Failure to Timely Report Sexual Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely reporting of a sexual abuse allegation to the State Agency in accordance with its abuse reporting policy and state and federal law. The facility’s policy, updated October 2022, required that all suspected or alleged abuse be reported immediately, and no later than two hours, when events involve allegations of abuse or result in serious bodily injury. Resident 1, admitted with bipolar disorder, agoraphobia, and anxiety disorder, had an admission MDS showing intact cognition, no refusal of care, no behaviors, and dependence on staff for toileting and personal care. The facility’s investigation documented that an alleged sexual allegation involving Resident 1 as the victim and a NAC (Staff H) as the alleged perpetrator occurred on 02/22/2026, but the allegation was not reported in the state Secure Reporting and Tracking System (STARS) until 02/23/2026 at 7:22 PM. Multiple staff members were informed of the allegation on the day it occurred but did not report it. Staff D, NAC, stated that during the 6:00 AM–2:00 PM shift on 02/22/2026, Resident 1 reported that Staff H made sexual comments and touched them inappropriately during care; Staff D only switched rooms with Staff H and did not report the allegation. During the 2:00 PM–10:00 PM shift on 02/22/2026, Staff E, NAC, was informed in shift report that Resident 1 had reported sexually inappropriate comments by Staff H and feeling uncomfortable, and Staff F, NAC, stated Resident 1 told them that Staff H had sexually assaulted them and made inappropriate comments during care; neither Staff E nor Staff F reported the allegation. The DON later stated the sexual allegation should have been reported immediately once the first staff member was informed, and the Administrator was unaware that multiple staff had knowledge of the allegation on 02/22/2026 and had failed to report it.
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