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F0609
D

Failure to Timely Report Alleged Sexual Abuse to State Agency

Winsted, Minnesota Survey Completed on 06-18-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an allegation of sexual abuse to the State Agency (SA) within the required two-hour timeframe. A cognitively intact resident with paraplegia, neurogenic bowel, and major depressive disorder reported that, during assistance with a brief change, a nursing assistant inserted a finger into her anus in a manner the resident described as painful and upsetting. The resident reported the incident to a nursing assistant, who delayed reporting the allegation to the charge nurse, citing that no other nurse was available at the time. The nursing assistant eventually reported the allegation to the registered nurse at approximately 8:30 a.m., who then spoke with the resident and subsequently reported the incident to the administrator and the SA. Interviews and document review revealed that staff were aware of the expectation to report abuse allegations immediately to the charge nurse and to the SA within two hours, as outlined in the facility's policy. Despite this, there was a delay in reporting the incident, as the allegation was not communicated to the appropriate personnel and the SA within the required timeframe. The deficiency was identified for one of three residents reviewed for abuse reporting.

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