F0610

K

Failure to Thoroughly Investigate Sexual Abuse Allegation and Restrict Alleged Perpetrator

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

Penalty

Fine: $158,650

Summary

The deficiency involves the facility’s failure to thoroughly investigate and substantiate an allegation of sexual abuse made by a cognitively intact resident, and the failure to restrict the alleged perpetrator’s access to residents during and after the investigation. One resident (R1), who was admitted with multiple medical diagnoses including COPD, Type 2 diabetes, major depressive disorder, heart disease, and overactive bladder, required extensive physical assistance with ADLs and used a wheelchair. R1 had no cognitive impairment, no documented behaviors, and no history of making false allegations. At the end of February, R1 reported to the Social Services Director (V3) and then to the Administrator (V1) that a CNA (V4) had touched her breast during care a couple of days earlier. V3 acknowledged that when R1 began to describe an incident involving her chest, he stopped her from continuing, did not obtain full details, and focused only on notifying the Administrator. V1 documented a telephone interview with R1 in which R1 stated that during a brief change, V4 touched her breast while repositioning her, that she told him to stop, and that he stopped. V1 also interviewed V4, who denied any inappropriate touching.

On 3/7/26, during the survey, R1 provided a more detailed account of the incident, stating that about a week earlier, around 9–10 PM, V4 got into bed with her, lay sideways on top of the comforter, rubbed the side of her breast through the blanket, giggled, and made repeated sexual comments such as that she could be his girlfriend and that she wanted it. R1 reported that she told him to get out and leave her room. She stated that she had anticipated not being believed and therefore called her friend and fellow resident R2 on the phone when V4 came into the room so R2 could hear the interaction. R1 reported that she had told V3 exactly what she later told the surveyor, but that V3 had told her not to talk about it and that the facility would handle it. R1 also stated that after the incident she was moved to another room and staff ensured V4 was not assigned to her, but that he continued to work in the facility.

R2, who also had no cognitive impairment or behaviors documented in her assessment and no history of making false allegations, corroborated R1’s account by describing what she heard over the phone. R2 stated she heard a male CNA, identified as V4, making sexual remarks, calling R1 “honey,” laughing, and repeatedly pressuring her while R1 told him to quit, said no, and told him to get out. R2 reported that no one from the facility had interviewed her about what she heard. R1’s sister (V7) and husband (V6) both reported that R1 had disclosed that a CNA had gotten into bed with her and touched her breast, and V7 stated that R1 was of sound mind, became unusually quiet and withdrawn after the incident, and was fearful at night about who was working on the floor. A local sheriff’s deputy (V8) confirmed that R1 reported that V4 jumped into bed with her, said she could be his girlfriend, and touched the sides of her breasts, and that R2 reported hearing V4 over the phone making inappropriate sexual remarks and trying to kiss R1 while R1 said no.

Despite these reports, the facility’s written investigation, completed on 3/2/26, concluded that the allegation was unsubstantiated. The investigation documentation stated that R1’s interview was inconsistent, that V4 denied the allegation, that R1’s roommate denied any incidents with V4, and that other residents and staff reported feeling safe and denied inappropriate behavior. The documentation also stated that V4 was “not on the schedule” and therefore not suspended, and that he was not scheduled until March 2, 2026, when his next shift began at 7:00 PM. However, the facility’s daily schedule showed that V4 had worked on 2/26/26, a couple of days before the allegation, and that after the investigation was marked complete and unsubstantiated on 3/2/26, V4 returned to work his scheduled shifts on 3/2/26, 3/3/26, 3/5/26, and 3/6/26 with access to all residents. During a later interview, the DON (V2) characterized the situation as “he said she said,” referenced both R1 and R2 as having behaviors and psychiatric consults, and suggested the allegation was suspicious in light of media reports about abuse at another facility, despite both residents being described elsewhere as alert, oriented, and reliable historians. The surveyors determined that the facility failed to thoroughly investigate the abuse allegation, failed to interview the identified witness R2 in a timely manner, and failed to substantiate the allegation, resulting in the alleged perpetrator continuing to have access to all residents.

The Immediate Jeopardy was determined to have begun when R1’s initial report of sexual abuse was made to V3 and V1 on 2/28/26, and continued while V4 remained on the schedule and worked multiple shifts after the facility had documented the investigation as completed and unsubstantiated. The facility’s abuse policy required immediate protection of residents involved in reports of possible abuse and prompt, aggressive investigation of all allegations, including sexual abuse defined as sexual harassment, sexual coercion, or sexual assault. In this case, the facility did not obtain or document a complete initial account from R1, did not promptly interview the identified witness R2, and relied heavily on V4’s denial and generalized resident interviews to conclude the allegation was unsubstantiated. As a result, the alleged perpetrator was allowed to continue working with access to all 93 residents in the facility until the Immediate Jeopardy was addressed on 3/10/26.