The incident occurred at Wright Rehabilitation and Healthcare Center on November 11, when Resident #10 complained of being cold during the evening smoke break. Laundry Aid #112 allowed her to wait inside the activity room instead of staying outside under supervision.
When the smoke break ended, staff assumed the resident had returned to the locked Memory Support Unit on her own. She hadn't.
Instead, Resident #10 entered the room of Resident #11, where a certified nursing assistant found her with her hand on his penis, stroking up and down. The male resident asked her to stop, but she continued until the staff member entered the room.
Staff separated the residents immediately and placed Resident #10 on one-on-one supervision.
Resident #10 had been admitted to Wright Rehabilitation in March 2022 with multiple diagnoses including alcohol-induced dementia, stroke, schizophrenia, and Wernicke's encephalopathy. Despite her cognitive impairments, her most recent assessment showed intact mental status. Her care plan specifically identified her as both an elopement risk and someone with aggressive behaviors.
The resident required assistance with eating, mobility, transfers, and toileting. She was also designated as a supervised smoker, meaning staff were supposed to watch her during smoke breaks.
Assistant Director of Nursing #102 acknowledged that Resident #10 lived in the Memory Support Unit because it was locked. During his interview with state inspectors, he explained that staff allowed her to go back inside unsupervised after she reported being cold, "which allowed her the opportunity to enter Resident #11's room."
Social Worker #110 confirmed that Resident #10 required the locked unit specifically because of her elopement risk. She said she was informed the resident had entered another resident's room "after she was left unattended by staff."
The facility's Director of Nursing and Administrator told inspectors that CNA #103 had contacted them about witnessing Resident #10 enter Resident #11's room. Their investigation revealed the breakdown in supervision during the 8:30 p.m. smoke break.
When Resident #10 told Laundry Aid #112 she was cold and wanted to wait in the activity room, the staff member agreed. After the smoke break ended and the resident wasn't found in the activity room, staff simply assumed she had returned to the Memory Support Unit without verification.
Both the Director of Nursing and Administrator confirmed it was facility policy that staff assigned to smoke breaks must observe Memory Support Unit residents at all times until they are returned and secured back in the unit.
The violation occurred despite clear protocols designed to prevent exactly this type of incident. Memory care units use locked doors and constant supervision specifically because residents with dementia and elopement risks cannot safely navigate facilities on their own.
Resident #10's care plan documented her history of aggressive behaviors, yet staff left her unsupervised in a general population area where she could access other residents' rooms. The locked Memory Support Unit where she lived was designed to prevent such encounters.
The facility failed to follow its own supervision requirements during what should have been a routine smoke break. Instead of maintaining visual contact with a high-risk resident, staff allowed her to wander unattended through areas where vulnerable residents were sleeping.
Federal inspectors cited Wright Rehabilitation for failing to ensure residents in the secure memory care unit were properly observed when outside the unit. The violation affected one of three residents reviewed during the complaint investigation.
The incident resulted in what inspectors classified as minimal harm or potential for actual harm to few residents. However, the sexual contact continued even after the victim asked it to stop, only ending when staff physically intervened.
Wright Rehabilitation operates with a census of 82 residents. The facility now faces federal scrutiny over its supervision practices in the Memory Support Unit, where some of its most vulnerable residents require constant oversight to prevent exactly these types of dangerous encounters.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wright Rehabilitation and Healthcare Center from 2025-11-19 including all violations, facility responses, and corrective action plans.
Additional Resources
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