F0610

J

Failure to Separate Alleged Perpetrator After Initial Sexual Abuse Allegation

Danville, Illinois Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to separate an alleged perpetrator of sexual abuse from other residents after an initial allegation, resulting in a second sexual assault. A family member visiting a resident in the dining room reported witnessing a male resident in a wheelchair intentionally poking his finger into the private area of a female resident who was also in a wheelchair. The family member stated she had to move the male resident’s wheelchair to stop the contact and then informed a CNA when the CNA entered the dining room. The family member reported that, because both residents were in wheelchairs, the contact could not have been accidental and she believed the act was intentional.

After receiving the report from the family member, the CNA stated she directed the alleged perpetrator to go down the hall to his room and then left the area to remove her coat. During this time, the male resident was not supervised. While the CNA was away, a housekeeper observed the same male resident in a female resident’s room, with the female resident lying in bed and the male resident touching her in her diaper area; the housekeeper clarified that the female resident was not wearing her diaper. The housekeeper reported this to the CNA and an LPN. When the CNA arrived at the second resident’s room after this report, she observed that the LPN was already removing the male resident from the room and that the female resident’s bed sheet was pulled to the side, her incontinent undergarment was unfastened exposing her genital area, and she was tearful.

The LPN who responded to the second incident stated she observed the female resident in bed with her bed sheet pulled to the side, her incontinent undergarment unfastened, and the male resident’s finger inside the female resident’s vagina. The facility’s Abuse, Neglect and Exploitation policy required immediate steps to protect alleged victims, including room and staffing changes to protect residents from an alleged perpetrator, and mandated that staff respond immediately to protect alleged victims. The administrator stated he expected staff to take steps to prevent further abuse, including immediately removing the resident from the incident and not contacting him until the situation was under control, and confirmed that facility policy required staff to remove the perpetrator from the incident. Despite prior abuse prevention in-service training for the involved staff, the male resident was left unsupervised after the first allegation and was able to access and sexually assault another resident, leading to a determination of immediate jeopardy.

Removal Plan

• R5 was placed on one-to-one continuous supervision pending full investigation.
• R5 was assessed by an emergency room physician.
• R5 was assessed by Social Services V4.
• A psychiatric evaluation was requested by Assistant Director of Nursing V3 and completed by Psychotherapist V49.
• R6 was assessed for injury, trauma, and psychosocial needs by Registered Nurse V22 and Social Services V4.
• R4 was assessed for injury, trauma, and psychosocial needs by Registered Nurse V22 and Social Services V4.
• Families and responsible parties of R5 and R6 were notified by Social Services V4.
• R4's family/responsible party was notified by Social Services V4.
• Law enforcement and required state agencies were notified per mandatory reporting requirements by Administrator V1.
• A room change was completed to ensure separation of R5 and R6, and R6 was later moved to the south building upon return from emergency room evaluation.
• All-staff in-service training for abuse prevention was conducted by Administrator V1, Director of Nursing V2, and Assistant Director of Nursing V3.
• Administrator V1, Director of Nursing V2, and President of Clinical Operations V33 reviewed the Abuse Prevention Policy to ensure inclusion of a clear step-by-step response protocol following any allegation, mandatory immediate separation of the alleged perpetrator, and immediate notification of the Administrator and Director of Nursing.
• A facility-wide risk assessment for abuse involving Social Services V15, Care Plan Coordinator V37, Director of Nursing V2, and Assistant Director of Nursing V3 was completed.