F0610

D

Failure to Thoroughly Investigate and Respond to 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 thoroughly investigate and appropriately respond to an allegation of possible sexual abuse between two cognitively impaired residents and to take steps to correct the situation. Resident #5, who had early onset Alzheimer’s disease, aphasia, depression, and a BIMS score of 00 indicating severe cognitive impairment, had a care plan initiated in August 2025 for behavior problems including poor safety awareness, wandering, and exit seeking, with interventions to protect the rights and safety of others. In January 2026, this care plan was updated to note that Resident #5 lifted her shirt exposing her breasts at times, but no new or revised interventions were added to address this behavior. Progress notes contained no entries related to the alleged incident or to Resident #5’s tendency to lift her shirt and expose her breasts.

Resident #8 had dementia with behavioral disturbances, type 2 diabetes, depression, and a BIMS score of 09 indicating moderate cognitive impairment. His care plan, revised in August 2025, identified behavior problems including wandering, exit seeking, and sexually inappropriate behavior, with interventions to intervene as necessary to protect the rights and safety of others. After the incident involving Resident #5, there was no indication that his care plan was revised to reflect modified interventions related to sexual behaviors. Behavior notes documented that Resident #8 was placed on 1:1 activity for increased supervision and monitoring and that he required redirection and supervision around other residents. A behavior note on January 2, 2026, documented that Resident #8 was observed kissing Resident #5 and that she was reciprocating, but no additional progress notes were found related to this alleged incident.

Interviews and the facility’s investigative documentation revealed inconsistencies and gaps in the investigation of the incident. Staff reported that Resident #5 and Resident #8 resided in rooms directly across from each other, and multiple staff expressed concern that this proximity was not safe for Resident #5. The DON stated that both residents were found in Resident #8’s room with Resident #5’s shirt up and that the residents were separated, and she reported that they concluded no sexual abuse had occurred, though she could not say with 100% certainty that nothing took place. The abuse coordinator stated that he was told the residents were in bed together with clothes on and that they liked to flirt, and he did not consider Resident #5 having her shirt up with Resident #8 hovering over her to be abuse, even though he acknowledged Resident #5 could not consent. The written investigation consisted only of statements from the witnessing RN, a CNA who did not witness the event, and the DON, with no evidence of broader interviews, additional observations, or further record review around the time of the incident, including no additional skin assessments beyond those dated December 22, 2025 and January 5, 2026. The incident was not reported to the State Agency’s complaint portal, despite facility policy and the State Operations Manual requiring investigation and reporting of allegations within required timeframes and the collection of evidence through observations, interviews, and record reviews, as well as immediate measures to protect residents from further abuse during the investigation.

Further, the RN who witnessed the incident later described finding Resident #5 in Resident #8’s room, in bed with her shirt off and Resident #8 hovering over her, after hearing giggling and having lost sight of them for a few minutes. She separated the residents and reported the situation to the DON, acknowledging that both residents were not alert and oriented and could not consent, which was why she intervened. She stated that she did not personally consider it sexual abuse because she believed they were two consenting adults and that there was not enough time for anything to happen, but she recognized that determining whether it was abuse and whether to report it was the responsibility of leadership. Review of the State Agency’s complaint portal showed no facility-reported incident related to these residents, and the facility’s own policy on abuse, neglect, exploitation, and misappropriation prevention required investigation and reporting of any allegations within federal timeframes. The combination of incomplete documentation, limited investigative steps, lack of care plan revisions, and failure to report the allegation to the State constituted the deficient practice identified by surveyors.

The facility also did not document any additional protective measures or environmental changes in the clinical record related to the proximity of the residents’ rooms, despite staff concerns that having the two residents directly across from each other was unsafe for Resident #5. CNA and RN staff interviews indicated that suspected abuse was to be reported to the administrator or DON, and that this process was followed in terms of initial reporting, but the subsequent investigation did not include comprehensive evidence collection as outlined in the State Operations Manual. The investigative report was treated as a quality measurement document and not part of the clinical record, and it did not demonstrate that the facility had thoroughly collected evidence through broader staff interviews, resident observations, or expanded record review around the time of the incident. These actions and omissions led to the finding that the facility failed to thoroughly investigate the allegation of abuse and to take steps to correct it.