SPRINGFIELD, IL –The Illinois Department of Public Health has fined Locustwood Health Care Center $10,000 (Statement of Violation) for failure to protect a female resident from sexual abuse by another resident. The 63-bed intermediate care facility is located at 3520 School St. in Rockford.

Responding to complaints, Department investigators learned a resident had been sexually assaulted, but the attack was not reported or investigated in a timely manner. A review of facility records and staff interviews determined that, at first, it was assumed the woman had a urinary tract infection and a urine culture was ordered. When staff went to collect a urine sample four hours later, evidence of an assault was detected. However, it was not until the next day that the woman was taken to a hospital for evaluation and a checkup determined she had been sexually assaulted.

Staff told surveyors they suspected a male resident, who had a history of aggression and had made sexual advances toward residents and staff, of committing the abuse. The man had a scratch on his nose and forehead and a body check revealed multiple scratches and marks.

The male resident had been admitted to the facility from a psychiatric hospital despite staff concerns they were not trained to handle someone with a history of aggressive behavior. A review of social services notes found the resident was not appropriate for this facility and he posed a risk to others. Following his admittance to the facility, staff were not instructed on how to fulfill the resident's needs, and they did not closely monitor his activities, which included physical intimidation and sexual advances toward staff and residents.

Surveyors also found the facility had admitted other mentally ill residents, including one who had spent 20 years in an institution for the criminally insane.

A Department-ordered plan of correction required the facility to immediately notify residents' physicians when aggressive or inappropriate behaviors occur, to establish procedures to determine the most suitable therapy and placement for perpetrators of abuse in order to ensure the safety of other residents and employees, and to assess the level of care required by residents to determine whether it is within the scope of the facility.

Locustwood Health Care Center has not requested a hearing on the Department's action.