Failure to Investigate and Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving a resident who had previously been discharged. On 11/6/25, the facility received a report from an outside agency that a resident alleged a male CNA, described as a bald, brown-skinned man with a black beard, had washed only her breasts while she was naked in the tub after dinner one evening. The incident was reported to have occurred during the resident's stay, with the only documented bath with a male CNA taking place on 9/23/25. Despite the facility's abuse policy requiring immediate investigation and reporting of all alleged violations, the facility did not initiate an investigation into the allegation. The Nursing Home Administrator (NHA) and Director of Nursing (DON) stated that, because the allegation was reported nearly a month after the resident's discharge and no staff member perfectly matched the description, they did not believe any action could be taken. As a result, they did not conduct interviews with staff or residents to identify the alleged perpetrator, nor did they assess or interview other residents to ensure their safety. The incident was also not reported to the State Agency as required by facility policy.