F0600

K

Failure to Protect Cognitively Impaired Residents From Repeated Resident-to-Resident Sexual Abuse

Moline, Illinois Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect cognitively impaired residents from sexual abuse by another resident with a known pattern of sexually inappropriate behaviors. One resident (R4), who had moderately impaired cognition, a history of hypersexual behavior, and was able to self-propel in a wheelchair, repeatedly engaged in sexual contact with other residents who were severely cognitively impaired and dependent on staff for ADLs. On 11/22/25, R4 took a glove from a nurse’s cart while in a hallway on B wing and placed her gloved hand on another resident’s (R7) vaginal area, fondling her labia. Staff separated the residents, but R4’s care plan was not updated to address this sexual behavior, and no interventions were added to prevent further sexual abuse. R7’s care plan, which identified her as low risk for abuse despite dementia with depression and anxiety, was also not updated with interventions to protect her from sexual abuse.

On 2/10/26, while in the dementia unit, R4 again engaged in sexual abuse, this time toward a male resident (R5) who had severe cognitive impairment and required assistance with ADLs. During the evening medication pass, staff observed R4 wheeling herself quickly toward R5, then placing her whole hand inside his pants and undergarments, touching his penile area. Staff immediately separated the residents, and R4 became upset and yelled that she wanted to return to R5. The incident was reported to the ADON, and R4 was reportedly placed on 1:1 supervision. However, R4’s care plan was not revised to address this sexual behavior, and R5’s care plan, which later documented him as moderate risk for abuse due to poor cognition, did not include interventions related to the sexual abuse incident or measures to protect him from further sexual abuse.

On 3/11/26, R4 again sexually abused another male resident (R6), who had severe cognitive impairment, Alzheimer’s dementia, bipolar disorder, and was identified in his care plan as high risk for abuse due to dementia and mental health diagnoses. During an activity in the common area, R4 and R6 were seated side by side in wheelchairs when staff observed R4’s hand in R6’s groin area, moving toward his private area in an up-and-down tapping motion. R4 loudly expressed sexual intent, stating she wanted to have sex with R6 and would do whatever she wanted. Staff immediately separated them, and R6 appeared wide-eyed and looking around as if for help. Despite this incident and R4’s known pattern of hypersexual behavior, R4’s care plan still did not include interventions addressing her sexual behaviors, and R6’s care plan, although identifying him as high risk for abuse, had no interventions to address the sexual abuse or to protect him from further sexual abuse.

Across these incidents, staff interviews confirmed that R4 had been hypersexual, touching other residents in their private areas and making sexually explicit statements to other residents. The DON acknowledged awareness that R4 had inappropriately touched residents in the dementia unit. The Dementia Director/Social Services stated that when abuse occurs, a trauma assessment should be done immediately to assess emotional and psychological impact and provide supportive interventions, but no trauma assessments were completed for R7, R5, or R6 at the time of their respective incidents. The physician reported he was not made aware of the sexual abuse incidents involving R4 and the other residents until 3/13/26. The Regional Director of Operations stated that the care plans for R4, R7, R5, and R6 should have been updated when the incidents occurred to ensure proper interventions were in place. The facility’s own Abuse, Neglect and Exploitation policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required protection of residents’ health, welfare, and rights, but the facility failed to implement timely care plan updates and protective interventions following repeated episodes of resident-to-resident sexual abuse.

These failures resulted in an Immediate Jeopardy situation beginning on 11/22/25 when R4 first sexually abused R7 and continuing through subsequent incidents involving R5 and R6. The surveyors determined that the facility did not protect residents from sexual abuse, did not promptly assess for trauma, did not notify the physician in a timely manner, and did not revise care plans or implement effective interventions despite clear evidence of ongoing sexually aggressive behavior by R4 toward severely cognitively impaired residents.