F0609

D

Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation

Temple, Texas Survey Completed on 01-03-2026

Penalty

Fine: $15,940

Summary

The deficiency involves the facility’s failure to immediately report alleged abuse involving two residents to the State Survey Agency (SSA) and law enforcement within the required 2-hour timeframe. A cognitively impaired, nonverbal female resident with dementia, anxiety, depression, gait abnormalities, and a BIMS score of 99 (unable to assess) was care planned for wandering and required supervision or touching assistance with transfers, bed mobility, and lower body dressing. On the date of the incident, a medication aide entered a male resident’s room during medication pass and observed the male resident on top of the female resident in his bed, with both residents’ pants down, the female resident’s brief still on, and the male resident thrusting his hips. The aide reported hearing moaning, noted the female resident’s flushed face and noises, and immediately separated the residents and called for assistance from other staff.

Subsequent nursing documentation for the female resident described her as nonverbal, severely cognitively impaired, and unable to meaningfully participate in a BIMS assessment. Nursing notes indicated that staff completed a head-to-toe physical and skin assessment, documented no signs of penetration or genital injury, and noted dried feces on the resident’s pubic hair. Psychosocial assessments documented no acute distress based on observation of nonverbal behaviors. The incident was recorded as an alleged abuse event in the facility’s incident report log, with the time of occurrence documented in the afternoon. The resident’s family later reported being notified by phone that a male resident had been found on top of her with clothing off and her brief loosened, and they stated that the resident was not sent to the hospital the day of the incident and that they only learned two days later that she had not been evaluated in the emergency department at the time of the event.

The male resident involved had vascular dementia, schizophrenia, auditory and visual hallucinations, and a documented BIMS score of 15 on a prior MDS, but facility notes around the incident described him as having a BIMS score of 6, indicating severe cognitive impairment. He resided on the secure unit for wandering and poor safety awareness. A change in condition note documented that he was observed lying in bed next to the female resident when staff intervened. Administrative documentation described him as found in bed with his pants down and genitalia exposed, with the female resident’s pants down but brief intact, and stated that there was no evidence of penetration on physical examination. The administrator’s narrative, which was later used as the self-report narrative to the SSA, was not sent to the SSA until the evening, and the administrator emailed the SSA stating that the website was down and he was unable to submit the report directly at the time. Interviews with staff and the social worker showed inconsistent knowledge of the incident details and of reporting timeframes, and the survey findings concluded that the facility failed to report the alleged abuse incidents involving both residents to the SSA and law enforcement within 2 hours after the abuse was observed.