F0609

D

Failure to Timely Report and Document Allegations of Sexual Abuse Between Residents

Grand Junction, Colorado Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report and thoroughly document allegations of sexual abuse to the State Agency and other required authorities, as required by its own abuse, neglect, exploitation, and misappropriation reporting policy. The policy, revised in September 2022, states that all reports of resident abuse, neglect, exploitation, or theft are to be reported to local, state, and federal agencies and thoroughly investigated, with findings documented and reported. It further specifies that suspicions of abuse or related concerns must be reported immediately to the administrator and other officials, and that allegations involving abuse or serious bodily injury must be reported within two hours, while other allegations must be reported within 24 hours. Despite this, the facility did not meet these timelines or fully implement the policy in at least two separate incidents involving three residents.

In the first incident, an allegation of sexual abuse occurred when one resident entered another resident’s room at night and kissed her on the mouth while she was asleep in bed. The alleged victim was an older adult with progressive multiple sclerosis, generalized muscle weakness, major depressive disorder in remission, PTSD, generalized anxiety, and delusional behavioral symptoms, but was cognitively intact with a BIMS score of 15 and largely independent in ADLs. She reported that the same resident had previously kissed her on the forehead and that the mouth kiss made her fearful and angry at the time. The incident occurred on 10/13/25 at 2:30 a.m., but the facility first became aware of the allegation on 10/14/25 at 8:30 a.m., and did not submit the initial report to the State Agency until 10/16/25 at 4:59 p.m. The occurrence report itself identified that the report was submitted late. Additionally, progress notes for both the alleged victim and the alleged assailant on and around the date of the incident did not document the allegation.

In the second incident, another cognitively intact resident, with heart failure, unspecified mood disorder, anxiety disorder, and nicotine dependence, reported that the same male resident leaned down to kiss her while they were on the outside smoking porch; she moved her head so the kiss landed on her cheek, but she felt very uncomfortable and did not view him as a romantic interest. She also reported that his behavior had become increasingly invasive, including standing outside her door and listening to her phone conversations, and she expressed feeling unsure what to do. A later nursing note documented that she came to the nurses’ station stating she felt unsafe with this resident, reporting that he had tried to kiss her on the porch and had come into her room; the ADON was informed. A behavior note for the alleged assailant documented that a CNA saw him kiss a female resident on the smoking porch, and that he became defensive, denied the incident, and refused to continue the conversation when approached by an RN. The NHA acknowledged that this was a second incident of potential sexual inappropriateness involving the same resident and stated he did not report it to the State Agency because he believed the kiss was mutually agreed upon, despite the ADON and DON indicating that a report of a resident feeling uncomfortable when kissed and any potential abuse should have been investigated and reported. This incident was not reported to the State Agency at all, constituting a failure to timely report an allegation of abuse.