F0609

D

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

Atlanta, Georgia Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The facility failed to timely report an allegation of sexual abuse involving two residents to the Administrator and the State Survey Agency (SSA), as required by its abuse, neglect, and exploitation policy dated 07/15/2025. The policy required all alleged violations, regardless of residents' cognitive status, to be reported to the Administrator, the state agency, and all other required agencies within specified timeframes, specifically immediately but not later than two hours after the allegation is made if the events involve abuse. Resident 35 was admitted on 09/05/2024 and Resident 236 was admitted on 10/26/2023. On 01/11/2026, according to a facility incident report dated 01/13/2026, Resident 236 was found in Resident 35's bed and was observed kissing Resident 35 on the lips. A document titled Abuse-Resident to Resident, dated 01/20/2026, indicated that CNA 9 wrote a statement on 01/11/2026 stating she witnessed Resident 236 in Resident 35's bed and kissing Resident 35 when she directed Resident 236 to get out of the bed, and that she reported the incident to a nurse, later identified by the facility as LPN 1, although no nurse's name was documented in the investigation.

The Administrator stated in an interview on 03/17/2026 that he was notified of the sexual incident on 01/13/2026 by the Assistant Director of Nursing (ADON 1), and that he reported the resident-to-resident incident to the SSA at that time. He also stated that CNA 9 reported the sexual encounter to LPN 1 and that the incident between the two residents was not considered sexual abuse, and that he reported it to the SSA out of an abundance of caution. In a separate interview on 03/18/2026, ADON 1 confirmed he learned about the sexual encounter two days after it occurred and that the staff involved were CNA 9 and LPN 1; he also confirmed he notified the Administrator two days after the incident and was unable to identify how he initially obtained the information. In another interview on 03/18/2026, LPN 1 stated she was not the nurse to whom CNA 9 reported the resident-to-resident incident. The record review and interviews showed a delay between the date of the incident and the date the Administrator and SSA were notified, and a lack of clear documentation and identification of the nurse who received the initial report, resulting in noncompliance with the facility’s abuse reporting policy and required reporting timeframes.