F0610

D

Failure to Thoroughly Investigate Alleged Resident-to-Resident Sexual Abuse

Dousman, Wisconsin Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to conduct a thorough investigation of an alleged abuse incident between two residents, R1 and R2. On 1/4/26 at approximately 2:00 PM, R2, who has a diagnosis of Alzheimer’s dementia, was observed in a common living room area with his hand partially down the top of R1’s pants/brief, moving back and forth, and R1’s shirt partially lifted. R1, who also has dementia, did not appear to be aware of what was happening, and when the witnessing staff member questioned R2, he responded, “what?” The Activities Director (C) immediately separated the residents, repositioned R2’s hand to his own lap, took R1 with her, and reported the incident to the nurse on duty, and law enforcement was contacted.

The facility’s written policy, “Freedom from Abuse, Neglect and Exploitation Policy and Procedure,” requires that all reports of abuse be promptly and thoroughly investigated, including immediate protection of residents, initiation of a root cause investigation and analysis, and collection of information to corroborate or disprove the incident. The policy specifies that a thorough investigation must adequately address the circumstances of the allegation, include facts necessary to form a reasoned conclusion, and document involved staff and witness statements, including identifying and interviewing other staff or residents in the immediate area and staff from previous shifts. Despite these requirements, the facility’s investigation of the 1/4/26 incident consisted only of a single written statement from the Activities Director who witnessed and intervened in the event.

Surveyor review on 1/29/26 found no evidence that the facility interviewed additional staff or residents who might have witnessed the incident or had knowledge of prior similar behaviors by R2. The Administrator could not state whether any other staff had witnessed the incident or whether other residents were present in the living area at the time. The facility did not determine whether R2 had previously been inappropriate with other peers, whether there were any other sexually related behaviors or statements by R2, or whether any other residents might have been affected. Documentation later submitted by the facility confirmed that any broader staff and resident interviews related to this incident were not conducted until 1/29/26, during or after the survey, rather than at the time of the original event, demonstrating that the facility did not promptly or thoroughly investigate the alleged abuse incident as required by its own policy.