Failure to Timely Report Staff-to-Resident Sexual Exploitation and Other Abuse Allegations
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Report Allegation of Verbal Abuse: A resident with HTN, anxiety disorder, and hyperlipidemia reported that a staff member yelled at her during resident council. Facility records showed a nurse aide was disciplined and retrained on communication, but the allegation was not included in the abuse reports submitted to the State. The DON confirmed the required report was not filed.
Failure to Timely Report Alleged Abuse: The facility did not report an allegation of abuse involving a cognitively intact resident with stroke, coordination, and anxiety diagnoses to HHSC within the required 2-hour timeframe. The resident alleged that an CNA had bullied her during a smoke break, and the Administrator acknowledged the report should have been made within 2 hours but was not submitted until later that day.
Failure to Report Allegations of Verbal Abuse and Involuntary Seclusion: The facility did not report multiple grievances involving an RN and an LPN to the SA, including resident complaints of rude and disrespectful comments, yelling, scolding, and blocking residents from entering their rooms when they tried to self-transfer. Documentation showed incomplete grievance investigations, delayed administrator sign-off, and no timely reporting of the allegations as verbal abuse or involuntary seclusion.
A resident reported being frightened after another resident repeatedly entered the room, grabbed belongings, and acted aggressively, but the concern was not reported to the SA within 2 hours. In a separate incident, a cognitively intact resident returned from the ER with a minor labial tear/perineal laceration and minimal bleeding, yet the DON and administrator did not treat it as reportable abuse or an injury of unknown source and did not investigate it.
A facility failed to report an alleged mistreatment during a resident’s hair grooming to the State Agency within the required timeframe. The resident had dementia, depression, severe cognitive impairment, and was dependent on staff for grooming and hygiene. Records showed a matted area of hair was removed, leaving a reddened scalp, and staff later described the event as an abuse allegation that should have been reported.
Failure to Timely Report Injury of Unknown Origin: A resident with dementia and multiple medical diagnoses developed unexplained right elbow swelling, redness, warmth, and pain, later found to be a dislocation with fracture. An LPN notified the NP, DON, and family and a STAT x-ray was ordered, but the initial report to IDPH was not made within the required two-hour timeframe after the injury of unknown origin was identified.
Failure to Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to submit a report of an allegation of verbal abuse involving one resident. Facility policy stated that all allegations of abuse must be reported immediately to the Administrator and the applicable State agency, and verbal abuse was defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms. Review of the resident’s record showed diagnoses including hypertension, anxiety disorder, and hyperlipidemia. Resident council minutes documented that the resident told staff that a staff member had yelled at her, and facility investigation documents showed a disciplinary action for a nurse aide related to the incident along with retraining on effective communication. The allegation was discussed in resident council, but the grievance documentation did not show a related grievance and the reported incidents submitted to the State did not include the verbal abuse allegation. During interviews, the Activities Director stated the incident happened and that the Director of Human Resources spoke with the aide, while the Director of Human Resources did not recall retraining or discussing the allegation. The resident stated the matter had been taken care of and that she had cursed the aide back. The DON confirmed that the facility failed to submit the required report of the verbal abuse allegation.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving Resident #80 was reported to HHSC within the required timeframe. Resident #80 was a female resident with diagnoses including cerebral infarction (stroke), lack of coordination, and anxiety disorder. Her quarterly MDS indicated she could make herself understood and understand others, and her BIMS score was 15/15, showing she was cognitively intact. Her care plan noted a behavior problem with interventions to protect the rights and safety of others, speak in a calm manner, divert attention, and remove her from the situation as needed. Record review showed the allegation involving Resident #80 was learned about at 1:00 p.m. on 08/03/2026, but it was not reported to HHSC until 5:04 p.m. the same day. The provider investigation report stated Resident #80 alleged that CNA P had bullied her sometime during the prior week, around 6:30 p.m. during a smoke break, though she could not recall exactly what was said or the setting. During an interview, the Administrator stated he initiated the investigation at 1:00 p.m. and acknowledged the allegation should have been reported within 2 hours. CNA P stated she was not the resident’s assigned CNA and said she had helped push Resident #80’s wheelchair after a smoke break when the resident accused her of trying to push her out of the wheelchair.
Failure to Report Allegations of Verbal Abuse and Involuntary Seclusion
Penalty
Summary
The facility failed to report allegations of verbal abuse and threats of involuntary seclusion involving an RN and an LPN to the State Agency. One grievance involved a resident who reported the LPN was rude, stern, and spoke in a manner the resident felt was not nice. During the related interview, the LPN acknowledged making comments about the resident not taking direction well from women and said her word choice was not the best, while the concern was addressed only as unprofessional communication and education on professional conversation was documented. The administrator did not sign off on the report until months later, and there was no report made to the State Agency. A second grievance involved a resident who reported hearing the RN yelling loudly at another resident and then entering the resident’s room and saying she did not like him and that he was not a good patient. The RN denied yelling and said she was reminding the resident to ask for help. The resident who heard the exchange later stated she had no concerns about how the RN treated her, and the resident who was the subject of the yelling said he felt safe and that staff were treating him well. The grievance documentation did not identify the yelling as an allegation of verbal abuse, and it was not reported immediately to the State Agency or the administrator at the time it occurred. A third grievance involved a resident who reported the RN told her she was going into a time-out and said, "you don't know what you are doing," which made the resident feel inadequate. Additional interviews and an email described multiple residents being upset by the RN’s tone, yelling, and blocking residents from entering their rooms when they attempted to self-transfer. Staff described the RN as assertive and bossy, and one staff member reported the RN stood in front of a resident’s door and scolded him while preventing him from entering. The grievance record contained incomplete interviews, blank resolution and follow-up sections, and no indication that the allegations of verbal abuse or involuntary seclusion were reported to the State Agency as required.
Failure to Report Suspected Abuse and Unexplained Injury
Penalty
Summary
The facility failed to immediately report suspected resident-to-resident abuse to the state agency within 2 hours for a cognitively intact resident who reported being scared of another resident. The resident stated that the other resident had entered the room multiple times during the night, grabbed belongings, snarled at the resident, and left the room. Nursing documentation also showed the resident placed a walker in front of the door on two nights to keep the other resident out and stated, "I'm scared to death of him." The DON was notified of the situation, and staff interviews confirmed the concern was treated as a resident-on-resident altercation with possible abuse, but no state report was made because the facility did not believe it reached the level of potential abuse. The other resident involved had moderate cognitive impairment, vascular dementia with agitation, and Alzheimer's disease. The MDS indicated this resident paced and wandered daily and significantly disrupted the care or living environment of other residents. Progress notes described frequent roaming into other residents' rooms and frequent agitation toward staff and residents. During interviews, staff stated that any nursing staff could file a vulnerable adult report, and the DON acknowledged that a resident-on-resident altercation with concerns of abuse should be reported to the state agency within 2 hours of learning about it. The facility also failed to report and investigate a resident's unexplained perineal injury as potential sexual abuse or an injury of unknown source. The resident was cognitively intact, frequently incontinent, and required substantial to maximum assistance with activities of daily living and peri care. After an emergency room visit, the resident was found to have a very minor labial tear/abrasion at the 12 o'clock position with minimal blood present, and the AVS listed a diagnosis of laceration to the perineum. Staff asked the resident whether anyone had been rough or abusive during care, and the resident denied abuse. The DON and administrator stated they did not consider the injury reportable because they believed it was similar to a prior situation and did not feel the injury of unknown origin needed to be reported or investigated.
Failure to Report Alleged Mistreatment During Hair Grooming
Penalty
Summary
The facility failed to ensure an alleged mistreatment during grooming and hygiene was reported to the State Agency within two hours for one resident. The resident had diagnoses of dementia and depression, and a quarterly assessment showed a BIMS score of 3, indicating severe cognitive impairment. The assessment also showed the resident was dependent on staff for grooming and hygiene. A Concern/Grievance Report documented that a mat of hair was removed from the back of the resident’s head and a reddened area was noted afterward. A nurse’s progress note the same day stated the resident’s scalp was red and irritated and that the resident did not want to get up. The facility’s investigation records showed no documentation that the allegation of mistreatment during hair grooming was reported to the State Agency. During interviews, staff stated the resident had a matted area of hair that was brushed out, after which the resident was heard hollering in pain, and the administrator later stated the matter should have been reported as an abuse allegation.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its Injury of Unknown Origin Policy and did not report an injury of unknown origin within two hours of the incident to IDPH for one resident. The resident was 95 years old and had diagnoses including dementia with mood disturbance, major depressive disorder, anxiety disorder, Alzheimer's disorder, dislocation of the right ulnohumeral joint, essential hypertension, overactive bladder, and chronic kidney disease. Records and interviews showed the resident's right elbow became swollen, red, warm, and hard to touch, and the resident was yelling that the arm was broken. An LPN assessed the resident, gave pain medication, notified the NP, DON, and family, and a STAT x-ray was ordered. The x-ray results were received later that evening, and the resident was sent to the hospital early the next morning, where hospital documentation showed arrival at 7:11 AM and a diagnosis of right elbow dislocation with mildly displaced fracture of the tip of the coronoid and olecranon process. The Administrator stated the initial IDPH report was sent at 8:08 AM the following morning, but also stated the report should have been sent on the day the swelling was first identified because the source was unknown. The facility policy stated that any injury with an immediately undetermined cause, including swelling, fractures, and unexplained pain or tenderness, is to be treated as an injury of unknown origin, and the abuse policy required immediate reporting of reasonable suspicion of a crime against a resident, not later than two hours after the allegation when serious bodily injury results.
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