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F0600
D

Failure to Protect Residents from Sexual Abuse and Inappropriate Contact

Chicago, Illinois Survey Completed on 09-24-2025

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 policy to ensure residents are free from sexual abuse, as evidenced by multiple observations and interviews involving inappropriate sexual contact between residents and between staff and residents. One resident, a man with schizoaffective and bipolar disorder who is moderately cognitively intact, was reported by another resident to have groped a female resident, who is cognitively intact, despite her expressing that she did not like the behavior and had told him to stop. Another resident and a staff member confirmed witnessing or hearing about these inappropriate interactions, with the staff member indicating that such behavior was sometimes consensual and sometimes not. The staff member also minimized the seriousness of the behavior, attributing it to typical male conduct rather than recognizing it as potentially abusive. Additionally, the surveyor observed a staff member, an activity aide, patting the same female resident on the rear in a playful manner, which the Director of Nursing acknowledged as inappropriate and unprofessional. The care plan for the male resident included counseling on appropriate sexual behavior and the need for consent, but interventions such as redirection were not documented in the care plan. The facility's abuse policy affirms residents' rights to be free from abuse, including sexual abuse, but the policy was not effectively implemented in these cases, resulting in residents being subjected to unwanted physical contact.

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