SPRINGFIELD, Ill. -- The Illinois Department of Public Health has fined River Bluff of Cahokia Nursing and Rehabilitation Center $10,000 (Statement of Violation) for failure to protect residents from sexual abuse. The 130-bed skilled and intermediate care facility is located at 3354 Jerome Lane in Cahokia.

Responding to complaints, Department surveyors learned the facility had knowledge of a resident with inappropriate sexual behavior toward other residents, but staff did not conduct thorough investigations or implement preventative measures to protect residents from actual or potential sexual abuse.

On one occasion, staff observed the resident in bed with another resident and both were partially unclothed. According to the male resident's care file, he was placed on 15-minute monitoring for 72 hours following the incident. However, the female resident's record did not contain information about the encounter or steps taken to protect her from further incidents. Even though the woman was known to have poor decision-making skills, facility staff did not investigate the incident because they believed it was consensual.

The second incident came to the attention of staff after the resident was transferred to a local hospital for becoming physically aggressive with staff. After the resident was gone, a female resident told staff the man had sex with her.

The employee did not immediately report the incident because she did not believe the resident, despite noticing changes in her behavior. The employee later reported the incident to supervisors after the male resident called from the hospital to apologize to the woman for having sex with her on several occasions.

The Department-ordered plan of correction required the facility to ensure staff takes appropriate action when either witnessing or receiving reports of non-consensual sexual behavior, to ensure that staff identify and report significant changes in a resident's behavior and to train its employees on reporting suspected abuse.

River Bluff Cahokia Nursing and Rehabilitation Center has requested a hearing on the Department's action. No hearing date has been scheduled.