Failure to Timely Report Staff-to-Resident Sexual Exploitation and Other Abuse Allegations
Summary
The deficiency involves the facility’s failure to immediately report multiple allegations of abuse, neglect, and exploitation to the State Agency, local police, and the Administrator as required by policy. The facility’s Abuse, Neglect, and Exploitation policy required all alleged violations to be reported immediately, but not later than two hours, when the events involve abuse or result in serious bodily injury, and within 24 hours for other events. Despite this, when the Administrator became aware in June that a dietary aide was attempting to initiate a personal or romantic relationship with a resident who had a plenary guardian due to disability and lack of capacity to make responsible decisions, the Administrator did not notify the State Agency or local law enforcement. The aide resigned after the Administrator reviewed text messages showing boyfriend/girlfriend-type communications and the aide’s desire for a relationship and to get the resident pregnant, but no report was made at that time. The resident involved in this staff-to-resident situation had been adjudicated a disabled person in need of a plenary guardian of person and estate, with the guardian authorized to make residential decisions and protect the resident’s best interests. The guardian reported being told by the Administrator that the aide had resigned and that the facility did not have to report the matter to the state health department. The guardian stated that she informed the Administrator that the aide’s conduct constituted exploitation and that the state needed to know an employee was trying to have a sexual and boyfriend-girlfriend relationship with her disabled daughter. Staff interviews and documentation showed that the psychosocial rehabilitation coordinator and the prior dietary manager both observed or were informed that the aide was spending excessive time with the resident, expressing romantic feelings, and sending messages such as “I love you” and wanting to get the resident pregnant. A CNA also reported seeing the resident video chatting with the aide at night, and another CNA reported several evenings of sexually explicit video chatting between the aide and the resident, which she said she reported to nurses. The facility also failed to immediately report other abuse allegations involving the same resident and her roommate. On one date, progress notes documented that staff spoke with the resident after the roommate complained that the resident was completely naked in the room with the door and curtain open while talking or videoing on social media with a male. On another date, a behavior note documented that the roommate reported the resident was engaging in sexual conversation via video with a male, identified as the former dietary aide, and that when the roommate asked them to stop, the aide cursed at and called the roommate names. The psychosocial rehabilitation coordinator stated she reported this to the Administrator, but there was no evidence these allegations of sexual exploitation by video or the verbal abuse and threats toward the roommate were reported to the State Agency or local police. The roommate later stated she had watched the resident and the aide having sex on the phone several times and that the aide repeatedly yelled at and threatened her when she asked them to stop, and she reported feeling abused and worried. In addition, the facility did not timely report an allegation of resident-to-resident physical abuse involving the same resident. Emergency department notes documented that the resident presented with suicidal ideation and reported being physically assaulted by two other residents the previous day. The Administrator acknowledged learning of this allegation only after receiving the hospital records months later and confirmed that, as of the survey, he had not notified the local police or State Agency regarding this allegation. The police report and the facility’s own abuse investigation later documented that the resident reported multiple instances of non-consensual sexual contact by the former dietary aide in a church parking lot on Sundays, including episodes where she described feeling woozy and blacking out after eating food provided by the aide. The Administrator did not notify the State Agency or local police about the aide’s initial attempts to initiate a personal relationship with the resident while employed, and the police and State Agency were not notified about the sexual relations at church until several days after the guardian reported the situation to facility staff. The Immediate Jeopardy was determined to have started when the Administrator first became aware that the aide was engaging in behavior indicating an attempt to initiate a personal or romantic relationship with the resident and failed to report this to the police or State Agency. This failure coincided with ongoing sexually inappropriate conversations and video nudity by electronic communication between the aide and the resident, which were not reported. The facility’s records and staff interviews showed that, during this period, there was no documented evaluation of the resident’s capacity to consent to sexual activity in the electronic health record, and staff reported they were never informed whether the resident could consent to sexual relationships or that she required supervision. The combination of unreported staff-to-resident sexual exploitation, unreported staff-to-resident verbal abuse toward the roommate, and unreported resident-to-resident physical abuse formed the basis of the cited deficiency for failure to timely report suspected abuse, neglect, and exploitation.
Removal Plan
- V7 resigned from the facility.
- V1 initiated an abuse investigation into R3's abuse allegation and notified IDPH; a final report will follow.
- V1 initiated an abuse investigation into R3's abuse allegation and notified IDPH; a final report will follow.
- V1 initiated an abuse investigation into R3 and R6's abuse allegations and notified IDPH; a final report will follow.
- V1 initiated an abuse investigation, notified IDPH, and notified the local police regarding R3's abuse allegation.
- V5 completed assessments on R3's capacity to consent to sexual relations with the involvement of V3, V35, and V36.
- The facility is evaluating R3's capacity to consent to sexual relations and implemented precautions to keep R3 safe.
- The facility developed a plan to ensure R3 has staff supervision while using the facility phones to ensure safe communication with others.
- V3 removed R3's phone and restricted R3's church visits.
- R3's care plan was updated with interventions to increase R3's safety.
- V26 reviewed all residents to ensure no residents suffered from past abuse.
- The Quality Assessment and Assurance Committee met for an emergency QAPI meeting and developed and implemented plans to ensure no further abuse occurred within the facility and all policies and procedures were followed correctly.
- The facility's abuse policies were reviewed by the QA committee prior to educating staff.
- The facility's staff intimate relationships policy was reviewed by the QA committee.
- V1, V2, and V38 educated all staff on abuse prevention, abuse reporting, and all abuse-related policies and procedures.
- V25 educated V1 on the facility's Abuse, Neglect and Exploitation Policy and compliance with reporting allegations of abuse, neglect, and exploitation to IDPH.
- V1, V2, and V38 educated all staff on maintaining professional boundaries with residents and that staff are not to have any inappropriate relationship with residents.
- R3 and R6's care plans were updated with safety interventions to protect them from abuse.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to report an alleged misappropriation of resident funds. A resident with COPD, anxiety, and PTSD reported $1,600 missing and believed another resident took it, but the SSD reportedly said it was too long ago to investigate. The CNO recalled hearing about missing funds from a family member but did not pursue it, and the CEO stated the allegation should have been reported to the State Agency.
Failure to report alleged sexual abuse within required timeframe. A resident with intact cognition and significant ADL dependence alleged that a CNA raped them during incontinence care; the resident later described possible penetration and burning, while the CNA said they only provided brief care and applied ointment. The family member contacted law enforcement and requested hospital transfer, but facility leadership did not report the allegation to DOH within 2 hours, stating they believed the allegation had changed to rough handling and did not meet the reporting threshold.
Failure to Immediately Report Abuse Allegations and Injury of Unknown Origin: Staff did not immediately report two resident-to-resident sexual abuse incidents involving one resident touching two others, and staff also did not immediately report bruising of unknown origin on another resident. A CNA redirected the resident during the abuse incidents but did not notify the charge nurse, DON, or Administrator, and an RN and LPN did not escalate the bruising after assessing it and hearing it described as handprint-like. The delayed reporting prevented timely initiation of the abuse investigation process and resident assessment.
Failure to Report Alleged Physical Abuse: A resident alleged that two CNAs were rough while repositioning them in bed and that the resident’s head was bumped into the headboard, causing pain. One CNA confirmed the head bump occurred during care, and the administrator stated the abuse allegation and failure to report were substantiated because the staff did not report the incident immediately.
Failure to Timely Report Allegation of Abuse: A nurse witnessed one resident touch another resident inappropriately, but the incident was not reported within the required timeframe. The LPN separated the residents and addressed boundaries with the resident involved, but did not report the event because she believed the RN would notify the DON. The DON and Administrator later stated the incident had not been reported immediately as required.
Failure to Immediately Report Verbal Abuse Allegation: A CNA was heard using foul and disrespectful language toward a cognitively impaired resident during care, but the allegation was not reported immediately to the DON/Administrator. The witness delayed reporting for several hours, and the DON, ADON, and Administrator confirmed the report was not made until later that morning. The resident had severe cognitive impairment, was dependent on staff for care, and received nutrition via GT.
Failure to Report Alleged Misappropriation
Penalty
Summary
The facility failed to ensure an allegation of misappropriation was reported to the State Agency as required for Resident #23, who was admitted with diagnoses including COPD, anxiety, and PTSD. Resident #23 stated that approximately two months before the survey, he reported $1,600.00 missing to the Social Services Director and believed another resident had taken the money. He reported that the SSD asked how long ago it happened, and when he said about one and a half months earlier, he was told it had been too long ago to investigate. During the survey, the SSD did not respond to a call for interview, the CNO stated she recalled a family member mentioning the missing funds but did not ask further questions, and the CNO said the allegation was never made directly to her or facility staff. The CEO stated the allegation should have been reported to the State Agency.
Failure to Report Alleged Sexual Abuse Within Required Timeframe
Penalty
Summary
The facility failed to ensure that an alleged incident of abuse was reported to the New York State Department of Health and local law enforcement within two hours of the allegation. The deficiency involved one resident who had diagnoses including obstructive and reflux uropathy, hemiplegia, and hemiparesis following cerebral infarction. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and the care plan showed the resident required assistance with ADLs, including two staff members for transfers and toileting and extensive assistance for dressing, bathing, grooming, and bed mobility. According to the facility’s incident report, the resident told an LPN that they had been raped by a CNA while receiving care. The resident later described that the CNA entered the room to change a wet brief, applied cream to the hip and then to the anus and vaginal area, and that they felt something enter the anus and vagina while asking the CNA to stop. The CNA stated they provided incontinence care and applied A and D ointment to the perianal area, and the video review showed the CNA entered the room at 4:43 AM and exited at 5:19 AM. The resident’s family member reported that the resident called them, said to come immediately, and later stated that a staff member had raped them. The family member contacted law enforcement and requested hospital transfer. Facility leadership acknowledged awareness of the allegation but did not report the alleged rape to the Department of Health, stating they believed the allegation changed to rough handling and did not meet the reporting threshold. The DON, Administrator, and Social Worker each described differing understandings of the allegation and reporting status, and the report states there was no documented evidence that the allegation was reported to local law enforcement or the Department of Health within two hours as required.
Failure to Immediately Report Abuse Allegations and Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure staff immediately reported allegations of abuse to administration for two separate resident-to-resident sexual abuse incidents involving three residents. One CNA witnessed Resident #3 inappropriately touch Resident #1’s breasts while Resident #1 was asleep, and later saw Resident #3 reach under Resident #2’s blanket while Resident #2 pushed the hands away and told Resident #3 to stop. The CNA redirected Resident #3 during both incidents but did not immediately notify the charge nurse, DON, or Administrator. The incidents were later identified by the DON through electronic medical record alerts, and the DON and Administrator stated they were not notified when the events occurred. The facility also failed to ensure staff immediately reported an injury of unknown origin for Resident #4. Two CNAs observed multiple bruises, including bruises resembling handprints, while providing care and notified an RN and LPN. The RN assessed the resident and documented bruising of unknown origin, but neither the RN nor the LPN notified the DON or Administrator at that time. The LPN stated the CNAs were discussing the bruises with the RN and therefore did not contact higher management, while the RN did not believe the bruising was concerning because the resident had fragile skin and was on a blood thinner. Because the allegations were not immediately escalated, the facility’s abuse investigation process was delayed, including resident assessment and collection of investigative information. For Resident #4, the DON stated the resident had already been transferred to the hospital before the facility initiated an abuse investigation and could not be assessed as part of the initial investigation. The Administrator acknowledged that facility protocol requiring immediate reporting of abuse allegations was not followed in both events.
Failure to Report Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure an allegation of physical abuse was reported for one resident. A written statement from the resident said that a night shift CNA and the CNA’s helper slid the resident up in bed and rammed the resident’s head into the headboard, causing the resident to holler out in pain. The resident later stated that the staff had hurt them by being rough. An email statement from one CNA said that the resident’s head bumped the headboard while the resident was being pulled up in bed after a change, and that the CNA apologized and asked several times if the resident was okay. Employee counseling records showed two CNAs were terminated for failure to report an allegation of abuse. The administrator stated the abuse allegation and failure to report were substantiated after the facility investigation, and stated the staff should have reported the incident immediately when the resident said they were hurt.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the regulated timeframe for 2 of 27 residents reviewed for abuse. The facility policy stated that suspected abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source must be reported immediately, defined as within 2 hours for allegations involving abuse or serious bodily injury, or within 24 hours for allegations that do not involve abuse or serious bodily injury. R15 was admitted with diagnoses including dementia, essential hypertension, depression, and pure hyperglyceridemia, and R14 was admitted with diagnoses including hypertension, left above-the-knee amputation, anxiety disorder, neurogenic bladder, and COPD. Staff interviews and record review showed that a nurse witnessed R14 touch R15 inappropriately in the dining room on 06/22/26, with the Social Services Director later stating the incident was reported to her on 06/24/26. The LPN stated she was told by an RN that R14 touched R15 inappropriately, separated the residents, discussed boundaries with R14, and did not report it because she thought the RN would report it to the DON. The DON stated she was made aware on 06/24/26 of an incident that had occurred a couple of nights earlier, and the Administrator stated the nurse assigned to the residents did not report the incident immediately.
Failure to Immediately Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse was reported immediately to the Administrator when a CNA was witnessed using foul language at the bedside within earshot of a resident. The deficiency involved one resident reviewed for abuse/neglect and was based on interviews and record review showing that the allegation was not reported right away, but instead was brought to the DON hours later the same morning. The resident involved was a female with multiple serious diagnoses, including respiratory failure, a stage 2 sacral pressure ulcer, encephalopathy, anemia, diabetes, malnutrition, non-Alzheimer's dementia, depression, hypertension, severe chronic kidney disease, difficulty walking, failure to thrive, leukemia in remission, and a bone marrow transplant history. Her quarterly MDS showed a BIMS score of 07, indicating severe cognitive impairment, with delusions and inattentiveness. She was dependent on staff for personal hygiene, dressing, toileting, positioning, and transfers, was always incontinent of bowel and bladder, and received nutrition through a feeding tube. A CNA reported that while assisting the resident with care, another CNA repeatedly used disrespectful language toward the resident, including calling her a derogatory name while the resident was in the room and within hearing distance. The witness said she did not report the allegation immediately because she was thinking about it and did not want to jeopardize the other CNA's job, and she ultimately reported it later that morning to the DON. The DON and ADON confirmed the allegation was not brought to the Administrator until hours after it occurred, and the Administrator stated she was unaware of the behavior until the report was made. The facility records also showed policies requiring immediate reporting of suspected abuse and defining verbal abuse as communication within hearing distance that can cause humiliation, intimidation, fear, shame, agitation, or degradation.
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