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F0835
F

Unlicensed Administrator and Failure to Investigate and Report 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 employ a licensed administrator, as required, to ensure the protection of all residents from abuse, proper investigation and reporting of abuse allegations, and the provision of mandatory staff training. The individual acting as Administrator was hired without evidence of a bachelor's degree or a temporary or permanent administrator's license. This individual admitted to not having the required qualifications and did not receive a temporary license at any time during their tenure. The facility's records also showed that staff did not receive required annual in-service trainings, including the 12-hour CNA training, QAPI, behavioral health, infection control, and compliance and ethics program trainings. Multiple staff members reported that the acting administrator failed to investigate and report a witnessed incident of sexual abuse between two residents. Staff described the administrator as attempting to minimize or cover up the incident, altering witness statements, and failing to notify the state agency, police, or resident representatives. Staff also reported a lack of direction from the administrator regarding the separation of the involved residents. The Director of Nursing confirmed the absence of required staff trainings, and several staff members expressed concerns about the administrator's truthfulness and intimidating behavior.

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