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F0609
D

Failure to Immediately Report Alleged Sexual Abuse and Notify Law Enforcement

Chicago, Illinois Survey Completed on 10-28-2025

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 implement its abuse prohibition policy by not immediately reporting an allegation of staff-to-resident sexual abuse to the abuse coordinator and by failing to notify local law enforcement of a suspected crime. A resident with a history of mood disorder, schizoaffective disorder, bipolar disorder, major depressive disorder, and generalized anxiety disorder was admitted for therapy following knee surgery. On the evening of admission, the resident alleged that a male CNA performed inappropriate and non-consensual touching during personal care, including touching her genital area and breast, and attempting to kiss her. The resident reported these actions to a nurse the following morning and also communicated the incident to her social worker via text messages. Multiple staff members became aware of the resident's allegations at different times, but failed to follow the facility's abuse policy requiring immediate reporting to the administrator and law enforcement. The night shift nurse, morning nurse, and wound care nurse each received information about the alleged abuse, but did not promptly report it as required. Some staff expressed disbelief in the resident's account due to her psychiatric history, and others admitted not knowing the reporting requirements or failing to act due to the time of day or personal judgment. The administrator was eventually informed by the wound care nurse, but this was not immediate, and the facility did not report the incident to police, citing the resident's refusal, despite policy requiring such reporting. The facility's abuse policy, consistent with federal guidelines and the Social Security Act, mandates immediate reporting of all allegations or suspicions of abuse to the administrator and law enforcement, especially in cases of sexual abuse. The policy specifically defines sexual abuse to include unwanted touching of the breast or perineal area and requires notification of law enforcement within a specified timeframe. The failure to adhere to these procedures resulted in a delay in both internal and external reporting of the alleged abuse, contrary to established protocols.

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