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F0609
D

Failure to Timely Report Alleged Sexual Abuse Incident

Beaumont, Texas Survey Completed on 05-17-2025

Penalty

Fine: $299,465
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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 ensure timely reporting of an alleged incident of sexual abuse between two residents, as required by both facility policy and state regulations. On the date of the incident, a male resident with moderate cognitive impairment and a history of dementia and Alzheimer's disease was observed by an LVN touching a female resident's breast over her clothes in a common area. The LVN redirected the male resident and notified the ADON and the administrator. Shortly after, a medication aide witnessed the same male resident reaching under a blanket near the female resident's private area. Both residents were fully dressed, and neither recalled the incident when questioned. The female resident involved had moderate cognitive impairment related to dementia and was unable to participate in a psychosocial assessment following the incident. She was observed to be restless but showed no signs of distress or agitation. The facility social worker notified the resident's power of attorney about the incident, and the male resident was placed on one-to-one monitoring to ensure safety. Documentation in the nurse's notes and care plans confirmed the cognitive status and relevant medical history of both residents. Despite the immediate internal reporting to facility leadership, the incident was not reported to the State Survey Agency within the required two-hour timeframe. The facility's own policy mandates that all allegations of abuse be reported to the appropriate authorities immediately, but not later than two hours after the allegation is made if abuse is involved. The actual report to the state agency was made nearly 24 hours after the incident occurred, constituting a failure to comply with regulatory requirements for timely reporting of abuse allegations.

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