F0610

J

Failure to Prevent, Investigate, and Report Staff-to-Resident Sexual and Verbal Abuse

Galesburg, Illinois Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect two residents from staff-to-resident sexual and verbal abuse, to implement safety interventions and adequate supervision, and to promptly investigate and report allegations of abuse to the State Agency. One resident had a plenary guardian due to physical and mental conditions that rendered her unable to manage her person or property or make responsible decisions, and her record lacked any evaluation of her capacity to consent to sexual activity. Despite this, a dietary aide began engaging in boyfriend/girlfriend-type texting, video chatting, and sexually inappropriate communications with her while employed at the facility, including messages expressing love, wanting to get her pregnant, and plans to remove her from the facility. Staff, including the dietary manager, psychosocial rehabilitation coordinator, CNA, and administrator, became aware over time that the aide was spending excessive time with the resident, was texting and video chatting with her, and was attempting to have an intimate relationship, yet the aide was allowed to resign without an abuse investigation or report to the State Agency, and no care plan interventions or supervision measures were implemented to protect the resident.

The resident later reported to the administrator and police that the former dietary aide sexually assaulted her on at least three Sundays in a church parking lot, describing non-consensual intercourse, being lured into the aide’s vehicle, feeling woozy after eating food he provided, blacking out, and waking up alone before attending services. Her guardian, who had been told by the administrator that the aide had resigned due to growing feelings for the resident, stated that she had previously informed the facility that the aide was trying to have a sexual relationship with the resident and that this constituted exploitation, and she expected the facility to keep the resident safe and to report the aide’s conduct to the State Agency. The guardian later learned from a van driver that the resident had been sneaking around with the aide at church for weeks and reported that the resident admitted to having intercourse with the aide while he was working at the facility. The resident’s psychotherapy notes documented ongoing stress, fear of the aide approaching her when not with staff or family, night tremors, and a desire to leave town to feel safer, and she told the surveyor she had asked the aide to stop, that the encounters were not consensual, and that she had reported the rapes to both the police and the administrator.

The facility also failed to protect the resident’s roommate from verbal abuse and exposure to sexually explicit conduct by the same former staff member and failed to investigate and report these allegations. The roommate reported witnessing the resident and the former aide engaging in sexual conversations and acts via phone video on multiple occasions and stated that when she asked them to stop, the aide cursed at her, called her derogatory names, and threatened that she would get her “a** kicked,” causing her to feel abused and worried. The psychosocial rehabilitation coordinator documented the roommate’s report of sexually inappropriate conversations and acts on video and the aide’s profane verbal abuse, and stated this was reported immediately to the administrator; however, there was no documentation of an abuse investigation, no final report submitted to the State Agency, and no updates to the roommate’s care plan to address safety from the aide’s threats. Additionally, when the resident reported in an emergency department visit that she had been physically assaulted by two other residents, the facility did not initiate an immediate investigation or submit a final report to the State Agency, and the administrator later acknowledged he had not started an investigation into that allegation even after receiving the hospital records. These combined failures led to an Immediate Jeopardy determination related to the ongoing access and exploitation by the former dietary aide and the lack of timely investigation and protective interventions for both residents.

Removal Plan

• Initiate an abuse investigation into R3's abuse allegation and submit the initial report to IDPH, with a final report to follow.
• Initiate an abuse investigation into R3's abuse allegation and submit the initial report to IDPH, with a final report to follow.
• Initiate an abuse investigation into R3 and R6's abuse allegations and submit the initial report to IDPH, with a final report to follow.
• Complete assessments of R3's capacity to consent to sexual relations with involvement of R3's plenary guardian, physician, and psychiatrist.
• Continue evaluating R3's capacity to consent to sexual relations and implement precautions to keep R3 safe.
• Develop a plan to ensure R3 has staff supervision while using facility phones to ensure safe communication with others.
• Update R3's care plan with interventions to increase R3's safety.
• Hold an emergency QAPI meeting and develop and implement plans to ensure no further abuse occurs within the facility and all policies and procedures are followed correctly.
• Review the facility's abuse policies through the QA committee prior to educating staff.
• Review the facility's staff intimate relationships policy through the QA committee.
• Educate all staff on abuse prevention, abuse reporting, and all abuse-related policies and procedures.
• Educate the administrator on the facility's Abuse, Neglect and Exploitation Policy and compliance with reporting allegations of abuse, neglect, and exploitation to IDPH.
• Educate all staff on maintaining professional boundaries with residents and that staff are not to have any inappropriate relationship with residents.
• Update R3 and R6's care plans with safety interventions to protect them from abuse.