SHAWNEE, KS - Federal inspectors found that Shawnee Gardens Healthcare & Rehab Center failed to implement effective behavioral monitoring for a male resident with a documented history of inappropriate sexual behaviors toward female residents, resulting in multiple incidents between March 2024 and February 2025.
Pattern of Inappropriate Behaviors Documented
The 117-bed facility's records revealed a troubling pattern of incidents involving a cognitively impaired male resident who repeatedly engaged in unwanted touching and sexual behaviors despite staff awareness of his psychiatric illness-related sexual behaviors. The resident's medical records documented diagnoses including depression and a history of sexual behaviors related to psychiatric illness.
The most serious incident occurred on February 8, 2025, when staff observed the male resident touching a female resident's breast and buttocks during meal service. This incident resulted in the male resident being moved to a different unit and placed on one-on-one supervision.
Timeline of Concerning Incidents
Federal inspectors documented multiple incidents spanning nearly a year:
- March 4, 2024: Staff observed the male resident sitting on a female resident's walker with his head between her breasts as she pushed him to lunch - July 10, 2024: The resident was found inappropriately touching another severely cognitively impaired female resident in the dining room - July 14, 2024: Staff had to intervene when the resident began patting a distressed female resident on the shoulder despite her attempts to push him away - February 2, 2025: The resident approached a female resident in a recliner, touched her arm, and resisted when she tried to push him away - February 8, 2025: The most serious incident involving touching of intimate body parts
Care Plan Inadequacies Identified
The inspection revealed significant gaps in the facility's care planning and monitoring systems. While the resident's care plan noted his sexually inappropriate behaviors related to psychiatric illness, it lacked critical details about required supervision around female residents and specific monitoring protocols when he left his room.
Progress notes indicated that staff were supposed to supervise the resident "at all times while outside of his room and around other residents," but the facility failed to implement consistent monitoring. On the day of inspection, investigators observed the resident walking unaccompanied from his room to the dining area.
Medical and Safety Implications
Residents in nursing homes have the right to feel safe and secure in their environment. When facilities fail to properly monitor residents with known behavioral issues, it creates risks for vulnerable populations who may be unable to protect themselves or report incidents.
The resident in question had mild cognitive impairment with a Brief Interview for Mental Status score of 12, indicating his understanding of appropriate social boundaries was compromised by his condition. However, this cognitive impairment made proper behavioral interventions and supervision even more critical for protecting other residents.
Documentation and Monitoring Failures
Inspectors found the facility's documentation systems were inadequate for tracking and preventing behavioral incidents. The resident's electronic medical records showed no entries for behavioral monitoring in the Tasks section, despite staff stating this was required protocol.
Treatment and medication administration reports lacked monitoring related to sexual behaviors, even though the resident was receiving psychotropic medications for behavioral management. Staff interviews revealed confusion about proper documentation protocols and monitoring responsibilities.
Staff Awareness vs. Implementation Gap
While staff members demonstrated awareness of the resident's behavioral history during interviews, the inspection revealed a significant gap between knowledge and implementation of protective measures. A certified nurse's aide acknowledged the resident's history of touching females and stated that staff should monitor and document behaviors, yet systematic monitoring was not occurring.
Administrative staff confirmed that the resident had been moved to a different unit following the February 8 incident and that medication changes were being implemented. However, the lack of consistent documentation and monitoring protocols meant similar incidents could continue to occur.
Regulatory Standards for Behavioral Health
Federal regulations require nursing homes to provide necessary behavioral health care and services for all residents. This includes developing comprehensive care plans that address known behavioral issues and implementing effective monitoring systems to prevent harm to other residents.
Facilities must ensure that residents with cognitive impairments receive appropriate supervision and that care plans are regularly updated based on ongoing assessment of behavioral patterns and intervention effectiveness.
The violations at Shawnee Gardens represent a failure to meet these basic standards, placing vulnerable female residents at continued risk despite documented awareness of the problematic behaviors.
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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