Waters of Dunkirk: Resident Rights Failures in Sexual Behavior Cases - IN

The inspection, completed March 30, 2026, followed a complaint. What investigators found was a facility navigating one of long-term care's most difficult problems without the basic tools to do it.

The resident at the center of the complaint, identified in the report as Resident C, was on medroxyprogesterone, a hormone-suppressing medication sometimes used to manage hypersexual behavior in men. He held hands with Resident B. He patted the legs of Resident D and Resident E. Staff described his hypersexuality as increasing as he made more female friends inside the facility. When staff tried to redirect him, he pushed back. He wanted to know why he couldn't talk to the female residents.

Nobody had a clean answer.

The facility's social services director told inspectors that the situation was "a fine line between being appropriate or infringing on their rights." The Ombudsman who had been consulted took a firm position: the physical contact was an infringement on the female residents' rights, and cognitive scores alone shouldn't determine whether the behavior was acceptable. The social services director disagreed, at least in part. She believed residents had the mental capacity to consent to sexual behaviors, though perhaps not the physical capacity.

What the facility did not have was an assessment designed to resolve that question. Inspectors confirmed there was no sexual behavior assessment in place.

The cognitive gap the social services director described was real and documented. The BIMS, a brief cognitive screening tool, produces scores ranging from 0 to 15. A score of 15 indicates intact cognition. A score of 3 indicates severe impairment. The social services director said she would consider contact between a resident with a 15 and a resident with a 3 to be inappropriate. But the facility had no formal process for determining where any given resident fell on that spectrum in the context of consent, and no protocol for what to do with that information once it existed.

The monitoring system the facility did have was fragmented. Staff completed behavior tracking sheets that were stored in folders at each nurses' station. Those sheets captured some of what was happening. But the certified nursing assistants who provided daily hands-on care could not access care plans in the facility's electronic records system, PointClickCare. They could see the behavior sheets. They could not see the fuller clinical picture.

Resident C's behavior monitoring in PointClickCare was embedded in the medication administration record, because his medroxyprogesterone required psychotropic monitoring. The director of nursing or assistant director of nursing added that monitoring to the records. It was reviewed monthly.

The behavior sheets reviewed on the morning of the inspection told a fractured story. Resident C had documented behaviors, including irritability with other residents, episodes of anxiety in which he believed he had missed a flight or was late for an appointment, and repeated searches for a family member. Interventions listed included reassurance, family calls, and offers of coffee or ice cream. Residents B, D, and E, the women he had touched, had no behaviors monitored on their sheets at all. Resident F, another female resident, had documented anxiety and pacing, with interventions that included calling her daughter and talking about where she grew up.

The facility told inspectors it had updated care plans after speaking with the Ombudsman. The Ombudsman's involvement had apparently prompted some action. But the assessment gap remained. There was still no structured tool for evaluating whether residents could consent to physical contact with one another, no documented process for weighing cognitive capacity against the nature of the contact, and no way for the aides closest to these residents to see the full care plan when a situation unfolded in front of them.

The facility's own behavior management policy described a monthly meeting process designed to review residents with behaviors, ensure interventions were in place, and promote each resident's psychosocial well-being. The policy assigned nursing staff the responsibility of monitoring target behaviors daily and documenting them. Social services was responsible for maintaining a list of residents with behaviors and assisting in behavior care plans.

Whether the women Resident C touched understood what was happening to them, or wanted it to stop, the inspection report does not say. Their behavior sheets showed nothing being monitored. Their voices, if they had objected, left no record that inspectors found.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Waters of Dunkirk Skilled Nursing Facility, The from 2026-03-30 including all violations, facility responses, and corrective action plans.

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