F0610

D

Failure to Thoroughly Investigate and Care Plan Resident-to-Resident Sexual Abuse Allegations

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely and thoroughly investigate multiple allegations of sexual abuse and boundary violations involving one male resident and several female residents, contrary to its abuse policy requiring immediate reporting and comprehensive investigations. The facility’s policy mandated that all allegations of abuse, neglect, or exploitation be reported within specified time frames and that investigations include review of documentation, medical records, interviews with residents, staff, and witnesses, and detailed documentation of findings. In the case of an allegation that a male resident kissed a female resident while she was asleep in bed, the incident allegedly occurred in the early morning hours, but the facility did not become aware until the following day and did not report the allegation to the State Agency until several days later, beyond the required reporting timeframe. The investigation that was completed did not document when the involved residents were interviewed, did not identify the events leading up to the alleged incident, did not specify where staff or the alleged perpetrator were at the time, and did not include documented interviews of staff or other residents, despite the policy’s requirements.

The female resident who alleged being kissed in bed had progressive multiple sclerosis, was cognitively intact with a BIMS score of 15, used a wheelchair, and had documented delusional behavioral symptoms. She reported that the male resident had come into her room, closed the door, and kissed her on the mouth while she was asleep, and that he had previously kissed her on the forehead. She also reported that he would look into her room window from outside, prompting her to yell for staff, and that she kept her blinds down because she did not feel safe enough to keep them open. Her behavior care plan noted a history of making allegations about peers standing over her bed and a history of flirtation and conflict with caregivers, but it did not include interventions to ensure her privacy, address unwanted room entry, or guide staff response if another resident entered her room while she was sleeping. Observations on the smoking porch showed the same male resident pushing her wheelchair through the facility despite a care plan intervention stating it was not safe for him or any resident to push other residents, and staff were not observed intervening or offering assistance.

A second female resident, who was cognitively intact with a BIMS score of 13 and independent with mobility, reported that the same male resident leaned down to kiss her, that she turned her head so the kiss landed on her cheek, and that the kiss made her feel very uncomfortable. She also reported that he had become increasingly invasive, including standing outside her door listening to her phone conversations, and later told nursing staff she felt unsafe with him, stating he had tried to kiss her on the porch and had come into her room. A CNA reported seeing the male resident kiss this female resident on the smoking porch, and an RN reported the incident to management. However, there was no investigation located or provided for this allegation, no evidence that it was reported to the State Agency, and no new care plan interventions were added for either resident following these events. Another female resident reported that the same male resident frequently entered her room without knocking to ask for soda and cigarettes, and that a stop sign banner intended to deter entry was not kept across her doorway. Staff interviews confirmed that the male resident could become too familiar with female residents, enter their rooms, and had kissed other female residents, yet one CNA stated she had not been informed of any specific behaviors or interventions to watch for with him. The NHA and DON acknowledged that documentation of interviews and investigations was lacking, that the report to the State Agency for one allegation was late, and that there were no new care plan interventions after the allegations involving the two female residents.