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F0609
F

Failure to Report and Respond to Resident-to-Resident Sexual Abuse

East Peoria, Illinois Survey Completed on 05-28-2025

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 follow its abuse policy and procedures by not immediately reporting and investigating an incident of resident-to-resident sexual abuse. Two certified nursing assistants witnessed a resident placing their hand up another resident's shorts and touching the resident's vagina on two separate occasions. The first incident was not reported to the administrator, and only after the second incident did the nursing assistants inform the LPN, who then contacted the administrator in training. Despite these reports, the administrator in training did not notify the state agency, local law enforcement, or the resident's representative as required by the facility's policy. During the period following the incident, the resident who committed the abuse continued to have unsupervised access to all other residents in the facility. The facility's policy mandates immediate reporting of all abuse allegations to the administrator, state agency, and law enforcement, with a summarized investigation to be completed within five business days. However, the administrator in training confirmed that no report was made to the required authorities regarding the witnessed sexual abuse, resulting in a failure to protect residents and comply with mandated reporting requirements.

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