Failure to Investigate Resident-to-Resident Inappropriate Contact
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of resident-to-resident inappropriate, nonconsensual contact. A behavior progress note for resident #73 dated 12/14/25 documented that this resident had repeatedly been removed from female residents’ rooms and had been rubbing the legs of other female residents. The note indicated that staff had repeatedly corrected and educated the resident on this inappropriate behavior. Despite this documentation, there was no evidence that the specific incident involving residents #46 and #73 on 12/14/25 was reported to the State Survey Agency or investigated by the facility. During an interview on 2/24/26, staff member A reported that while reviewing the former resident #73’s chart in connection with a possible return to the facility, they discovered a progress note describing a reportable event involving residents #46 and #73 that had not been reported or investigated. Staff member A stated they had not been aware of the incident prior to this chart review. Review of the facility’s incident reports confirmed that the event between residents #46 and #73 on 12/14/25 was not included among incidents reported or investigated. This failure occurred despite the facility’s written Abuse, Neglect, and Exploitation policy, which requires an immediate investigation upon suspicion or reports of abuse, neglect, or exploitation, including identifying responsible staff, interviewing all involved persons and witnesses, determining whether abuse or related mistreatment occurred, and thoroughly documenting the investigation.
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