed awareness of the ongoing problem and relief that supervision had finally been implemented. Their observations confirmed that the resident had been accessing female residents' rooms without adequate oversight despite the documented care plan.
The facility's plan to discharge the resident rather than develop long-term management strategies raised questions about their commitment to serving residents with challenging behaviors. The decision suggested that intensive supervision was viewed as a temporary measure rather than a sustainable approach.
Federal regulations require nursing homes to protect residents from all forms of abuse, including sexual misconduct by other residents. The Forestville case illustrated how inadequate investigation and response can allow patterns of abuse to persist despite documentation and stated interventions.
The inspection findings showed that having a care plan alone was insufficient without effective implementation and monitoring. The facility's interventions of monitoring, redirection, and education failed to prevent the resident from continuing to access other residents' rooms and engage in inappropriate touching.
The nearly three-year gap between identifying the problem and implementing adequate supervision represented a significant failure in resident protection. During this period, female residents and staff remained at risk of inappropriate contact despite the facility's awareness of the pattern.
The case highlighted the importance of immediate and effective intervention when sexual misconduct is identified in nursing home settings. Delayed or inadequate responses can expose vulnerable residents to ongoing abuse while creating liability for facilities.
Resident 2's case demonstrated how behavioral issues in nursing homes require intensive management and supervision to protect other residents. The facility's eventual implementation of 24-hour supervision showed such measures were possible but had been delayed until after another incident occurred.
The inspection report did not indicate whether the facility had reported the pattern of behavior to state authorities or law enforcement as required for suspected abuse cases. The focus on discharge rather than rehabilitation also raised questions about the facility's approach to managing residents with sexual behavioral issues.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Forestville Healthcare Center from 2025-11-06 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Forestville Healthcare Center
- Browse all MD nursing home inspections