Failure to Report Allegation of Sexual Abuse to Administrator
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse involving one resident (R5) allegedly touching another resident (R4) to the Administrator/abuse coordinator as required by facility policy. The Administrator (V1) stated he is the abuse coordinator and that all staff are trained to report all allegations of abuse to him, but he confirmed he had no active investigation regarding an allegation of sexual abuse involving R5 touching R4 until the surveyor informed him on 2/5/26. The facility’s abuse policy dated 10/1/25 requires all alleged violations to be reported to the Administrator immediately, but not more than two hours if the allegation involves abuse or bodily harm. Training records dated 8/29/25 show that the CNA (V13) had received abuse prevention and reporting training. Interview and record review showed that on 2/2/26, a family member (V21) witnessed R5 in a wheelchair intentionally poking a finger into the private area of R4, who was also in a wheelchair, in the dining room. V21 reported this incident to CNA V13 at the time and stated she had to move R5’s wheelchair to prevent further inappropriate contact. Despite this report, V1 did not receive any report of this allegation from staff. The record also documents a prior allegation on 5/7/25 that R5 had touched R4’s breasts, and a previous CMS-2567 dated 4/17/24 citing an incident in which R5 (then R205) was identified as the perpetrator of sexual abuse toward R4 (then R206) by touching her breasts. These prior documented incidents further establish that R5 had a known history of sexually inappropriate contact toward R4, yet the new allegation reported to staff on 2/2/26 was not reported to the Administrator as required.
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