The resident screamed that "she was raped last night" in front of her husband during his visit on February 1st. But the facility's administrator and director of nursing weren't notified until February 3rd, violating the facility's own policy requiring reports within 24 hours.
Registered Nurse 10 was on duty when Resident 12 made the allegation around 4:00 PM during her husband's visit. The resident had been yelling that she wanted to go home and demanding an ambulance when she suddenly disclosed the sexual assault from the previous night.
The nurse knew it was serious. She had been trained that such allegations must be reported immediately. But she didn't tell anyone.
"She knew it was a serious allegation and was previously educated that it should be reported, but did not report it because she was busy and forgot," according to the March inspection report.
The resident's allegation wasn't documented until February 4th, when the nurse made a "late entry" in the progress notes. Even then, the entry simply stated: "resident screaming she raped last night, in front of husband."
Nobody had notified the administrator or director of nursing.
The facility's abuse and neglect policy, dated March 3, 2021, is explicit about timing. All alleged violations involving abuse must be reported "no later than 2 hours after the allegation is made, if events that cause the allegation abuse or result in serious bodily injury; or not later than 24 hours if the events that caused the allegations do not involve abuse and do not result in serious bodily injury."
The administrator confirmed during her interview that staff should notify the clinical on-call person immediately, who then contacts her by phone. "She confirmed the incident occurred on 02/01/25, but was notified on 02/03/25, and she should have been notified right away."
The director of nursing echoed this understanding. "Anytime there is an allegation of abuse, staff should immediately call the Administrator and DON. She confirmed that she was notified on 02/03/25 and that was not immediate."
The delay meant the facility didn't submit its report to the state agency until February 3rd at 11:08 AM via email. The initial report section showed a completion time of 11:06 AM on February 3rd, nearly two full days after the resident's allegation.
Police weren't contacted until February 3rd either, the same day the facility finally began its internal investigation.
The administrator acknowledged during her interview that the report "was not initiated within the time frame as stated in the facility policy." She reviewed the state agency event report with inspectors, confirming that February 1st at 5:00 PM was listed as the incident time and February 3rd at 11:06 AM as when the initial report was completed.
Federal inspectors found that this delayed response put not just Resident 12 but other residents at potential risk for physical and psychological harm. The facility's failure to immediately investigate and report the allegation meant a potential predator could have remained on the premises with access to vulnerable residents.
The inspection report classified the violation as having "minimal harm or potential for actual harm" affecting "some" residents. But the consequences of the nurse's admission that she simply forgot about a rape allegation because she was busy extended beyond a single resident.
During the February 1st incident, Resident 12 had been agitated during her husband's visit, demanding to go home and asking for an ambulance. It was in this context of distress that she disclosed the sexual assault from the night before.
The registered nurse's failure to act immediately meant the facility couldn't begin protective measures, couldn't separate potential perpetrators from victims, and couldn't fulfill its basic obligation to safeguard residents from abuse.
The facility's own policy recognized the urgency of such situations, requiring reports within hours, not days. The policy specifically addresses the need to contact not just internal administrators but also external agencies including police, Adult Protective Services, the Office of Inspector General, and the Attorney General.
None of that happened for 48 hours.
The state complaint inspection, completed March 20, 2025, found the facility failed to "prevent potential abuse" and failed to "respond appropriately to all alleged violations." Inspectors documented how the delay in reporting violated both federal regulations and the facility's internal policies designed to protect residents.
Resident 12's husband had been present when she made the allegation, witnessing his wife's distress as she disclosed the assault. The couple's ordeal extended for two additional days while the facility failed to act on information that should have triggered immediate protective measures and investigation.
The registered nurse's admission that she was "busy and forgot" to report a rape allegation highlights a fundamental breakdown in the facility's abuse prevention system. Despite training and clear policies, the most vulnerable moment for a resident became lost in the daily routine of a nurse who had other priorities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ann Pearl Nursing Facility from 2025-03-20 including all violations, facility responses, and corrective action plans.