F0600

J

Failure to Prevent Sexual Abuse by Resident With Known Inappropriate Behaviors

Danville, Illinois Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from sexual abuse by another resident with known sexually inappropriate behaviors. One resident with Alzheimer’s disease, prior transient ischemic attacks, altered mental status, muscle weakness, difficulty walking, and a documented risk for abuse had previously been identified as an alleged victim of sexual abuse by the same perpetrating resident, who had touched her breasts in past incidents. This prior incident was serious enough to have been cited on a previous CMS Form 2567, and the resident’s care plan had been revised to reflect her status as an alleged victim of abuse. Despite this history and the resident’s inability to formulate relevant responses to questions, the facility did not prevent further sexual contact from occurring.

Another resident with dementia, depression, pseudobulbar affect, reduced mobility, anxiety, lack of coordination, bipolar disorder, and a care plan indicating risk of abuse was also involved. This resident’s diagnoses list later included confirmed adult sexual abuse. On the day of the incident, a housekeeper observed that this resident, who resided alone, had a second wheelchair in her room. Upon entering, the housekeeper saw the perpetrating resident with his hand in the resident’s diaper area while the resident lay on the bed without a diaper. A CNA who had provided care 15–20 minutes earlier reported that at that earlier time the resident’s undergarment had been fastened and she was covered with a sheet, but when she returned after the report, the sheet was pulled aside, the undergarment was unfastened exposing the genital area, and the resident was tearful. A nurse who responded to the report stated she observed the perpetrating resident’s finger inside the resident’s vagina.

The perpetrating resident had a documented history of sexually inappropriate behavior and criminal offenses. His care plan noted that he wandered aimlessly throughout the facility, inappropriately touched other residents and staff, and made inappropriate comments. His diagnoses included high-risk heterosexual behavior, schizoaffective disorder bipolar type, and moderate vascular dementia with agitation. During an interview, he admitted to touching a woman’s vagina in her room and stated he believed she wanted him to touch her. A family member of another resident reported witnessing this same resident poking his finger into the private area of the first cognitively impaired resident while both were in wheelchairs in the dining room and intervened by moving his wheelchair. Facility leadership, including the DON and Administrator, confirmed that the two victim residents did not have the cognitive capacity to consent to sexual activity. The facility’s own policies defined sexual abuse as any nonconsensual sexual contact of any kind with a resident, including unwanted touching of the perineal area and all types of sexual assault, and committed the facility to implement policies to prevent all types of abuse. Despite these policies and the known history and care plan information, the facility did not prevent the resident with known sexual behaviors from making sexual contact with the two cognitively impaired residents.

Removal Plan

• R5 was placed on one-to-one continuous supervision.
• R5 was assessed by an emergency room provider, Social Services V4, and a psychotherapy provider.
• R4 received a head-to-toe nursing assessment by Registered Nurse V22.
• R6 received physician notification and medical evaluation by Nurse Practitioner V9.
• R5 received physician notification and medical evaluation by Nurse Practitioner V9.
• R5 received a psychosocial assessment and emotional support by Social Services V4.
• R4 received a psychosocial assessment and emotional support by Social Services V4.
• R6 received a psychosocial assessment and emotional support by Social Services V4.
• Families/responsible parties for R5 and R6 were notified by Social Services V4.
• R4's family/responsible party was notified by Social Services V4.
• Law enforcement and state reporting requirements were completed for R5 and R6 by Administrator V1.
• Law enforcement and state reporting requirements were completed for R4 and R5 by Administrator V1.
• R6 was transferred to the hospital for evaluation and relocated to the south building upon return.
• A facility-wide resident assessment for abuse risk was conducted by Social Services V15, Care Plan Coordinator V37, Director of Nursing V2, and Assistant Director of Nursing V3.
• All-staff in-service training for abuse prevention was conducted by Administrator V1, Director of Nursing V2, Assistant Director of Nursing V3, and Social Services V4.
• The Abuse Prevention Policy was reviewed by Administrator V1, Director of Nursing V2, and President of Clinical Operations V33 to ensure inclusion of defined staff response steps and immediate Director of Nursing and Administrator notification.