F0600

J

Failure to Protect Resident From Sexual Abuse and Inadequate Abuse Investigation

Long Grove, Illinois Survey Completed on 03-10-2026

Penalty

Fine: $158,650

Summary

The deficiency involves the facility’s failure to protect a resident from sexual abuse by a CNA. The cognitively intact resident, who required staff assistance for most ADLs and used a wheelchair, reported that on a night shift the CNA who routinely put her to bed and provided incontinence care climbed into her bed around 9–10 PM, lay sideways on top of the comforter, rubbed the side of her breast through the blanket, and made sexually inappropriate comments including that she could be his girlfriend, “you know you want it,” and “come on honey.” The resident stated she repeatedly told him to stop, to get out, and to leave her room. She reported that the night before this incident the CNA had been “way too friendly,” which led her to anticipate further inappropriate behavior.

The resident reported the incident to the Social Services Director at the end of February, telling him what had happened. The Social Services Director acknowledged that when the resident began to describe an issue involving her chest, he stopped her, focused only on the fact that it involved her breasts, and immediately contacted the Administrator, without listening to or retaining the full details of her report. The Administrator then spoke with the resident by phone; the Administrator’s documentation and interview reflect that the allegation was characterized as the CNA touching the resident’s breast during routine ADL/peri care while she was on the edge of the bed, and the facility’s written incident report framed the allegation as occurring during routine care and described the resident’s interview as “inconsistent.” The facility’s investigation concluded the allegation was unsubstantiated, and the CNA denied any inappropriate touching, stating he only repositioned the resident during care and asserting that she sometimes said things that were not true.

Another cognitively intact resident reported that she was on the phone with the abused resident during the incident and heard the male CNA making sexual remarks such as “come on honey” while the resident repeatedly told him to quit, go away, and get out of her room; she stated no one from the facility had interviewed her about what she heard. The abused resident’s sister reported that the resident, whom she described as of sound mind and normally very talkative, became unusually quiet and withdrawn, and later disclosed that the CNA had “jumped into bed” with her and rubbed her breast, and that another person told her “don’t start anything, we will take care of it.” The sister stated the resident was embarrassed and fearful at night and that she had been told the CNA was moved to a memory floor. The resident’s husband confirmed that his wife told him a CNA had gotten into bed with her. Facility records showed that prior to the surveyor’s investigation, the resident’s care plan had been revised to describe her as having “socially inappropriate behavior” and a history of telling different stories to different staff, despite no documented history of false abuse allegations, and the facility’s abuse policy required immediate protection of residents and prompt, aggressive investigation of all abuse reports, including sexual abuse such as sexual harassment, coercion, or assault.

Law enforcement later interviewed the resident and the phone witness; the deputy summarized that the resident reported the CNA jumped into bed with her, said she could be his girlfriend, and touched the sides of her breasts, while the other resident reported hearing the CNA fall into the bed, attempt to kiss the resident, and persist in making sexual remarks and pushing for relations while the resident said no. Staff familiar with the resident, including an RN and the Social Services Director, described her as alert, oriented, and without behaviors, and similarly described the phone witness as alert, oriented, and a reliable historian. Despite these consistent accounts and corroborating witness information, the facility’s internal documentation continued to characterize the allegation as unsubstantiated and did not reflect that the phone witness had been interviewed as part of the initial investigation. These actions and omissions resulted in the facility’s failure to protect the resident from sexual abuse by a staff member and to fully and accurately investigate and respond to the allegation in accordance with its abuse policy.