Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of sexual, physical, and verbal abuse for four of six sampled residents. In one case, a cognitively intact resident reported being hit and sworn at by another resident with severe cognitive impairment, and also reported a prior incident of being slapped. The administrator acknowledged being informed of the incident and speaking to a potential witness but did not document interviews or conduct a full investigation. Staff confirmed witnessing an altercation and reporting it to nursing staff, but no comprehensive investigation was initiated as required. In three additional cases, residents with varying levels of cognitive function reported allegations of sexual abuse by staff or unidentified caregivers. One resident reported to a complainant that a staff member fondled them, but there was no documentation or investigation of the allegation. Two other residents reported that a male caregiver had touched their breasts, and while the social services director was aware and reported the allegations to the administrator, no investigations were completed. Staff interviews confirmed knowledge of the allegations but no evidence of investigations was found in the records.