F0600

J

Failure to Protect Resident From Staff Sexual and Verbal Abuse and to Assess Capacity for Sexual Consent

Galesburg, Illinois Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident with a plenary guardian from staff-to-resident sexual abuse, failure to assess the resident’s capacity to consent to sexual activity, and failure to protect residents from staff-to-resident verbal abuse. The facility had an Abuse, Neglect, and Exploitation policy prohibiting all forms of abuse, including sexual and verbal abuse and abuse facilitated through technology, and an employee union agreement that specified discharge for any employee maintaining or attempting to maintain a sexual or romantic relationship with a resident. Despite these policies, a dietary aide (V7) developed and pursued a personal, romantic, and sexual relationship with a resident (R3) who had a court-appointed plenary guardian due to inability to manage her person or property and lack of capacity to make and communicate responsible decisions. The facility did not complete or document any evaluation of R3’s ability to consent to sexual activity in her electronic health record and did not incorporate her guardianship status or consent capacity into her care plan.

R3’s medical and psychosocial history included Borderline Personality Disorder, ADHD, Major Depressive Disorder (including with severe psychotic symptoms), Anxiety Disorder, suicidal ideation, and impaired social interaction. Her care plan documented that she frequently spoke with, texted, or called men, became easily emotionally involved, made poor decisions related to the opposite sex, manipulated situations and staff to leave the building unsafely, used her cell phone to manipulate men online to pick her up, and made false accusations. However, the care plan was not updated after the facility became aware of sexually inappropriate conversations and video nudity via electronic communication between R3 and V7, nor after the guardian restricted R3’s contacts to specific family and staff. The IDT noted that R3 required assistance to think logically about safety and was at risk of exploitation or abuse related to smartphone and social media use, and recommended supervised phone use with the smartphone secured at the nurses’ station, but these interventions were not added to the care plan.

The facility also failed to protect R3 and her roommate (R6) from ongoing inappropriate and abusive interactions involving V7. Progress notes documented that R6 complained about R3 getting completely naked in the room with the door and curtain open while talking or videoing on social media, and a behavior note recorded that R6 reported R3 engaging in sexual conversation with a male on a call, during which the male (identified as V7) cursed at R6 and called her names when R6 asked them to stop. Text messages later obtained from R3’s phone showed ongoing personal, romantic, and sexually explicit communication between R3 and V7, including expressions of love, plans for a future together, and explicit sexual content. The facility’s own abuse investigation and a police report documented that R3 reported at least three non-consensual sexual encounters with V7 in his vehicle in a church parking lot during church services, involving forced intercourse, episodes of feeling woozy or blacking out after consuming food or a pill provided by V7, and threats of harm if she disclosed the events. Although the facility’s QAPI/QAA documentation referenced immediate protection measures and increased supervision for R3, these measures were not incorporated into her care plan, and sign-in/sign-out sheets for community outings did not consistently document who accompanied her, allowing continued unsupervised contact with V7 in the community and ongoing verbal abuse toward R6.

The facility’s handling of V7’s employment further contributed to the deficiency. V7 had received multiple in-services on abuse prevention, sexual abuse, personal boundaries, and the facility’s abuse policy, yet he was allowed to resign due to “growing feelings for a resident” without the incident being treated and reported as abuse or exploitation at that time. The guardian reported being told by the Administrator that V7 left on his own and that the facility did not have to complete paperwork or report to the state agency, despite the guardian’s assertion that V7’s conduct constituted exploitation and that R3 could not consent to a relationship. After V7’s resignation, R3 continued to attend church services in the community without staff supervision, and the van driver and a nurse reportedly knew R3 had been “sneaking around” with V7 at church. The facility’s root cause analysis acknowledged that R3 attended church with no staff supervision, met V7 there, and left services to go to the parking lot with him, where sexual relations were reported, yet the care plan and supervision practices were not adjusted in a timely or effective manner to prevent further abuse or protect R3 and R6 from staff-to-resident sexual and verbal abuse.