Failure to Timely Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The facility failed to follow its abuse, neglect, exploitation, or mistreatment policy requiring that all alleged violations concerning abuse be reported immediately and verbally to the Facility Abuse Coordinator, the Administrator, and the State Survey and Certification Agency. The policy also states that employees have the right to report allegations directly to the state agency. Despite this, allegations of sexual abuse involving three residents were not reported to the State Agency within the required 2-hour timeframe. The abuse allegations were discussed in a morning staff meeting on 02/06/2026, and some staff reported learning of the allegations as early as 02/04/2026 and 02/05/2026, but there was no timely notification to the State Agency as required. The residents involved all had significant cognitive impairments. One resident had diagnoses including cognitive communication deficit and dementia, with an admission BIMS score of 2/15 indicating severe cognitive deficits. Another resident had diagnoses including alcohol dependence with alcohol-induced persisting dementia, PTSD, anxiety disorder, major depressive disorder, and schizophrenia, and a Quarterly MDS documented that a BIMS was not conducted because the resident could not understand and was not understood. The third resident had diagnoses including dementia, TIA, cerebral infarction, convulsions, adult failure to thrive, and cocaine use, with a Quarterly MDS BIMS score of 6/15 indicating severe cognitive deficits. Allegations included one resident being observed by a CNA with her hands in the brief of another resident, and a separate allegation that two residents had sexual intercourse when one was found in the bed of the other. Progress notes for all three residents contained no documentation of alleged abuse, and although multiple staff members, including department heads and LPNs, were aware of the allegations and the allegations were reported to a nurse when they occurred, staff did not report them to the Abuse Coordinator, and the Abuse Coordinator did not report them to the State Agency.
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