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F0610
D

Failure to Investigate and Report Alleged Sexual Abuse

Chandler, Arizona Survey Completed on 11-17-2025

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 investigate an allegation of sexual abuse involving a resident who had intact cognition and multiple medical diagnoses, including myoneural disorder, toxic encephalopathy, dysphagia, ataxia, and post-traumatic stress disorder. The resident reported to police that an unknown male x-ray technician allegedly touched her breast while she was receiving medical care at the facility. The resident stated she informed a nurse at the facility about the incident, but there was no evidence that the facility initiated an internal investigation or reported the allegation as required. A review of facility records showed no documentation of a self-reported incident or a 5-day investigation report submitted to the State Agency regarding the alleged sexual abuse. Interviews with the resident’s former roommate confirmed that while a detective questioned her about the incident, facility staff did not approach her for information. Staff interviews revealed that the expected protocol in the event of an abuse allegation was to ensure resident safety and immediately notify the abuse coordinator or administrator, followed by a prompt investigation. However, the administrator and DON both stated they were unaware of any abuse allegations or investigations related to the resident in question, despite police involvement and requests for video footage. Facility policy required immediate reporting and thorough investigation of all abuse allegations, including interviews with all involved parties and preservation of evidence. Despite these requirements, the facility did not document any investigation or reporting of the alleged incident, nor did they interview potential witnesses or the alleged perpetrator. The lack of action and documentation directly contradicted the facility’s own policies and regulatory requirements for responding to abuse allegations.

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