F0600

D

Failure to Prevent Sexual Abuse by Staff and Physical Abuse Between Residents

Nashville, Illinois Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The facility failed to protect a severely cognitively impaired resident from sexual abuse by an employee. The resident, who had vascular dementia with behavioral disturbance and multiple other medical conditions, required substantial to maximal assistance with transfers. According to the facility’s abuse investigation reports, an activity director reported to the administrator that a unit aide kissed this resident on the mouth/lips in her room. The aide admitted in his statement that he kissed the resident once on the lips. The facility’s investigation, including interviews with staff and residents, concluded that the incident did occur and substantiated that the resident was subjected to sexual abuse.

The facility also failed to prevent physical abuse between residents when one resident threw a cup of coffee on another resident. One resident, who was cognitively intact, independent with ADLs, and had diagnoses including end stage renal disease, COPD, major depressive disorder, diabetes, and anxiety disorder, reported that another resident had previously harassed him. On the day of the incident, the aggressor resident went outside, yelled at the cognitively intact resident, then returned to his room. When the cognitively intact resident came back inside and passed the aggressor’s room, the aggressor opened his door and threw coffee on him, after which the cognitively intact resident pushed the aggressor in the chest with open hands. The incident was witnessed, residents were separated and assessed, and no injuries were noted. These events occurred despite the facility’s written policy affirming residents’ rights to be free from abuse and describing measures intended to prevent abuse and mistreatment.