F0609

J

Failure to Timely Report Staff-to-Resident Sexual Exploitation and Other Abuse Allegations

Galesburg, Illinois Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately report multiple allegations of abuse, neglect, and exploitation to the State Agency, local police, and the Administrator as required by policy. The facility’s Abuse, Neglect, and Exploitation policy required all alleged violations to be reported immediately, but not later than two hours, when the events involve abuse or result in serious bodily injury, and within 24 hours for other events. Despite this, when the Administrator became aware in June that a dietary aide was attempting to initiate a personal or romantic relationship with a resident who had a plenary guardian due to disability and lack of capacity to make responsible decisions, the Administrator did not notify the State Agency or local law enforcement. The aide resigned after the Administrator reviewed text messages showing boyfriend/girlfriend-type communications and the aide’s desire for a relationship and to get the resident pregnant, but no report was made at that time.

The resident involved in this staff-to-resident situation had been adjudicated a disabled person in need of a plenary guardian of person and estate, with the guardian authorized to make residential decisions and protect the resident’s best interests. The guardian reported being told by the Administrator that the aide had resigned and that the facility did not have to report the matter to the state health department. The guardian stated that she informed the Administrator that the aide’s conduct constituted exploitation and that the state needed to know an employee was trying to have a sexual and boyfriend-girlfriend relationship with her disabled daughter. Staff interviews and documentation showed that the psychosocial rehabilitation coordinator and the prior dietary manager both observed or were informed that the aide was spending excessive time with the resident, expressing romantic feelings, and sending messages such as “I love you” and wanting to get the resident pregnant. A CNA also reported seeing the resident video chatting with the aide at night, and another CNA reported several evenings of sexually explicit video chatting between the aide and the resident, which she said she reported to nurses.

The facility also failed to immediately report other abuse allegations involving the same resident and her roommate. On one date, progress notes documented that staff spoke with the resident after the roommate complained that the resident was completely naked in the room with the door and curtain open while talking or videoing on social media with a male. On another date, a behavior note documented that the roommate reported the resident was engaging in sexual conversation via video with a male, identified as the former dietary aide, and that when the roommate asked them to stop, the aide cursed at and called the roommate names. The psychosocial rehabilitation coordinator stated she reported this to the Administrator, but there was no evidence these allegations of sexual exploitation by video or the verbal abuse and threats toward the roommate were reported to the State Agency or local police. The roommate later stated she had watched the resident and the aide having sex on the phone several times and that the aide repeatedly yelled at and threatened her when she asked them to stop, and she reported feeling abused and worried.

In addition, the facility did not timely report an allegation of resident-to-resident physical abuse involving the same resident. Emergency department notes documented that the resident presented with suicidal ideation and reported being physically assaulted by two other residents the previous day. The Administrator acknowledged learning of this allegation only after receiving the hospital records months later and confirmed that, as of the survey, he had not notified the local police or State Agency regarding this allegation. The police report and the facility’s own abuse investigation later documented that the resident reported multiple instances of non-consensual sexual contact by the former dietary aide in a church parking lot on Sundays, including episodes where she described feeling woozy and blacking out after eating food provided by the aide. The Administrator did not notify the State Agency or local police about the aide’s initial attempts to initiate a personal relationship with the resident while employed, and the police and State Agency were not notified about the sexual relations at church until several days after the guardian reported the situation to facility staff.

The Immediate Jeopardy was determined to have started when the Administrator first became aware that the aide was engaging in behavior indicating an attempt to initiate a personal or romantic relationship with the resident and failed to report this to the police or State Agency. This failure coincided with ongoing sexually inappropriate conversations and video nudity by electronic communication between the aide and the resident, which were not reported. The facility’s records and staff interviews showed that, during this period, there was no documented evaluation of the resident’s capacity to consent to sexual activity in the electronic health record, and staff reported they were never informed whether the resident could consent to sexual relationships or that she required supervision. The combination of unreported staff-to-resident sexual exploitation, unreported staff-to-resident verbal abuse toward the roommate, and unreported resident-to-resident physical abuse formed the basis of the cited deficiency for failure to timely report suspected abuse, neglect, and exploitation.

Removal Plan

• V7 resigned from the facility.
• V1 initiated an abuse investigation into R3's abuse allegation and notified IDPH; a final report will follow.
• V1 initiated an abuse investigation into R3's abuse allegation and notified IDPH; a final report will follow.
• V1 initiated an abuse investigation into R3 and R6's abuse allegations and notified IDPH; a final report will follow.
• V1 initiated an abuse investigation, notified IDPH, and notified the local police regarding R3's abuse allegation.
• V5 completed assessments on R3's capacity to consent to sexual relations with the involvement of V3, V35, and V36.
• The facility is evaluating R3's capacity to consent to sexual relations and implemented precautions to keep R3 safe.
• The facility developed a plan to ensure R3 has staff supervision while using the facility phones to ensure safe communication with others.
• V3 removed R3's phone and restricted R3's church visits.
• R3's care plan was updated with interventions to increase R3's safety.
• V26 reviewed all residents to ensure no residents suffered from past abuse.
• The Quality Assessment and Assurance Committee met for an emergency QAPI meeting and developed and implemented plans to ensure no further abuse occurred within the facility and all policies and procedures were followed correctly.
• The facility's abuse policies were reviewed by the QA committee prior to educating staff.
• The facility's staff intimate relationships policy was reviewed by the QA committee.
• V1, V2, and V38 educated all staff on abuse prevention, abuse reporting, and all abuse-related policies and procedures.
• V25 educated V1 on the facility's Abuse, Neglect and Exploitation Policy and compliance with reporting allegations of abuse, neglect, and exploitation to IDPH.
• V1, V2, and V38 educated all staff on maintaining professional boundaries with residents and that staff are not to have any inappropriate relationship with residents.
• R3 and R6's care plans were updated with safety interventions to protect them from abuse.