Failure to Recognize and Report Potential Sexual Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to implement its Abuse Prevention and Reporting policy when presented with a situation that met criteria for a potential sexual abuse allegation. The facility’s policy, effective 12/2025, states that residents have the right to be free from abuse, neglect, exploitation, and misappropriation of property, and that staff will be oriented and trained on what constitutes abuse and how to recognize and report incidents or allegations. A Resident Grievance form dated 12/8/25 documented that a CNA reported finding a transportation driver in a resident’s room with the door closed; when the CNA partially entered, the resident had her shirt pulled up, covering her face, and her bra exposed. Once the CNA was able to fully enter the room, the transportation driver was found behind the door, facing the resident, and he repeatedly stated, “don’t say anything.” The grievance also documented the driver’s explanation that he was delivering a sub sandwich to the resident over a football bet and that he denied any inappropriate behavior, and that the resident gave the same account when questioned. During an interview, the Administrator confirmed awareness of the situation between the resident and the transportation aide and stated she had been called at home by the DON, with the CNA present, and informed of what the CNA had witnessed. The Administrator acknowledged that the CNA had reported seeing the resident with her shirt up and bra exposed, and the transportation aide behind the door, and that the aide had repeatedly told the CNA not to say anything. The Administrator stated she consulted with corporate staff and they concluded that the CNA was making trouble because she knew the aide was the Administrator’s brother and wanted to get him in trouble. The Administrator stated she did not consider the situation to be potential abuse, did not report it to the state agency, and did not notify local law enforcement, despite the facility’s policy requiring recognition and reporting of occurrences and allegations of abuse. This failure to recognize and report a potential sexual abuse allegation for one of four residents reviewed for abuse led to the cited deficiency.
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