F0609

D

Failure to Report Alleged Resident-to-Resident Sexual Abuse to Authorities

Red Oak, Iowa Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The facility failed to report an allegation of abuse involving two residents who were observed inappropriately touching each other. Resident #1 had moderate cognitive impairment with a BIMS score of 11 and a diagnosis of early-onset Alzheimer's disease. Resident #2 had severe cognitive impairment with a BIMS score of 3 and a diagnosis of vascular dementia with behavioral disturbance. On 12/20/26, a CNA (Staff H) observed Resident #1 and Resident #2 sitting at the nurses’ station with their hands down each other's pants. Staff H separated the residents, assisted Resident #2 back to his room, and reported the incident to the nurse (Staff A) and another nurse (Staff I). A progress note entered by Staff A documented that both residents were assessed for trauma and none was observed, and that the DON, Social Services Director (Staff G), and the Administrator were aware of the incident.

The Administrator later stated that he determined the incident was not reportable because both residents had documented dementia. He reported that, after speaking with Staff A, he understood the situation as the residents holding hands in each other's laps rather than having hands down each other's pants, and on that basis decided not to report the incident to the state agency or conduct a formal investigation. The Administrator acknowledged that he did not interview the CNA or nurse directly at the time and did not review available camera footage from the lobby for the date of the incident. The DON stated she was on vacation at the time, was only told there was an “incident” without details, and believed the Administrator handled the situation. She also stated she was not aware that Resident #2 had his hands down another resident’s pants and therefore did not report the incident to the state agency.

Staff H consistently described the event as both residents having their hands in each other's pants or waistbands, possibly with Resident #1 holding Resident #2’s penis, and stated she knew it needed to be reported to the nurse for safety reasons. Staff G recalled being informed that Resident #2 was reaching toward Resident #1 but did not document the incident and did not convey specific details such as “hands in pants” to the DON. A subsequent progress note on the same day documented Resident #2 reaching to touch another resident and becoming combative when redirected. Both residents later told surveyors they felt safe, were treated with dignity and respect, and denied inappropriate touching, though both had cognitive impairment. Family members of both residents reported being notified of an incident in December involving inappropriate touching or hands in waistbands, but did not recall being told it was considered abuse. The facility’s abuse and neglect policy required that all alleged or suspected abuse, including mistreatment by other residents, be immediately reported to the Administrator and designated agencies within specified time frames, but the allegation involving Residents #1 and #2 was not reported to the state survey agency as required.

The facility’s written policy on abuse and neglect specified that all alleged or suspected violations involving mistreatment, neglect, exploitation, or abuse, including injuries of unknown origin, must be promptly reported and investigated, and that designated agencies, including the State Survey and Certification Agency, must be notified in accordance with state law. The policy further required immediate reporting of allegations of abuse or serious bodily injury, and reporting within 24 hours for other allegations, as well as documentation of notifications and review of incidents by an investigation team. Despite this policy, the Administrator and DON did not initiate or complete a formal abuse investigation or report the allegation to the appropriate state agency after being made aware, at least in part, of the incident between Resident #1 and Resident #2. This failure to follow the facility’s own abuse reporting and investigation procedures led to the deficiency for not timely reporting suspected abuse to the proper authorities.