F0609

D

Failure to Timely Report Resident Sexual Abuse Allegation to State Agency

Carlisle, Iowa Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report a resident’s allegation of sexual abuse to the State Agency within the required 2-hour timeframe. Resident #4, who had severe cognitive impairment with a Brief Interview for Mental Status score of 4 and was dependent on staff for personal care and transfers, made multiple statements over two consecutive mornings alleging rape by a male individual. On the morning of 1/21/26, several CNAs (Staff F, G, and H) reported that Resident #4 stated a black man had raped them, with one CNA documenting that the resident also mentioned a black girl and identified the man as the one who comes in and turns the light on. Staff H’s written statement indicated they informed Staff I, an RN, at approximately 8:00 AM on 1/21/26 of the allegation. Staff I later acknowledged that Staff H reported the allegation to them that morning and stated they then called the DON around 7:30–8:00 AM to report it.

Despite these reports, the DON stated they were not contacted on 1/21/26 and first became aware of the allegation the morning of 1/22/26 via a phone call from an LPN. The facility’s Incident Investigative Report showed that the online report of sexual abuse involving Resident #4 was submitted to the Iowa Department of Inspections, Appeals, and Licensing on 1/22/26 at 8:13 AM. Staff interviews revealed confusion and uncertainty among CNAs about who had notified nursing leadership on 1/21/26, with some staff believing others had reported the allegation to a nurse or the DON but unable to confirm this. The facility’s abuse policy, updated 10/19/22, required that allegations of resident abuse be reported to the State Agency no later than 2 hours after the allegation is made, which did not occur in this case.