Failure to Timely Report Injury of Unknown Origin
Summary
The facility failed to report an injury of unknown origin for a resident who was nonverbal and unable to advocate for himself. The resident, who had Lewy Body dementia and multiple medical diagnoses, was found by CNAs to have deep purple discoloration, swelling, and pain in his left leg. Upon assessment by a nurse, the leg was noted to be in an abnormal position, very firm to the touch, and the resident exhibited facial grimacing when range of motion was attempted. Emergency medical services were called, and the resident was transported to the emergency department, where a comminuted and markedly displaced fracture of the left femur was diagnosed. There was no reported fall, and staff were unable to explain how the injury occurred. The Director of Nursing (DON) did not report the injury immediately to the appropriate authorities, stating that the facility had not completed its investigation and was unsure if the injury was of known or unknown origin. The investigation was not started until two days after the injury was discovered, and the DON was unaware of the requirement to report injuries of unknown origin within two hours if serious bodily injury is involved, or within 24 hours if not. Facility policy required immediate reporting of suspected abuse or injury of unknown source, but this was not followed in this case.
Plan Of Correction
POC accepted with Spencer Hadley, admin 6/3/25 at 3:40pm. BIC date 5/15/25. CM, HFES 35362 Preparation and/or execution of this response and Plan of Correction (POC) do not constitute an admission or agreement by the provider of truth or accuracy of alleged facts or conclusions set forth in this Statement of Deficiencies. This POC is prepared and/or executed solely for provisions of Federal and State required regulations. This POC is not an admission of noncompliance with cited regulation(s). F 609 How corrective action(s) will be accomplished: All Residents may potentially be affected by this deficiency. A facility wide audit was conducted by the Assistant Director of Nursing (ADON) on 5/15/25 to review with facility Primary Care Physician (PCP) all residents. Nine (9) residents were identified as high risk related to diseases and co-morbidities. Care plans and diagnosis were updated on 5/15/25. PCP reviewed and ordered supplements if not contraindicated. In addition, a facility wide staff interview was conducted on 5/5/25 to determine if there are any residents who have visible injuries of unknown origin that need to be reported as an unusual occurrence. The results of the interviews did not determine any injury of unknown origin, which will require investigation. How will facility identify other residents having the potential to be affected: Director of Staff Development (DSD) proactively gave an in-service to staff on skin discolorations reporting, root cause analysis collaboration with team including nurse and peers on 5/6/25. DSD and DON collaborated in providing in-service to staff on Unusual Occurrence Policy and Procedures including time frame and reporting to appropriate agencies on 5/14/25. Administrator/Designee is the ultimate person responsible for reporting injuries of unknown origin to the Department of Health and other agencies. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not reoccur: Director of Staff Development (DSD) proactively gave an in-service to staff on skin discolorations reporting, root cause analysis collaboration with team including nurse and peers on 5/6/25. DSD and DON collaborated in providing in-service to staff on Unusual Occurrence Policy and Procedures including time frame and reporting to appropriate agencies on 5/14/25.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
Failure to timely report alleged verbal abuse: A volunteer reported that an activities staff member yelled at a resident during bingo, told the resident to stop interrupting, and also yelled at the volunteer when she intervened. The resident later described the staff member as rude and said the comment made him/her angry. Survey review found no evidence the allegation was reported, and the RCD confirmed the facility had no evidence of reporting despite policy requiring immediate reporting of abuse allegations.
The facility failed to ensure that alleged abuse and serious injuries were reported to the State Survey Agency as required, instead either reporting only to a state patient safety system or not reporting at all. One resident with severe cognitive impairment sustained bilateral femur fractures after a fall, another cognitively impaired resident with Parkinson’s disease was later found to have a femur fracture after being discovered on the floor, and a third cognitively impaired resident required ORIF surgery for fractures following a fall; none of these incidents were reported through the State Survey Agency’s incident reporting website, per the ADM. In addition, an allegation that a resident with dementia and sensory impairments may have been molested was documented in the abuse binder but not in the medical record, and the ADM did not report the allegation to agencies or law enforcement after deeming it not credible, despite interviewing the resident and family. These actions and omissions resulted in multiple unreported events that met criteria for immediate reporting of alleged abuse and injuries of unknown source.
A resident kicked another resident in the leg, causing a fall and subsequent hip pain that required assessment and an X-ray. Multiple residents and CNAs witnessed the aggressor resident grabbing and shaking the victim’s leg, then kicking it, and staff, including an LPN, DON, and ADON, acknowledged this as physical abuse. The LPN reported the incident to the administrator, but the administrator did not notify the state surveying agency or law enforcement, and no ambulance was called for the victim, despite facility policy requiring immediate reporting of any abuse allegation or injury to the state health department.
The facility failed to report an allegation of abuse after a resident with a history of cerebral infarction, moderate cognitive impairment, and wheelchair use told an LPN that another resident hit him and showed a bruise on his arm. The resident later described being punched by another resident in the hallway, stating that a CNA and another staff member witnessed the incident. The Administrator and DON focused on investigating the bruise as resulting from the resident bumping into a door frame or another resident’s wheelchair and, based on that conclusion, did not report the allegation to authorities, despite the facility’s abuse policy requiring immediate protection of residents and prompt investigation of all possible abuse reports.
The facility failed to timely complete and document the results of an abuse investigation after a resident with TBI, anxiety, and mild neurocognitive disorder became increasingly agitated, allegedly attacked staff, and was subsequently taken to the floor by a nurse, resulting in severe left hip pain with leg shortening and external rotation and transfer to the ED. Although an event report was submitted to the State Agency, the investigation report produced later lacked the required PB-22 and did not include the outcome of the investigation, and the DON confirmed the investigation remained incomplete beyond the required timeframe.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse was reported timely for resident #55. A volunteer submitted a grievance stating that during bingo on 2/14/26, activities staff member #1 yelled at resident #55 after the resident called out bingo and told the resident to stop interrupting while she was talking. The volunteer reported that the staff member continued yelling for a couple of minutes, and when the volunteer intervened and told the staff member to stop yelling at the resident, the staff member yelled at the volunteer as well. The grievance also stated that two residents, including resident #55 and resident #66, reported that the activities staff member yells at them all the time and speaks to them the same way every time they play bingo. Resident #55 later stated that the issue involved the activities staff member being rude during bingo and saying, in a smart-ass way, "weren't you paying attention?" The resident said the comment made him/her angry and that [he/she] called the staff member names. The volunteer confirmed hearing the staff member speak loudly and rudely to the resident and then yell at the volunteer before storming off. Review of the state survey agency incident database showed no evidence the allegation was reported, and the regional clinical director confirmed the facility had no evidence the verbal abuse allegation was reported. The facility policy required alleged abuse to be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, immediately but no later than 2 hours when the allegation involved abuse or serious bodily injury.
Failure to Report Alleged Abuse and Serious Injuries to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all alleged violations of abuse, including injuries of unknown source and incidents involving major injuries, were reported immediately to the State Survey Agency and other officials as required by state law. For four sampled residents, the Administrator acknowledged that incidents were reported only to the state’s patient safety website and not to the State Survey Agency’s incident reporting website. This omission meant that the State Survey Agency did not receive timely notice of serious events, including an allegation of sexual abuse and multiple incidents resulting in significant fractures and surgery. For one resident with severely impaired cognition and diagnoses including hemiplegia and hemiparesis, nursing notes documented that the resident was found on the floor after attempting to get out of bed, was sent to the ER, and returned with immobilizing braces on both legs due to bilateral femur fractures. The resident’s bones were not strong enough for surgery, and he was placed on comfort care. Despite the seriousness of the injuries and the requirement to treat such events as potential abuse or neglect until ruled out, the Administrator stated that this incident was reported only to the state’s patient safety website and not to the State Survey Agency’s incident reporting system. Another resident with Parkinson’s disease and severely impaired cognition was found on the floor after a wheelchair alarm sounded, initially with no visible injury and able to bear weight. A few days later, staff documented complaints of left leg pain, tenderness, and wincing with movement, leading to an order for x‑rays and transfer for imaging. X‑ray results revealed a femur fracture, and surgery was not pursued. The Administrator reported this incident to the state’s patient safety website but not to the State Survey Agency’s incident reporting website. A third resident with severe cognitive impairment experienced a fall with complaints of pain in the left knee, left elbow, and fingers, and later underwent ORIF surgery for fractures of the right fourth and fifth metacarpals; this incident also was not reported to the State Survey Agency’s incident reporting system, according to the Administrator. For another resident with dementia, adjustment disorder with anxiety, hearing and visual loss, and age‑related debility, a document in the facility’s abuse binder described a possible molestation allegation originating from a phone call by the resident’s nephew. The nephew reported that his mother, the resident’s sister and then‑POA, was emotionally unstable and had stated she felt the resident had reported being molested. The Administrator documented that the nephew did not believe the allegation was credible, that the sister had dementia and emotional issues, and that the Administrator considered the report “not a viable allegation.” The Administrator noted that he interviewed the resident, who denied being touched, and that the sister could not provide more details beyond stating that a man had groped the resident’s breast. The Administrator concluded the allegation was not credible and did not report it to any agencies or law enforcement. The incident was not documented in the resident’s medical record, and the Administrator confirmed in interview that he did not report this sexual abuse allegation to the State Survey Agency’s incident reporting website. Across these four residents, the common deficiency was the facility’s failure to treat serious injuries and a sexual abuse allegation as reportable events to the State Survey Agency, as required. Instead, the Administrator limited reporting to the state’s patient safety website or chose not to report at all when he personally judged an allegation as not credible. This pattern of inaction regarding mandated reporting requirements formed the basis of the cited deficiency.
Failure to Report Resident-to-Resident Physical Abuse to State Agency and Police
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of resident-to-resident physical abuse to the state surveying agency and to law enforcement, despite multiple witnesses and staff acknowledging the event as abuse. According to interviews, one resident (R2) stated that another resident (R1) attacked him by kicking him in his left knee, causing him to fall. A third resident (R3) reported witnessing R1 become aggressive with R2, grabbing R2’s legs in an attempt to push him down, and then kicking R2’s left knee when he did not fall, resulting in R2 landing on his left hip. R1 admitted to kicking R2. Two CNAs (V8 and V9) also reported witnessing R1 aggressively grabbing and shaking R2’s leg, then kicking R2’s left leg when R2 did not move, which caused R2 to fall. Both CNAs characterized the incident as physical abuse. Staff interviews confirmed that the incident met the facility’s definition of physical abuse and should have been reported. The LPN (V7) who assessed R2 after the incident stated that R1 kicking R2 was a reportable incident and that she immediately notified the Administrator (V1). The Administrator acknowledged being aware that R1 kicked R2, that R2 fell, and that an assessment and a hip X-ray were ordered for R2 due to hip pain. However, the Administrator stated that the facility did not call the police or an ambulance for R2 and did not report the incident to the state surveying agency. The DON (V2) and ADON (V3) both stated that one resident kicking another resident is physical abuse and should be reported to the state surveying agency. This failure to report occurred despite a written facility policy requiring that any allegation of abuse or any incident resulting in injury be reported to the Illinois Department of Public Health immediately, but not more than two hours after the allegation of abuse.
Failure to Report Resident’s Allegation of Physical Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving one resident when the resident reported being hit by another resident and presented with a bruise. The resident, who had a history of cerebral infarction, was moderately cognitively impaired per the MDS and used a wheelchair, and was care planned as being at risk for abuse and neglect. The resident told an LPN that someone had hit him and showed a bruise on his left arm; the LPN notified the Administrator. The resident later stated he had been going down the hall, asked another resident to move, and that the other resident punched him in the arm, allegedly witnessed by a CNA and another staff member. The Administrator stated she was not aware of the abuse allegation and that they investigated the bruise as having resulted from the resident bumping into a door frame, and therefore it was not reported. The DON stated she conducted interviews regarding the bruise and concluded it was caused by the resident running into another resident’s wheelchair, and also did not report the allegation, despite the facility’s abuse policy requiring immediate protection of residents and prompt investigation of all reports and allegations of abuse. The deficiency centers on the facility’s failure to treat the resident’s statement that another resident hit him as a reportable allegation of abuse and to report it to the proper authorities, instead focusing only on determining an alternative cause for the bruise. This inaction occurred despite the resident’s documented risk for abuse and the facility’s written abuse policy that requires immediate protection and aggressive investigation of all possible abuse reports.
Failure to Timely Complete Abuse Investigation After Staff–Resident Altercation With Serious Injury
Penalty
Summary
The deficiency involves the facility’s failure to timely complete and report an investigative report for an allegation of physical abuse resulting in serious bodily injury. Facility policy on Reporting Unusual Occurrences requires that suspected, alleged, or actual abuse, neglect, misappropriation of resident property, fractures, incidents requiring transfer for medical evaluation, and staff-to-resident altercations be reported to appropriate agencies, with a written report forwarded within five working days. Federal regulation at 42 CFR §483.12(c)(4) similarly requires that, at the conclusion of the investigation and no later than five working days of the incident, the facility must report the results of the investigation. The facility’s Abuse policy states that each resident has the right to be free from abuse, including infliction of injury with resulting physical harm, pain, or mental anguish. Clinical record review showed that the resident had diagnoses including traumatic brain injury, anxiety, and mild neurocognitive disorder with behavioral disturbance. A nursing progress note documented that supervisors were urgently called to a unit for a resident attacking staff; upon arrival, the resident was found lying on his right side, screaming, and complaining of left hip pain. The resident stated that a staff member had “tackled” him and that he had intended to “knock his ass out.” Witness accounts indicated the resident had increasing agitation and attempted to punch the nurse and nurse aides; the nurse reported that when the resident swung at him, he grabbed the resident’s arm/shoulder and took him down to the floor. The resident had 10/10 left hip pain with left leg shortening and external rotation, and the physician ordered transfer to a local emergency room. An event report was submitted to the State Agency the following morning, but the facility’s investigation report produced a week later did not include a PB-22 or the outcome of the investigation. In an interview, the DON confirmed the investigation was not complete and acknowledged the facility failed to timely complete the investigative report for this allegation of physical abuse with serious bodily injury.
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