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F0600
J

Failure to Protect Non-Verbal Resident from Sexual Abuse

Edwardsville, Illinois Survey Completed on 10-21-2025

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

A deficiency occurred when a facility failed to protect a non-verbal, severely cognitively impaired resident from sexual abuse by another resident. The first incident took place when a CNA observed a male resident with his hand inside the female resident's diaper in a public area. The CNA intervened, removed the male resident, and reported the incident to two LPNs. However, the incident was not reported to law enforcement or the Department, and no immediate interventions were implemented to prevent further contact between the two residents. The following day, the same male resident entered the female resident's room, pulled down her brief, applied shaving cream to her, and stated his intent to have sex. Staff discovered the male resident in the female resident's room with his pants down and shaving cream on his hands. The female resident was found lying in bed, non-responsive, with shaving cream on her buttock. The male resident was subsequently sent to the hospital for evaluation, but prior to this, he was not placed under enhanced supervision and was able to move freely throughout the facility. The female resident involved was non-verbal, unable to communicate, and severely cognitively impaired, making her unable to consent to any sexual activity. The male resident had a documented history of inappropriate contact with peers and staff, and his care plan reflected this risk. Despite this, the facility did not implement measures to prevent further abuse after the initial incident, nor did they promptly report the abuse as required by policy. The failure to act resulted in a second incident of sexual abuse the following day.

Removal Plan

  • V1 and V2 were in-serviced on abuse and neglect by V41
  • Department heads were in-serviced on abuse and neglect policy and procedure by V1
  • 24 hour reports were reviewed
  • 24 hour report audits were initiated
  • Interviews with staff members were initiated to ensure staff know who to report abuse and neglect to
  • Root cause analysis was completed for abuse and neglect
See complete original report
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