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F0610
D

Failure to Investigate Allegation of Sexual Abuse

Inverness, Illinois Survey Completed on 04-16-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to investigate an allegation of sexual abuse involving a resident with diagnoses including anxiety disorder, unspecified dementia, and major depressive disorder. The resident reported to multiple staff members and hospice personnel that a male staff member had inappropriately touched her and, at one point, stated she was raped while being transferred with a mechanical lift. The resident's sister also expressed concerns to a nurse, who reported it to the administrator. However, the administrator denied being informed of the specific allegation of rape and did not initiate an investigation, stating that the resident denied inappropriate touching when interviewed. Multiple staff interviews revealed that the resident's statements about the incident were communicated to various facility and hospice staff, including a hospice CNA, a hospice social worker, and a psychiatric nurse practitioner. Despite these reports, the information was not consistently relayed to the administrator, and no formal investigation or protective measures were initiated. The facility's policy requires immediate reporting and investigation of any suspected abuse, but this protocol was not followed in this case. Documentation reviewed included hospice communication logs and psychiatric notes, which confirmed that the resident expressed feelings of vulnerability and described being left undressed and touched inappropriately. The lack of a timely and thorough investigation, as well as the failure to remove potentially implicated staff from duty, constituted a failure to respond appropriately to an alleged violation of abuse prevention policies.

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