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F0609
D

Failure to Report Alleged Abuse Involving Cognitively Impaired Residents

Hillsboro, Oregon Survey Completed on 08-12-2025

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 abuse to the State Agency involving two residents with cognitive impairments. One resident, admitted with dementia and a BIMS score indicating severe cognitive impairment, and another resident with a moderate cognitive impairment, were both determined through Sexual Capacity Evaluations to lack the cognitive ability to consent to sexual activity. On two occasions, staff observed these residents engaging in intimate behaviors, including kissing and inappropriate touching, with one resident offering money to the other. Staff intervened and separated the residents each time. Despite these observations and the completion of sexual consent evaluations confirming both residents' inability to consent, there was no evidence that the incident was reported to the State Agency as required. The administrator acknowledged the lack of reporting and confirmed it was his responsibility to do so. The failure to report the suspected abuse placed the residents at risk.

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