PUEBLO, CO- ROCK CANYON RESPIRATORY AND REHABILITATION CENTER

Based on record review, observations, and interviews, the facility failed to create an environment that protected two (#37 and #124) of six residents reviewed for abuse out of 38 sample residents.

Resident #69, with moderate cognitive impairment, exhibited inappropriate sexual behavior toward one resident (#37) who had severe cognitive impairment. Resident #37 was sexually abused on 8/6/22 by Resident #69.

In response to the 8/6/22 incident, the facility temporarily moved Resident #69 to another unit and provided one-on-one staff supervision for six days. Resident #69 returned to his original unit and 15 minute checks were instituted from 8/13/22 to 8/19/22. Supervision was changed to 30 minute checks between 8/20/22 and 8/31/22. The resident was returned to 15 minute checks on 8/31/22 however, this level of supervision was ineffective in protecting female residents on the unit from Resident #69’s inappropriate sexual advances.

Following the sexual abuse that occurred on 8/6/22, Resident #69 attempted to bring Resident #37 and other female residents to his room on 8/14/22, 8/21/22, 8/23/22, 9/5/22, and 9/8/22.
On 10/3/22, Resident #69 removed Resident #37’s pants and attempted to touch her vagina while the two residents were in the front lobby. They were separated by staff, however Resident #69 attempted to take Resident #37 to his room approximately five minutes later.

The facility’s failure to develop and implement effective interventions to prevent cognitively impaired residents from being repeatedly subjected to inappropriate sexual behavior by Resident #69 made serious harm likely if the situation was not immediately corrected.

In addition, the facility failed to protect Resident #124 from physical abuse by Resident #123.

Incident 8/6/22

The nurse documented the following, The housekeeper and this nurse were looking for Resident #37. She was looking for Resident #37 and she was missing. I went down the girl’s hall and the housekeeper was going down the men’s hall when we heard ‘HELP, HELP me up.’ Resident #69’s room was the first room we entered to check to see if someone had fallen. What we found was Resident #69 standing with the side of his bed and Resident #37 was lying in his bed. Her adult pad had been taken off and thrown on the other side of the bed. Resident #37 was screaming ‘Let me Up’ and crying. Resident #69 had his fingers or his hand in her vagina plunging it in and out (thrusting). When Resident #69 saw me and immediately left the room, wiping his hand on his shirt. The housekeeper and I immediately went to Resident #37 comforting her and assessing her. No injuries could be seen. The housekeeper and certified nurse aide (CNA) helped Resident #37 stood and placed her in a wheelchair. We then took her to her room and further assessed her. My director of nursing (DON) was notified, police and families called.

Incident on 10/3/22

Nursing log note dated 10/3/22 at 6:45 p.m., documented in part: This nurse observed Resident #69 had pulled Resident #37 pants down in the lobby and was attempting to put his hand in the resident’s vagina. When approached by this nurse and asked the resident to stop and let him know what he was doing was inappropriate. Resident #69 responded ‘I am not doing anything you (expletive). Resident #37 was separated from this resident and taken to the other side of the lobby. Approximately five minutes later resident was attempting to take Resident #37 to his room, this nurse intervened and took Resident #37 to her room and again let the resident know this was inappropriate behavior. Resident #69 responded ‘What are you talking about?’ and walked off and sat down in a chair in the lobby. 

The nursing home administrator (NHA) was interviewed on 11/30/22 at 9:16 a.m. He said he was the abuse coordinator for the facility. He said the staff had found Resident #37 in Resident #69’s room on 8/6/22. He said she was partially naked from the waist down and he had his hands in her vagina. He said they were immediately separated and all necessary parties contacted. He said the investigation was inconclusive because they could not define if the sexual act was consensual or non-consensual. He said neither resident was interviewable. He said all care plans were updated to address Residents #69 and Resident #37’s behaviors. He said, I wouldn’t classify her yelling out for help as a sign of non-consensual as she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] .