F0609

D

Failure to Ensure Timely Reporting of Verbal Sexual Abuse Allegation

Teague, Texas Survey Completed on 01-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that an allegation of verbal sexual abuse was reported immediately to the administrator and appropriate authorities, as required by federal regulations and the facility’s abuse policy. A male resident with intact cognition, complete dependence on staff for mobility and ADLs, and a history of spinal cord injury, osteomyelitis, PTSD, and muscle weakness reported that a CNA made sexually inappropriate comments to him in his room. The resident stated that in approximately November 2025, while being assisted with repositioning, the CNA commented on his buttocks, told him he had a “nice ass for a white boy,” indicated he would go to her house if he ever left the facility, and provided her home address. Another CNA was present in the room and heard the comments.

The resident did not report the incident at the time it occurred, stating he feared being removed from the facility or experiencing retaliation from the CNA. He later disclosed the comments during an emotional distress/psychosocial assessment conducted by the social worker in early January 2026, at which time he reported feeling uncomfortable, awkward, humiliated, and embarrassed by the comments and by the CNA continuing to provide his care afterward. The resident identified the second CNA as a witness to the incident and stated that the perpetrating CNA had told both him and the witness that the witness was the only one who could corroborate the incident and that she would deny it, which he interpreted as a directive not to report.

The witness CNA confirmed to the DON that she had been present when the sexually inappropriate comments were made and that she did not report the incident at the time. She stated she believed the resident did not appear bothered when the comments were made, did not recognize the comments as inappropriate at the time, and acknowledged that she and the perpetrating CNA were longtime friends and that the perpetrating CNA had a history of inappropriate comments and behavior. The DON and ADM both stated it was their expectation that any staff member who witnessed or became aware of alleged abuse, including verbal sexual harassment, would report it immediately. Despite this expectation and the facility’s written Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy requiring investigation and reporting of allegations within federal timeframes, the witness CNA did not report the incident when it occurred, and the facility did not become aware of the allegation until months later, after the resident’s disclosure to the social worker.

Interviews with the DON, ADM, SW, and the witness CNA confirmed that the event occurred in approximately November 2025 and that the facility did not receive any report of the incident until January 2026. During this period, the CNA who made the comments continued to work with the resident and provide ADL care. The DON acknowledged that the witness CNA failed to report the incident in a timely manner and that no disciplinary action was taken against the witness for this failure. The facility’s policy, last revised April 2021, stated that allegations of abuse, neglect, exploitation, and misappropriation must be investigated and reported within timeframes required by federal requirements, but the delay between the incident and the facility’s awareness and reporting of the allegation demonstrates that the facility did not ensure that all alleged violations involving abuse or mistreatment were reported immediately as required.