F0610

D

Failure to Investigate Alleged Resident-to-Resident Sexual Abuse

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately and comprehensively investigate an allegation of potential resident‑to‑resident sexual abuse involving two cognitively impaired residents. 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 other behavioral disturbance. On 12/20/26, a CNA (Staff H) reported to nursing staff that she observed Resident #1 and Resident #2 sitting at the nurses’ station with their hands down each other’s pants. The residents were separated, Resident #2 was taken to his room, and a nurse (Staff A, RN) documented that both residents were assessed for trauma with none observed. The RN’s progress notes also documented that the DON, Social Services Director (Staff G), and the Administrator were aware of the incident, and that the Administrator stated the incident was not reportable because both residents had documented dementia.

Additional documentation in Resident #2’s record on the same date showed that later that day Resident #2 was observed reaching to touch another resident and had to be redirected by a CNA, after which he hit staff and told them to leave him alone. Interviews with the involved CNA confirmed that she had seen the two residents with their hands in each other’s pants and that she believed Resident #1 might have been holding Resident #2’s penis, although she did not see movement. She reported that she separated the residents and informed the RN and an LPN. She also stated she did not see the nurses complete an assessment at that time and that she reported the incident to the nurse because of safety concerns and the possibility that Resident #2 might repeat the behavior. The Social Services Director recalled being informed of an incident involving Resident #2 reaching toward Resident #1 around the time before Christmas but stated she did not document the incident, did not clearly report that there were hands in pants, and could not recall the exact wording used when she notified the DON.

The DON stated in interview that she had not been made aware that Resident #2 had his hands down another resident’s pants and acknowledged she had not completed an investigation into the reported incident documented on 12/20/25 between Resident #1 and Resident #2. She indicated that if she had been notified of such behavior, she would have come in and completed an investigation, including talking to residents and staff, and that she should have been informed. The Administrator reported that he spoke with the RN by phone and was told that the CNA initially thought the residents had their hands in each other’s pants but later believed they were holding hands in a lap, and based on that, he decided the situation did not warrant reporting or further investigation. He acknowledged that he did not interview the nurse or CNA in person, did not review available camera footage at the time of the incident, and concluded that no investigation was needed. The facility’s abuse and neglect policy required that all alleged or suspected abuse, including mistreatment by other residents, be reported immediately to the Administrator or designee, that the charge nurse complete an initial investigation, and that an investigation team review all incidents by the next working day. Despite this policy, no comprehensive investigation was initiated or completed in response to the CNA’s allegation that the two residents had their hands down each other’s pants.

Interviews with both residents later indicated that each reported feeling safe at the facility, believed staff treated them with dignity and respect, and denied that other residents had touched them inappropriately or that they had touched others inappropriately. Family interviews showed that Resident #2’s son was informed of an incident of inappropriate touching between the two residents and considered it inappropriate but did not view it as abuse, and Resident #1’s daughter recalled being told of an incident described as the residents holding hands or having hands in each other’s waistbands. However, these later perceptions and characterizations did not change the fact that the original CNA report described hands down each other’s pants and that the facility’s own policy required immediate reporting and investigation of such allegations. The failure to follow the abuse policy, to fully clarify and document the allegation, to interview all involved staff promptly, and to conduct a comprehensive investigation into the reported incident constituted the deficiency.

The facility’s written abuse and neglect policy, revised 7/6/23, specified that all alleged or suspected violations involving mistreatment, neglect, exploitation, or abuse, including injuries of unknown origin, must be reported immediately to the Administrator and, in the Administrator’s absence, to designated leaders such as the DON or Social Services Director. The policy required the charge nurse to assess the situation, determine if emergency treatment or action was required, complete an initial investigation, and ensure that any potential for further abuse was eliminated. It also required timely notification of designated agencies, the physician, and family, and mandated that an investigation team (social worker, Administrator, and DON) review all incidents no later than the next working day. In this case, despite a documented allegation that two residents with dementia were observed with their hands down each other’s pants, the DON was not fully informed, the Administrator decided the incident was not reportable without a thorough fact-finding process, and no formal investigation consistent with policy requirements was conducted.

The DON later acknowledged that she should have been informed and that an investigation should have been started if such an incident occurred. The Administrator acknowledged that if the residents had indeed had their hands down each other’s pants, it would have been a different situation, but he relied on a second-hand clarification that the residents were only holding hands in a lap and did not pursue further inquiry. No contemporaneous documentation by Social Services was made, and there was no evidence that the investigation team convened or that a structured review of the incident occurred by the next working day. This sequence of actions and inactions—failure to clearly communicate the nature of the allegation up the chain of command, failure to follow the facility’s abuse reporting and investigation policy, and the Administrator’s decision not to investigate further—led to the deficiency for not completing a comprehensive investigation immediately when an allegation of abuse was reported for Resident #1.