F0610

D

Failure to Immediately Remove Alleged Perpetrator After Sexual Abuse Allegation

Carlisle, Iowa Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The facility failed to protect residents from further potential abuse after an allegation of sexual abuse was reported. On the morning of 1/21/26, a CNA (Staff H) reported that Resident #4 stated a black man raped me and the black girl when asked how they had slept, and further identified the alleged perpetrator as the man who comes in and turns the light on. After completing personal cares, Staff H informed an RN (Staff I) of the allegation. Staff I acknowledged being approached by Staff H that morning and stated they called the DON at approximately 7:30 AM to report the allegation. However, the DON reported they were not contacted on 1/21/26 and first became aware of the allegation on the morning of 1/22/26.

Upon becoming aware of the allegation on 1/22/26, the DON reviewed staffing schedules from the previous day and identified a CNA (Staff J) whose general description matched that provided by Resident #4 and who had worked the night shift on 1/21/26. Staffing schedules showed Staff J worked the night shifts of 1/20/26 and 1/21/26. Staff J was not suspended until 1/22/26, meaning they continued to work and had access to residents after the allegation was initially reported to staff. This sequence of events conflicted with the facility’s written Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, which requires the facility to immediately implement measures to prevent further potential abuse upon receiving an allegation, including suspending or segregating the accused employee or otherwise ensuring no resident contact while an investigation is in process. The facility submitted an online report of the sexual abuse allegation involving Resident #4 to the state agency on 1/22/26 at 8:13 AM.