Failure to Report Resident-to-Resident Sexual Abuse
Penalty
Fine: $12,740
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
Facility staff failed to report an incident of resident-to-resident sexual abuse to the State Survey Agency as required by facility policy. The incident involved two residents, both with severely impaired cognition as identified in their admission Minimum Data Sets. One resident with Alzheimer's disease and psychotic disturbance was found fully clothed on a bed in another resident's room, while the other resident was naked, straddling the first resident, and had his hand in the other's brief. Despite the facility's policy mandating immediate reporting of alleged or suspected abuse to designated agencies, including the State Survey and Certification Agency, administrative staff confirmed that the incident was not reported.