Sabine Heights Nursing Home: Sexual Assault Violation - TX
He told her a second time. Then he reached into her brief and touched her vaginal area.
That is what happened on August 14, 2025, inside a resident's room at Sabine Heights Nursing and Rehabilitation Center, according to a federal inspection report. The incident triggered an immediate jeopardy citation, the most serious level of deficiency federal regulators can assign, one that indicates a facility's failures have placed residents at risk of serious injury, serious harm, or death.
The female resident, identified only as Resident #1, and the male resident, Resident #2, were described in the report as friends. Resident #2 came into her room. He told her to lay back. She grabbed her bear and placed it on her lap. He told her to lay back again. Then he touched her.
The Assistant Director of Nursing, referred to in the report as the ADON, said she was in the conference room when CNA B came to get her. By the time she reached the hallway, LVN A was already wheeling Resident #2 out of Resident #1's room. Resident #2, the ADON said, was asking what was wrong and saying he didn't do anything wrong. His words, as recorded in the inspection report: "We were two consenting adults."
Staff separated them immediately. Resident #2 was taken to hall 100 for one-on-one supervision. The ADON went to Resident #1.
She said Resident #1 did not appear afraid. She was not crying. But she told the ADON she had not given consent. She said Resident #2 came into her room and told her to lay back. She grabbed her bear. He told her again. Then he started touching her vaginal area. She said she was not OK with it when he first started. She said she was not OK with him digging in her brief. She said she didn't enjoy it at first.
She also said, later, that she did start to enjoy it. She told the ADON they were friends.
The ADON interviewed Resident #2 within ten minutes of the incident. He told her Resident #1 was fine with him touching her. He said Resident #1 didn't tell him to stop. He said he didn't ask her if he could touch her. He said he figured it was OK because she never said no. He said they were two consenting adults. He said Resident #1 was his friend.
The inspection report does not describe the cognitive status of either resident, their diagnoses, or their legal capacity to consent. It does not say whether either resident had dementia or any condition affecting their ability to make or communicate decisions about sexual contact. What it records is what each person said, and what the staff did next.
LVN A conducted an assessment of Resident #1. CNA B washed Resident #2's hands. A one-on-one sitter stayed with Resident #1, who said she wasn't hurt and didn't want to go to the hospital. Staff called the responsible party for Resident #1 and had to leave a message. He showed up the next day. When notified, he did not want to send Resident #1 to the hospital either. The ADON called the doctor. New orders were written to send Resident #2 to a behavioral hospital. Police were called. Officers interviewed the ADON, LVN A, CNA B, and both residents.
The immediate jeopardy period began at 12:08 p.m. on August 14, 2025. It ended that same day at 6:34 p.m., after the facility put interventions in place.
What those interventions looked like, in practice, was a facility that spent the hours after the incident interviewing its own staff, then spent the day of the state survey, August 16, doing it again. Inspectors conducted interviews from 3:30 p.m. through 5:30 p.m. that day with more than three dozen employees across every shift, every department. The Director of Nursing, the ADON, licensed nurses, certified nursing assistants, dietary workers, housekeepers, rehabilitation staff, laundry workers, the admissions coordinator, the business office manager, human resources. The list of staff interviewed runs to more than thirty individuals identified by letter in the report.
Every one of them, according to the inspection report, said they had been trained on abuse and neglect, on reporting requirements, and on residents' rights when they were hired and at least annually after that. Every one of them said they were retrained after the incident on August 14. They could describe what to do first: separate the residents, get help, report to the administrator, who serves as the facility's abuse coordinator. They could name different types of abuse. They said they understood that residents had the right to sexual expression if it was consensual, and that their job was to identify whether both residents had the capacity to consent and to report all acts of sexual expression to nursing management for review.
On August 14, the same day as the assault, the Director of Nursing held an in-service attended by 54 employees. Fifteen licensed nurses were there. Eighteen certified nursing assistants. Three rehabilitation staff. Seven dietary workers. Four housekeepers. One social worker. One laundry employee. Five office personnel. The in-service covered resident rights, abuse and neglect, abuse reporting, how to recognize intimate acts between residents, resident safety, capacity to consent, and how to identify sexual abuse.
The inspection report notes that the noncompliance was identified as past noncompliance, meaning the facility had corrected the problem before surveyors arrived. The immediate jeopardy had been abated. On paper, the facility had done what it was supposed to do.
What the report does not resolve is the question that sat at the center of everything that happened in that room: whether Resident #1 had the capacity to consent, and whether what occurred was a sexual assault or something more complicated than that. The ADON's account of what Resident #1 said captures both things at once. She said she was not OK with it at first. She said she didn't enjoy it at first. She also said, later, that she did start to enjoy it. She said he was her friend.
Resident #2 said she never told him no. He said they were consenting adults. He did not say he asked.
She grabbed her bear and put it on her lap.
That detail appears once in the inspection report, embedded in the ADON's account of what Resident #1 told her. The ADON said Resident #1 said she grabbed her baby, which was a bear, and put it on her lap. Then Resident #2 asked her to lay back again.
Whether that moment was understood by anyone in the room as an answer is not something the inspection report addresses. What it records is that he asked again, and then he touched her, and that she said she was not OK with it when he first started, and that she was not OK with him digging in her brief.
The police were called. The doctor sent Resident #2 to a behavioral hospital. Resident #1 said she wasn't hurt and didn't want to go to the hospital. Her responsible party, when he finally arrived the next day, agreed.
The immediate jeopardy was closed before the surveyors walked in the door. Fifty-four employees sat through an in-service. Thirty-some staff members were interviewed and gave the right answers about abuse, reporting, and consent.
Resident #1 stayed in her room at Sabine Heights with her bear.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sabine Heights Nursing and Rehabilitation Center from 2025-08-16 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Sabine Heights Nursing and Rehabilitation Center in Port Arthur, TX was cited for violations during a health inspection on August 16, 2025.
Then he reached into her brief and touched her vaginal area.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.