F0610

D

Failure to Thoroughly Investigate Alleged Resident-to-Resident Sexual Abuse

Warren, Ohio Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to thoroughly investigate an allegation of resident-to-resident sexual abuse involving two residents. Resident #40, admitted on 04/07/16, had diagnoses including autistic disorder, developmental disorder, anxiety, hypertension, and scoliosis, and was documented as severely cognitively impaired, requiring extensive assistance with activities of daily living. Resident #52, admitted on 03/20/25, had diagnoses including diabetes, depression, high cholesterol, and respiratory disorders, was cognitively intact, and was independent in all ADLs. His care plan, initiated on 03/24/25, identified sexually inappropriate behaviors, including entering female residents’ rooms, with interventions focused on anticipating needs and addressing inappropriate behavior.

On 01/11/26 at 9:32 P.M., a nursing note documented that Resident #52 indecently exposed himself to another resident in the hallway. The facility’s self-reported incident (SRI) and investigation dated 01/12/26 stated that Resident #52 was observed standing to the left of Resident #40 in the hallway with his pants appearing to be positioned below his waist, but asserted there were no movements, physical contact, or behaviors suggesting concerning interactions, and concluded the allegation of sexual abuse was unsubstantiated. The SRI noted that Resident #40 lacked the cognitive ability to provide a statement and that other resident interviews revealed no findings of abuse.

However, a witness statement from CNA #213 documented that she saw Resident #52 standing in front of Resident #40, exposing his genital area and saying, "There you go, look at it," after which he rushed back to his bedroom when he saw her. CNA #213 reported that Resident #40 answered "yes" when asked if Resident #52 had shown his genitals and that Resident #40 was overheard telling another CNA she was scared. A police report recorded that staff reported Resident #52 exposing his genitals to Resident #40, though Resident #52 denied it. LPN #214 confirmed being told that Resident #52 exposed himself and acknowledged knowledge of his history of inappropriate sexual behaviors. The Administrator later confirmed he recalled reporting that Resident #52’s pants were down and his genitals were exposed to Resident #40, which was inconsistent with the SRI’s conclusion, and acknowledged that witness statements were not obtained from all involved staff and that sexual abuse could not be ruled inconclusive, contrary to the facility’s abuse policy requiring immediate, complete, and thorough investigation and documentation.