F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to follow their policies and procedures on reporting an
allegation of abuse for 1 of 7 residents (R1) reviewed for abuse in the sample of 7.
The findings include:
R1's face sheet shows she was admitted to the facility on [DATE] and has diagnoses that include
dysphagia, adult failure to thrive and a history of a cerebral infarction without residual deficits. R1's care
plan shows she is incontinent of bowel and bladder and requires staff assistance with all her activities of
daily living including toileting, bathing, and bed mobility.
On 11/4/24 at 9:00 AM, V5 (R1's Power of Attorney/POA and daughter) said she was at the facility on
10/11/24 and the facility staff were doing a trauma assessment on R1 while she was present in the room.
When the question was asked if (R1) had any history of sexual abuse she replied yes here. V5 said (R1)
then made the allegation that someone had come into her room and put something in her bottom. V5 said
at that point the staff person went and got (V1) the Administrator, who then took her mom to ask more
questions about the allegation. V5 said (R1) has never made an allegation like this before so she was
concerned that she may have been assaulted by someone. V5 said she is not sure if the facility called
(R1's) physician or not but they did not send her out for any examination.
On 11/4/24 at 10:48 AM, V8 (Social Services) said she was the person who did some of the admission
assessments on 10/11/24 with (R1) including a trauma informed screening. V8 said when she got to the
question if (R1) had ever been sexually abused (R1) replied here. V8 said (R1) went on to say staff, a nurse
or doctor, put something in her bottom. V8 said she went and called her supervisor (V7) and the Director of
Nursing (V2) immediately and they informed V1 who came to speak to (R1).
On 11/4/24 at 12:13 PM, V1 (Administrator) said she did receive an allegation on 10/11/24 that (R1) had
indicated she had been sexually abused at the facility by staff who put something in her bottom. V1 said
when she interviewed (R1) she would not give her any detail about the incident, so she interviewed a few
nursing staff asking questions if she had a suppository or something like that. V1 was not sure if the
physician had been called or not but she did not report the allegation to the state surveying agency.
On 11/6/24 at 9:15 AM, V4 (R1's Physician) said she was not notified of the allegation that (R1) had made
on 10/11/24 until 10/24/24 when (R1) made another allegation of continued sexual abuse in her room at the
facility. V4 said she should have been contacted about the allegation at the time and if she was not able to
come and examine the resident at the facility, she would have had her sent out
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145200
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145200
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Franklin Grove Living and Rehab
502 North State Street
Franklin Grove, IL 61031
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
to the emergency room for evaluation. V4 said she is familiar with (R1) because she had just been
transferred from another facility to the current facility, and she has never made a sexual abuse allegation
that she is aware of. V4 said she would expect the facility to do a thorough investigation and follow the
abuse policy and call the physician and police if a resident makes any potential sexual abuse allegation.
On 11/6/24 at 11:13 AM, V1 verified that R1's physician (V4) was not contacted about the allegation, the
police were not contacted, and the state surveying agency was not notified of an initial or final report. V1
said typically when an allegation is made that is founded, they then contact the state surveying agency. V1
said she probably should have notified (R1's physician) about the allegation. V1 said when a sexual abuse
investigation is done the physician is contacted, the police are called, and the resident is sent to the
emergency room if indicated. V1 said she did not do the facility abuse prevention program worksheet that is
part of the abuse policies and procedures because they thought (R1) may have made the allegation
because she is very tiny and had a hard bowel movement which may have been what (R1) was referring to.
The facility provided Abuse Prevention Program policy and procedure which includes an investigative
pathway worksheet last reviewed on 4/8/24 defines abuse as any physical, mental, or sexual assault that
may inflict trauma or mental anguish to a resident. The policy shows any allegation of abuse that results in
serious bodily injury the initial report should be reported to (state surveying agency) in 2 hours and if it
does not result in serious bodily injury should be reported to (state surveying agency) in 24 hours, followed
by a final report in 5 days. The policy also shows when an allegation of sexual abuse is made the physician
and local law enforcement should be contacted.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145200
If continuation sheet
Page 2 of 2
