F0609

D

Failure to Timely Report Alleged Sexual Assault to State Agency

Duluth, Minnesota Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The facility failed to timely report an allegation of sexual assault to the State Agency within the required 2-hour timeframe after an incident in which one resident groped another resident’s breasts without consent in the dining room. On the morning of 1/20/26 at approximately 9:15 a.m., a registered nurse (RN-A) observed that a male resident (R1) approached the dining room to greet his wife (R3), moved around a table when asked by an aide, and then came behind another resident (R2) and groped her breasts without her consent. R1 was redirected to his room and educated, and he demonstrated little to no remorse for his actions. RN-A reported that R2 was aware the incident occurred but soon closed her eyes and showed no visible negative reaction or distress, and later staff interviews found R2 had slight to no recall of the incident. Police and the responsible parties for R1 and R2 were notified, and RN-A, who had not worked at the facility for long and was unfamiliar with the residents’ plans of care, stated that the plan of care was nonetheless followed.

The facility’s incident report shows that the allegation was reported to the State Agency at 4:25 p.m. on 1/20/26, more than 2 hours after the incident. During an interview on 1/29/26, the social worker stated that the decision was made to report to the State Agency after most of the investigation had been completed and acknowledged she was not aware that the report should have been made first. She agreed that the incident was reported late and not within the 2-hour requirement set by regulations and the facility’s “Maltreatment Reporting Guidelines” policy, which requires immediate reporting, but no later than 2 hours after an allegation of abuse, neglect, financial exploitation, injuries of unknown source, or misappropriation of property.