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F0609
D

Failure to Report Alleged 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 facility failed to report an allegation of sexual abuse involving a resident with severe cognitive impairment and dependent mobility. The incident occurred when a certified nursing assistant (CNA) observed another resident, who had a history of inappropriate contact, with his hand inside the dependent resident's diaper while she was seated in her wheelchair. The CNA immediately informed an LPN, who then notified the facility administrator. Despite being notified, the administrator did not report the allegation to authorities, stating that nothing had happened. The resident who was the subject of the allegation had diagnoses including frontal lobe and executive function deficit following cerebral infarction and unspecified psychosis, and was documented as severely cognitively impaired. The care plan for this resident did not address risk of abuse or neglect. The facility's own abuse prevention policy requires prompt reporting and investigation of abuse allegations, but this protocol was not followed in this case. The incident was later reported to local police by an anonymous caller, not by the facility.

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