F0609

D

Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents

Safford, Arizona Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Agency as required by its own policy and federal requirements. One resident, identified as Resident #5, had early onset Alzheimer’s disease, aphasia, depression, and a BIMS score of 00, indicating severe cognitive impairment. Her care plan, initiated in August 2025, documented behavior problems including poor safety awareness, wandering, and exit seeking, with interventions to protect the rights and safety of others. In January 2026, the care plan was updated to note that she lifted her shirt and exposed her breasts at times, but no new or revised interventions were added to address this behavior. Progress notes contained no entries related to this behavior or to the alleged incident.

Another resident, identified as Resident #8, had dementia with behavioral disturbances, type 2 diabetes, and depression, and a BIMS score of 09, indicating moderate cognitive impairment. His care plan, revised in August 2025, documented behavior problems including wandering, exit seeking, and sexually inappropriate behavior, with interventions to protect the rights and safety of others. Behavior notes from early January 2026 showed that he was placed on 1:1 activity for increased supervision and required redirection and supervision around other residents. A behavior note documented that he was observed kissing Resident #5 and that she was reciprocating, but no additional progress notes were found related to this incident, and his care plan was not revised after the incident to reflect modified interventions for sexual behaviors.

Staff interviews and the facility’s internal investigation revealed that a nurse (Staff #9) found Resident #5 in Resident #8’s room, in his bed, with her shirt off and Resident #8 hovering over her after she had briefly lost sight of them. Staff #9 separated the residents and reported the incident to the DON (Staff #17). Multiple staff, including a CNA and RNs, stated that Resident #5 was not able to give consent due to cognitive impairment, and the abuse coordinator (Staff #2) confirmed that Resident #5 could not consent to being in bed with another person because she was not alert and oriented. Despite this, the abuse coordinator and DON concluded, based on staff statements and their belief that there was insufficient time for sexual contact, that no sexual abuse had occurred and therefore did not report the incident as an allegation of abuse to the State Agency. The abuse coordinator stated he did not consider Resident #5 having her shirt up and Resident #8 looking at her as abuse, even though Resident #5 could not consent. Review of the State Agency complaint portal showed no facility-reported incident related to these residents, and the facility’s policy required investigation and reporting of any allegations within required federal timeframes.

Resident room placement was also relevant to the events leading to the deficiency. Observations showed that the rooms of Resident #5 and Resident #8 were directly across the hallway from each other. Staff interviews indicated concerns about this proximity, with a CNA stating that this arrangement was not safe for Resident #5 because Resident #8 could easily access her, and RNs reporting that they had raised concerns and suggested moving the residents to different rooms. Nonetheless, the residents remained in close proximity. The combination of documented cognitive impairment, inability to consent, prior sexually inappropriate behavior, the observed incident of one resident in bed with clothing removed and another hovering over her, and the facility’s decision not to treat this as a reportable allegation of abuse led to the cited failure to timely report suspected abuse and the results of the investigation to the proper authorities, contrary to the facility’s abuse prevention policy.

The facility’s policy titled “Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program,” effective January 1, 2024, required the facility to investigate and report any allegations within timeframes required by federal requirements. Despite this policy, the DON acknowledged that she could not say with 100% certainty that nothing took place between the two residents during the time they were unsupervised. The abuse coordinator described the situation as merely a nurse reporting an incident and maintained that there was no allegation of abuse, even though he acknowledged that Resident #5 could not consent. The investigative report, which documented that Resident #5 was in bed with her shirt up and Resident #8 hovering or leaning over her, was not part of the clinical record and was initially characterized as a quality measurement document. These facts demonstrate that an allegation of potential sexual abuse involving a resident who could not consent was not reported to the State Agency as required, constituting the deficiency.

Review of the State Agency’s complaint portal confirmed that no facility-reported incident related to these residents had been submitted. Staff interviews consistently described the internal reporting chain, with suspected abuse to be reported to the administrator/abuse coordinator or the DON, who would then determine whether to report to external agencies. In this case, although staff recognized that both residents were not alert and oriented and that Resident #5 could not consent, the leadership determined that the situation did not constitute abuse and did not submit a report. This failure to report an allegation of sexual abuse, despite the circumstances and the facility’s own policy requiring reporting of any allegations, is the central deficiency identified by the surveyors.