F0610

J

Failure to Thoroughly Investigate and Protect Cognitively Impaired Resident From 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 conduct thorough investigations into multiple allegations of sexual abuse and to protect a cognitively impaired resident from potential further abuse during and after those investigations. The resident, admitted with diagnoses including hypertension with heart failure, dementia, narcolepsy, chronic respiratory failure, and osteoarthritis, was documented as severely cognitively impaired and unable to consent to sexual advances. Hospital records and family statements indicated the resident had always been mentally slow and did not like to be touched. Despite this vulnerability, the facility did not implement protective measures after repeated staff reports of concerning interactions between the resident and a family member.

The first allegation occurred when a CNA reported feeling uncomfortable after 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. The written investigation from the Administrator and Social Services Director concluded no abuse occurred, relying largely on the family member’s explanation that he was startled and holding a computer, and did not document any protective interventions or assessment of the resident’s vulnerability. Later interview with the CNA revealed additional details not included in the investigation, including that the resident’s shirt was lifted exposing her breast, that the resident would not have been able to expose herself, and that the family member intervened quickly when staff attempted to adjust the resident’s clothing. No additional staff statements or corroborating documentation were included in the investigation.

A second documented allegation involved staff observations of the same family member positioned very close over the resident, with the resident’s wheelchair reclined and the family member reacting abruptly when staff entered, including jumping up and requesting privacy. A dietary aide’s written statement indicated she saw the family member’s hands under the resident’s blanket and that he jumped up quickly when she entered, causing a pillow to fall. In interviews, staff described not being able to see the family member’s hands, the resident appearing shocked and jumpy, and reports that the resident cried after the family member’s visits and seemed not to want to be touched. These details, including the aide’s observation of the arm under the blanket, were not reflected in the facility’s written investigation, which the Administrator and Business Office Manager confirmed as complete.

Additional allegations arose in December when a CNA reported entering the room and seeing the family member with one leg on a chair and the resident’s shirt pushed up below her breasts, with the family member stating they were playing cards and telling the CNA to leave. The CNA stated he wrote a report and left it at the nurse’s desk, and another CNA confirmed being told of this incident but did not report it herself. The Administrator and Business Office Manager acknowledged being told about the leg-on-chair incident and viewing video footage from the family’s personal camera on the family member’s cell phone, but they did not initiate a formal investigation, did not verify the date or time of the footage, and relied on the video and the family member’s denial to decide not to investigate further. Another CNA later reported seeing the family member with his leg up on the resident’s wheelchair, wearing nylon shorts, jumping back and pulling his pant leg down when she entered, and appearing very anxious; she reported this to the Business Office Manager. Throughout these events, the facility did not initiate thorough investigations, did not consistently collect and reconcile staff statements, did not verify or preserve objective evidence, and did not implement care plan interventions or protective measures to keep the resident safe from further potential abuse.

The facility’s abuse policy required immediate reporting of suspected abuse to the Administrator and mandated that the Administrator or designee report abuse to the state agency per state and federal requirements, and that employees report reasonable suspicion of a crime against a resident to law enforcement. Despite this, the Administrator stated she did not begin a sexual abuse investigation when informed by the surveyor because she did not know who it involved, and acknowledged that the investigations from the earlier dates were the complete investigations. The resident’s care plan, updated shortly before the survey, addressed self-care deficits but did not include any potential for abuse or interventions to keep the resident safe. Law enforcement later indicated that a staff member reported seeing the family member drop his pants and have his penis in the resident’s face and stated that the facility needed to take action and remove the family member and find a new POA. The surveyors determined that Immediate Jeopardy began with the first allegation and that the facility failed to protect the resident from further allegations of abuse and failed to conduct thorough investigations into four separate sexual abuse allegations involving the same family member.