F0607

D

Failure to Follow Abuse Policy and Fully Investigate Repeated Sexual Abuse Allegations

Alhambra, Illinois Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its abuse policy in preventing, reporting, and investigating multiple allegations of possible sexual abuse involving one resident. The resident was admitted with diagnoses including hypertension with heart failure, dementia, narcolepsy, chronic respiratory failure, primary osteoarthritis, and was documented as severely cognitively impaired with a self-care deficit. Hospital records noted that a family member reported the resident had always been mentally slow and did not like to be touched. Despite this condition and vulnerability, the facility did not consistently treat staff reports of concerning interactions between the resident and a family member as abuse allegations requiring full investigation and reporting.

In one prior incident, a CNA reported entering the resident’s room and observing the family member quickly moving his hands away from the resident’s lap/stomach area on two occasions, which made the CNA uncomfortable. This incident was reported to the Social Services Director and Administrator, who notified the Ombudsman, Medical Director, local police, and the resident’s POA. The facility’s investigation concluded that no abuse occurred, based on the CNA’s statement that she did not actually see inappropriate touching. In a separate incident, two CNAs reported that when they entered the resident’s room to obtain vitals, the family member jumped, grabbed an electronic device, told them to come back later because they were busy, and was again observed standing over the resident with his hands down by her wheelchair, jumping when they entered. Police, Adult Protective Services, the Medical Director, POA, and Ombudsman were notified, and both external agencies stated there was no evidence of abuse; the facility deemed the allegation unfounded.

Later, additional staff reports in December described further concerning observations that were not handled in accordance with the facility’s abuse policy. One CNA stated she entered the room to get a mechanical lift and saw the family member standing next to the bed with one leg on a chair and the resident’s shirt pushed up below her breasts; the family member was rude, said they were playing cards, and told her she did not need to be there. She reported this to the Administrator and wrote a statement, but the Administrator later stated she never received the written statement. Another CNA reported seeing the family member with his leg up on the resident’s wheelchair, pant leg up to his thigh, wearing nylon shorts, and jumping back anxiously when she entered; she reported this to the Business Office Manager. The Administrator and Business Office Manager acknowledged being told that the family member had his leg on a chair and jumped back when staff entered, but stated they were told no body parts were exposed. They did not initiate a formal investigation, did not verify or preserve the date and time of the video footage shown on the family member’s personal device, and did not report the December concerns as abuse allegations, despite the facility’s policy and state rules requiring immediate reporting of suspected abuse or reasonable suspicion of a crime against a resident.

The facility’s abuse policy requires that any employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation, or misappropriation immediately report it to the Administrator, and that the Administrator or designee report abuse to the state agency per state and federal requirements. Nursing Home 1150B Rules and Regulations further require all employees to report any reasonable suspicion of a crime committed against a resident by calling 911 or the county sheriff. In the December incidents, the Administrator and Business Office Manager relied on unverified video footage from the family member’s personal cell phone, did not confirm the recording’s date or time, did not conduct or document a complete investigation, and did not treat the staff reports as reportable abuse allegations. These actions and omissions demonstrate the facility’s failure to implement its abuse prevention, reporting, and investigation policies for this resident.