Facility I.D. Number: 0037341
307 E. Jefferson
Sullivan, Illinois 61951
Date of Survey: 12/14/1999
The facility shall provide all services necessary to maintain each resident in good physical health. These services include, but are not limited to, the following:
Residents shall be provided with nursing services, in accordance with their needs and which shall include, but are not limited to, the following: The Health Services Supervisor's participation in:
An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident.
Based on observation, file verification and interview, the facility neglected to ensure that individuals of the facility are protected from sexual, physical and psychological abuse, with potential to affect 16 of 16 individuals who were residents of the facility on 08/06/1999.
Based on interview and review of facility documents, the facility neglected to investigate injuries of unknown origin for 2 of 2 non-verbal females with Profound Mental Retardation.
I. The facility did not pro-actively assure that R1, R2, R3, R4, R5, R6, R7, R8, R9, ZZ1, ZZ2, ZZ3, ZZ4, ZZ5, ZZ6 and ZZ7 were free from sexual, physical and psychological abuse as per the following examples:
A) Injuries of unknown origin were not investigated for ZZ4 and ZZ5.
ZZ4 and ZZ5 are females with Profound Mental Retardation and are non-verbal.
A review of incident reports for ZZ4, (dated 02/05/1998, 06/15/1999, 07/14/1999) indicate bruises on ZZ4's legs, upper thighs and forearms. Confirmed per E1 and Z27 (08/25/1999) that ZZ4's bruises were not further investigated.
On 08/02/1999 ZZ4 was again observed with significant bruises on the inside of both of her upper thighs. ZZ4's bruises were not investigated by the facility until 08/07/1999 (after a complaint was registered with the Department and entered with the facility on 08/06/1999).
Confirmed per E1 and Z27 on 08/25/1999.
On 08/12/1999 ZZ4 was taken to see a gynecologist (Z6) by Z2. Z6 wrote in her report the following: The patient (ZZ4) was examined by (Z23) about three years ago, and at that time, the introitus and hymen seemed to be virginal, and she was unable to insert a pediatric speculum." At the 08/12/1999 visit, the following is noted by Z6: "Introitus, a notch is present about 7 o'clock on the hymenal ring, which appears to be a well healed laceration...Introitus easily admits two fingers. Small speculum is inserted without difficulty and the cervix is visualized...Inspection of the perianal area reveals bruising, both posteriorly and anteriorly....The pelvic examination appears to have changed from when (Z23) examined the patient three years ago. We are able to insert fingers into the vagina without difficulty at this point. The bruising around the anus may be due to trauma, it seemed more than one would see if this was just due to hard bowel movements. The patient takes a stool softener daily anyway, so I doubt that hard stools would be a problem. The examination is consistent with sexual abuse. With the visualization of the bruising on the right thigh, I would also anticipate that physical abuse has also occurred."
A review of the 10/24/1996 gynelogical completed by Z23 stated that, "introitus is unremarkable...vagina showed normal vaginal rugae...there was not noted to be any unusual abnormalities or scarring or etc. The examination was a totally normal examination."
Per interview with Z2 on 12/08/1999, Z2 stated that ZZ4, (since her admit and subsequent discharge from the facility - 11/18/1991 - 08/10/1999), had spent all of her nights at the facility and had never been on overnight visits outside of the facility.
Per additional interviews with E8 (10/21/1999), E5 (10/19/1999), E4 (10/19/1999), E3 (10/19/1999), E12 and Z5 (10/20/1999), Z8 (08/27/1999), E9 (10/15/1999) and E7 (10/15/1999), all concur that ZZ4 engaged in either "itching" behaviors or "masturbating" behaviors. Additionally, all of the above individuals interviewed had never seen ZZ4 use her fingers to enter her vaginal or anal area. Z8 specifically stated that ZZ4 used an, "external type", of masturbation and basically used a,"flat hand". All individuals interviewed concurred that they had never seen any bleeding or excoriations created by ZZ4's itching or masturbation behaviors, and none had ever seen ZZ4 insert objects into her vagina or rectum or engage in any other behaviors that would cause damage to ZZ4 internally.
Per interviews with Z4 (08/26/1999), E4(08/25/1999), E6 (10/21/1999), Z5(10/20/1999) and E7 (10/15/1999), all concur that ZZ4 had never been observed to create bruises on the back of her thighs per her sitting behavior (pulling knees up to chest, with back of heels resting on upper thighs).
Per interview with E12 (10/20/1999) and E9 (10/15/1999), both concur that ZZ4 did often have large, hard stools, but did not observe rectal bleeding or bruising in the perianal area. E1 and Z27 also stated that ZZ4 did not become bruised in the anal area from her stools, that, "maybe some redness" would result, but no bruising. Nurses notes do not reflect any problems with ZZ4's bowel movements and E13 (on 08/27/1999) confirmed that he had not been made aware of any significant problems with ZZ4's bowel movements.
Additionally, interviews with Z11 (08/26/1999), Z24 (08/06/1999), Z3 (08/06/1999), and Z8 (08/06/1999), all concur that ZZ4 had experienced increased crying in recent past months and increased resistance in exiting the bus at the end of the day. Z11 specifically noted increased crying for ZZ4 when taken to the bathroom (seemed to escalate in 04/1999). ZZ4 would shrink back and put her arms up and hide her face. These observations were also communicated to the facility.
On 08/06/1999, surveyor rode the bus home from day training to the facility. When Z24 took ZZ4's hands and said, "Come on (ZZ4)", ZZ4 pulled away. Z25 then tried to assist ZZ4 to standing by guiding her legs to the outside aisle of the bus. ZZ4 again pulled away. Continued efforts by Z24 and Z25 were of no success.
E1 and Z27 then entered the bus with a gait belt and E1 instructed staff to get some cookies for ZZ4. ZZ4 still refused to leave her seat. A two person assist with gait belt also failed, as ZZ4 continued to refuse to move from her seat. Kool-aid was offered, with no success. Z24 then suggested letting ZZ4 ride the bus back to the day training site. When ZZ4 arrived back at the day training site, Z3 entered the bus, offered ZZ4 her hand, which ZZ4 immediately accepted and exited the bus. E1 and Z27 had arrived in the facility van to take ZZ4 back to the facility.
The facility failed to investigate ZZ4's bruises of unknown origin and failed to further investigate ZZ4's changing behaviors.
Additional example for ZZ5, whose bruises of 02/03/1998 and 07/01/1999 chin laceration, which resulted in sutures, was not investigated as to origin of injury (The hospital report states that the laceration was 1¼ inches in length and that 5 sutures were required for the laceration).
B. R3 does not currently, and has not had since admission, specific training regarding his roles and responsibilities in male/female relationships. Additionally, the facility admitted R3 to the facility without providing special precautions and/or increased supervision for R3, with regards to his documented sexual inappropriateness.
R3 is a 31 year old male who was admitted to the facility on 04/08/1997. R3 has a diagnosis of Moderate Mental Retardation, is ambulatory and verbal. Per file verification and confirmed per Z27 (08/11/1999), R3 was admitted to the facility while on probation, as R3 was convicted of Aggravated Criminal Sexual Abuse (Class A - victim less than 18 years of age) on 05/13/1996.
Per documentation provided by the facility on 08/06/1999, the facility provided residential services to other individuals as follows:
10 females - 4 of whom have Profound Mental Retardation; l with Severe Mental Retardation and 5 with Moderate Mental Retardation. 3 of the females are non-verbal and another is verbal, but exhibits significant expressive/receptive language impairments.
5 males - l who has Mild Mental Retardation; 1 with Moderate Mental Retardation; and 3 with Profound Mental Retardation - 2 of whom are non-verbal and 1 with a history of being sexually abused.
A review of R3's facility records indicates that R3 has a history of sexual inappropriateness with females as follows:
1) Prior to facility admission, R3 was convicted of molesting his niece (13 years old at the time). R3 was found unfit to stand trial and was sent to Chester Mental Health Center for treatment and was subsequently sentenced to 2 years probation for Aggravated Criminal Sexual Abuse (per a 05/13/1996 Client Supervision Record).
A police report dated 03/01/1995 also refers to allegations of R3's inappropriate sexual activity with a 4 year old male and a 3 year old female (relatives of R3).
2) Per review of Universal Notes for R3 the following was documented on 04/02/1997 (R3 was admitted to the facility on 04/08/1997 and on 04/02/1997 was only visiting the facility): "(Z5) was checking the living room for residents and observed (R3's) hand up a females shirt laying on her breast. As soon (as) they saw staff they both went to their own room on their own."
3) Per review of a document entitled, "Individual Client Contact Notes", dated 03/17/1999, the day training site had informed R3's residential facility that on 03/17/1999 a female consumer had informed Z8 that R3, "...had put his hand down another female consumer's shirt yesterday while sitting at a picnic table...she also said (R3) had wanted to kiss the other female consumer but the other female consumer had refused."
Per further review of the document, Z8 talked with the female consumer who verified that R3 had put his hand down her shirt and had, "rubbed" her.
When Z8 asked if this was okay with her, she stated, "no". The consumer further stated that R3 had asked for a kiss, but she had told him not to.
Per the report, Z8 told R3 that she needed to speak with him after lunch. R3 responded that he would make sure nothing happened again (before Z8 told him what she wanted to speak with him about). R3 confirmed later the same day that he had put his hand on her (consumers) chest and knew he shouldn't have done this and knew he could be in trouble with probation.
A handwritten note at the end of the report, also dated 03/17/1999 by Z27, stated that R3 also confirmed with her that the above described events, "...did happen the way this note states."
Per interview with R3 on 10/21/1999 in the presence of Z26, R3 stated that he, "can't remember", when asked about the above related incident.
4) Per interview with R2 on 08/11/1999 (a female with Moderate Mental Retardation and is verbal), R2 stated that R3, "touched me on the boobs last summer" (could not give a specific date). R2 stated that R3 used, "both hands...outside...on porch...". R2 further stated that she had told her parent of the incident and thinks that her parent called Z27. R2 stated that she was not to be alone with R3.
Per interview with Z9 (on 08/27/1999), Z9 confirmed that R2 had related to her the same information, that R3 had, "touched her boobs...last summer."
Per interview with R3 on 10/21/1999 in the presence of Z26, R3, stated, "No, I have not...I stayed away from her....". R3's voice began to raise as he shook his head side to side in a horizontal manner and began waving his hand in a horizontal side to side manner. At that time Z26 instructed R3 to just answer the surveyors questions.
5) A 04/23/1999 report of sexual inappropriate behavior was completed with regards to the behavior of R3 while working at a recycling center (offsite employment sponsored by the day training site). Per a summary report completed by Z27, there were allegations that R3 had been observed, "fondling himself several times while working on the line and that the last time he (R3) had taken his penis out of his pants while working on the line."
Per a handwritten note dated 04/08/1999 and signed by Z19, it states that on the above date R3 was, "rubbing his croch (crotch) and playing with himself - also on April 5th, had it in his hand." Per interview with Z19 on 12/03/1999, Z19 stated that two employees of the recycling center (Z20 and Z21) had come to her (Z19, who was line crew supervisor at the time), having witnessed the above behavior of R3. Z19 stated that she did not actually witness R3's alleged behavior, only wrote up the 04/08/1999 report and gave it to manager of the recycling center.
Reports generated by the facility and day training site document that other consumers on the line were interviewed, however there is no reproducible evidence that Z20 and Z21 were interviewed. The facility generated report (signed by Z27) states that, "After speaking to R3's co-workers and the manager of (the recycling center), who confirmed that the line crew supervisor (Z19) may have embellished the facts of her report to him, it is concluded that this inappropriate behavior did not occur."
A 04/01/1995 psychological evaluation for R3 states that, "he (R3) should not be left alone with young children...that (R3) will need to be supervised constantly throughout his life...but his behavior can be maximized in a positive direction if he is properly managed behaviorally."
On 04/04/1997 a facility document entitled "Pre-Admission Evaluation", page 3, under "Capacity for Independent Living", notes the deficits in major life areas for R3:
laundry (physical assistance required), money (problems with anything over $1.00), cooking - all skills; "sexual ed., - no knowledge".
The last sentence of the evaluation stated that the needs of R3 can be met by the facility and is signed by E1, Z27 and 2 other staff, who were employees of the facility on that date.
A review of evaluations/assessments by facility consulting staff reveal the following recommendations:
4/3/97 psychological - "...supportive services should include assistance to (R3) in attending probation meetings and recommended counseling sessions which are related to previous legal charge. He should be supervised closely in all community and home settings."
R3 has not, since admission, received specific training regarding his roles and responsibilities in male/female relationships; and, R3 was admitted to the facility without providing increased precautions and/or increased supervision for R3 with regards to his documented sexual inappropriateness. Confirmed per E1 on 10/28/1999.
II. ZZ4's 02/05/1998, 06/15/1999 and 07/14/1999 bruises of unknown origin were not investigated; and, ZZ4's 08/02/1999 bruises of unknown origin were not investigated until a formal complaint was initiated.
ZZ4 is a 30 year old female with Profound Mental Retardation, is ambulatory and non-verbal. ZZ4 also has Convulsive Epilepsy and Constipation. Per an 08/12/1999 report from Z6 (who is a gynecologist), ZZ4 has been sexually abused (hymenal laceration, perianal bruising and probable physical abuse).
Per review of facility documents entitled, "Incident Reports" and "Individual Client Contact Notes", the following information is documented for ZZ4:
02/05/1998 - "Bruised spots were noticed on (ZZ4's) upper right leg today when staff took her (ZZ4) to the restroom...the spots appeared to be finger marks...called (Z27) at (facility) to report our findings." (Report is from day training site.)
06/15/1999 - 8:30 a.m. - "RSD came in to work and noticed that (ZZ4) had a bruise on her R (right) leg above her knee. It is unknown how or where this bruise came from."
07/14/1999 - 6:15 p.m. - "On 07/14 staff was bathing (ZZ4) and noticed she had 2 bruises - l above and l below her rt. (right) elbow and one on her left forearm - it is unknown as to how or where she got them."
08/02/1999 - 8:40 a.m. - "Staff were getting (ZZ4) ready for workshop when they noticed bruising on the inside of both of her upper thighs. The bruises seem to coincide with the heels of her shoes." Under "comments" - "looks as if she (ZZ4) was bruised from the heel of her shoes. Pulling her feet up quickly towards her bottom."
An Accident/Illness Report was also sent to the facility (from the day training site) on 08/05/1999 concerning ZZ4's bruises.
Per review of the 1998 incident report, the 06/15/1999 and 07/14/99 incident reports, there is no reproducible documentation that the facility investigated ZZ4's bruises of unknown origin. Confirmed per E1 and Z27 on 08/25/1999.
On 08/05/1999 a complaint was registered with the Illinois Department of Public Health (IDPH) regarding ZZ4's bruises of 08/02/1999. Surveyor presented the Nature of Complaint Form to Z27 on 08/06/1999 at approximately 1:00 p.m.
Per the 08/02/1999 incident report under, "Follow Up Sent" - "Over", the back side of the report has an 08/07/1999 date with the following documentation:
"Staff supervisor was giving (ZZ4) a bath tonight when she called RSD, UD and ADM down to the bathroom. She showed us the bruises and then showed us the bottom of (ZZ4's) shoes and the lines thru the bruises matched the bottom of ZZ4's shoes exactly. Then the UD said she has seen ZZ4 sitting on the couch w/ (with) her feet underneath her with the shoes being in the exact spot that the bruises are."
There is no reproducible documentation per the 08/02/1999 incident report, that the facility staff/day training staff of residents were interviewed, or that further investigation ensued until after the 08/05/1999 complaint was entered with the facility. Confirmed per E1 and Z27 on 08/25/1999.
Per a facility document entitled, "Alleged Resident Abuse Report Form", and dated 08/07/1999 interview with residents, facility staff and day training staff were completed. The report was faxed to the Department on 08/09/1999 at 2:45 p.m.
Per surveyor observations on 08/06/1999, file verification (as far back as 1995) and per interviews with E1, Z27, E3, E4, E5, E6, Z3, Z4 and Z5, it was confirmed that ZZ4 has a long time habit of pulling her legs up to her chest when she sits down, with heels touching/resting on the back of her thighs. All of the individuals interviewed above have never seen ZZ4 bruise herself from sitting in this position.
The facility failed to investigate injuries of unknown origin for ZZ4 and failed to ensure that information relevant to the incident was obtained and considered.
III. ZZ5's 07/11/1999 cut on chin, (of unknown origin), which required sutures, was not investigated.
ZZ5 is a 26 year old female with Severe Mental Retardation, is non-verbal and ambulatory. ZZ5 has an additional diagnosis of Anxiety and a history of biting herself and others.
Per review of a facility document entitled, "Unusual Incident Report", which is dated 07/01/1999, the following information is noted for ZZ5:
At approximately 6:20 p.m. staff, "was in the med. (medication) room and heard (ZZ5) begin crying. Staff went to check her and (ZZ5) was just going into her room...when (ZZ5) turned, staff saw she had blood on her hands and chin and a cut on her chin." (The hospital report states that the laceration was 1¼ inches in length).
ZZ5 was taken to the hospital emergency room, where she received treatment and 5 sutures for the chin laceration.
Further review of the report states, "pos (possible) fall", with location of incident, "unknown." There is no reproducible evidence that the cause of ZZ5's injury was investigated by the facility, nor that further interviews with staff and residents were completed. Confirmed per E1 on 10/26/1999.
On 10/15/1999, E7 stated to surveyor that ZZ5 probably had cut her chin on her bed, as ZZ5 has a habit of sitting on her bed and bouncing (also observed by surveyor). E7 further stated that ZZ5 would pull her box springs out from under the mattress at the foot of the bed, creating a gap at the head of the bed. ZZ5 would bounce so hard that the head board was broken and there was also damage to the wall. E7 stated that ZZ5, when finished, would push the mattress back into position, and E7 thinks that ZZ5 cut her chin in that manner. E7 showed surveyor dried blood on the foot end of ZZ5's box springs and stated that there was also blood on the carpet at the foot of ZZ5's bed after the 07/01/1999 cut. E7 stated that the facility had secured the box springs so that ZZ5 could no longer continue to move them.
E3 (on 10/19/1999) related the same information as E7, concerning ZZ5's chin cut, stating that ZZ5 had probably sustained her chin cut in this manner.
Per interview with Z7 on 10/21/1999, Z7 stated that she had never been informed as to the possible cause of ZZ5's chin cut and would have expected to have such information related to her, even if it was only a theory.
Additional example for ZZ5 on 02/03/1998 when ZZ5 was found crying in her room at 8:00 a.m. ZZ5 had a, "large bruise on her left front forehead." There is no reproducible documentation that the origin of ZZ5's bruise was investigated.
The facility failed to investigate ZZ5's 07/01/1999 chin laceration, which resulted in the need for 5 sutures.
IV. Additional example for R3, who on 04/23/1999, allegedly engaged in inappropriate sexual behavior while at his work training site. There is no reproducible documentation that the actual witnesses to R3's alleged behavior were interviewed; and the facility report concluded that inappropriate behavior did not occur.
Z27 confirmed that all of the information presented to surveyor on 08/13/1999 concerning the 04/23/1999 incident, was all of the information/interviews concerning the incident.
V. ZZ4 did not receive nursing services in accordance with her needs, with regards to her significant bruises first observed on 08/02/1999.
On 08/12/1999, ZZ4's gynelogical exam was consistent with sexual abuse.
Review of facility incident reports indicate that on 08/02/1999 at 8:40 a.m., ZZ4 was observed by facility staff to have bruising on the, "inside of both of her upper thighs." The report documents that the facility (Z27) was notified at 8:40 a.m. and that the consulting nurse was notified at 9:00 a.m. There is no reproducible documentation that ZZ4 was evaluated further for her bruises until 3:45 p.m. when the incident report states that (Z27), "looked at the bruises while (ZZ4) was sitting in a chair outside with her feet up in the chair (after exiting the bus) that brought her home from the day training site.
Per Z1 (on 08/06/1999), Z1 stated that she was notified of ZZ4's bruises and that pictures were taken of the bruises at the day training site on 08/05/1999, prior to ZZ4's lunch and that ZZ4's bruises were measured after ZZ4's lunch (approximately 1:00 p.m.). Per Z1, a total of four bruises were measured.
Per facility nursing notes dated 08/08/1999, Z10 writes that on 08/05/1999, E8 asked Z10 to help her, as ZZ4 did not want to get up from the couch to take her medication. Per the note, Z10 went to the living room and saw ZZ4 sitting with her feet on the couch, pulled up against the back of her thighs, knees in the air, with arms wrapped around her legs. Z10 noted the purple bruises on the back of her thighs.
Per interview with Z10 on 10/29/1999, Z10 confirmed that she did not assess ZZ4's bruises until 08/05/1999 and did not pursue any further assessment of ZZ4 on 08/05/1999 to look for other areas of bruising/trauma on ZZ4's body. Z10 was again in the facility on 08/08/1999 and noted that she attempted to look at ZZ4's bruises again, but was not able to, as ZZ4 had on long pants and refused to get up from her chair, and no further attempt was made to assess ZZ4's bruises.
Per review of ZZ4's current IPP (07/09/1999), ZZ4 had the following programs:
intervention for sitting down
go to medication door for medications
eating - slow down
A review of facility documentation (Universal Notes, Communication Log between facility and day training) notes the following:
04/02/1999 (Communication Log - day training to facility) - "(ZZ4) went to the bathroom 4X today but has been going into the bathroom and coming out (without) her clothes."
05/03/1999 "(ZZ4) went to the bathroom 3X's today and stripped her clothes off (waist down) and just sat on floor."
05/04/1999 - "(ZZ4) came out of the bathroom 4X's today naked and stood in the bathroom door way naked."
05/25/1999 - "(ZZ4) had her pants down several X's today."
05/26/1999 - "(ZZ4) took her pants off 2X's this AM...".
Per facility Universal Notes -
05/26/1999 - "...in living room when she (ZZ4) pulled her shorts and underwear off...an hour and half later...found (ZZ4) in hallway with pants down and underwear."
06/09/1999 - 8:50 a.m. - "...(ZZ4) in womens end...with her pants off...".
Assessments for ZZ4 indicate the following:
Maladaptive Assessment Summary for 07/10/1999 - "...inappropriate removing clothing 5-8 times daily."
Maladaptive Behavior Assessment of 07/10/1996 - "...undresses at the wrong time - daily; takes off all clothing while on toilet - daily."
Sexuality Assessment of 06/27/1997 - "...takes off all clothing - while on toilet 2-3 times weekly."
Sexuality Assessment of 07/02/1998 - "undresses at the wrong time - daily."
Maladaptive Behavior Assessment of 01/15/1999 - "...removes clothing while toileting...".
Maladaptive Behavior Assessment of 07/08/1999 - "...undresses at the wrong time of day and takes off clothing while on toilet - almost daily."
Maladaptive Behavior Assessment Summary of 07/09/1999 - "...removes clothing while toileting."
Per interview with E7 on 10/15/1999, E7 stated that ZZ4 would pull her own pants down, that she, "just did it", that her action of pulling down her pants did not always signify her need to go to the bathroom. E7 further stated that when ZZ4 was in the bathroom at the facility, ZZ4 would take her pants all the way off and would leave the bathroom that way if staff were not in the immediate area.
E7 and E9 both confirmed that staff would take ZZ4 to the bathroom, leave her, then return to check on her and assist her with hygiene care.
E3 (on 10/19/1999) and E8 (on 10/21/1999) confirmed that ZZ4 would remove her own pants in the bathroom. E9 (on 10/15/1999) and E4 (on 10/19/1999) and E6 (on 10/21/1999) stated that they have seen ZZ4 in the living room of the facility with her outer pants and underwear down on more then one occasion. E5 (on 10/19/1999) noted that she had observed ZZ4 on the men's end a couple of times (no dates given) and ZZ4 had removed her outer and under pants.
R6 (on 10/19/1999) stated that he sometimes (could not remember dates) saw ZZ4 remove her pants (outer and under) and sometimes her shirt. Per R6, "...was just something she just did...". ZZ6 (on 08/11/1999) stated that she observed ZZ4 sitting in the bathroom on the toilet, door open, pants (outer and under) down, "itching" herself. ZZ6 demonstrated the word, "itching" by gesturing to her own vaginal area and moving her hand back and forth in an itching motion.
E3 (on 10/27/1999) and Z8 (On 10/27/1999) confirmed that when ZZ4 was taken to the bathroom or when she went to the bathroom on her own, ZZ4 would not close the door herself, that staff always had to close the door for ZZ4 to ensure her privacy.
Review of IPP's for ZZ4 for the past three years indicate that ZZ4 has not had any formal programming for her disrobing behaviors. Additionally, ZZ4 has had no programming or
protocol for staff to consistently follow when assisting ZZ4 in her toileting, with regards to ensuring ZZ4's privacy (Prior interviews confirm that ZZ4 would be taken to the bathroom, then left and checked on, but that ZZ4 would often emerge in various states of disrobe before staff came back to check on ZZ4).
Per file verification and interview, the facility currently provides residential services to R3, who is a 31 year old male with Moderate Mental Retardation, is verbal and ambulatory, who was admitted to the facility on 04/08/1997 while on probation for a conviction of Aggravated Criminal Sexual Abuse - Class A on (05/13/1996) and has documented incidents of inappropriate touch with females at the facility and at the day training site.
The facility failed to provide training in personal skills essential for ZZ4's privacy.
ZZ4 was not provided nursing services in accordance with her needs, in that nursing failed to fully assess ZZ4's bruises in a timely manner and failed to assess ZZ4's bruises in a thorough manner.
The facility failed to ensure that individuals of the facility are protected from physical, sexual and psychological abuse.
The facility neglected to thoroughly investigate incidents of unknown origin.