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F0609
D

Failure to Timely Report Allegations of Abuse to State Agency

Chicago, Illinois Survey Completed on 07-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report allegations of abuse to the State Agency within the mandated 24-hour timeframe for two residents. In the first instance, a cognitively intact resident with a history of dementia and other medical conditions expressed distress to a unit manager, requesting to speak with administration. The unit manager relayed the concern to the assistant administrator, who was occupied at the time. Later, it was reported that a nurse had made an obscene gesture toward the resident, which the unit manager recognized as potential mental abuse and again reported to the assistant administrator. Despite this, the initial report to the State Agency was not submitted until more than 24 hours after the facility became aware of the allegation. In the second case, the Director of Nursing was informed by a CNA that an LPN had used a racial slur while recounting an incident involving a resident with severe cognitive impairment. The DON investigated and spoke with the LPN, who admitted to repeating the story but claimed the language was not directed at the resident. The DON initially decided not to report the incident to the State Agency, believing it did not constitute reportable abuse. However, the initial report was eventually submitted several days after the allegation was made, again exceeding the required reporting timeframe. Both incidents demonstrate that the facility did not adhere to its own abuse policy, which requires immediate reporting of abuse allegations to the State Agency within 24 hours. The policy emphasizes the importance of timely and accurate reporting to ensure resident safety and compliance with regulatory requirements. The delays in reporting were confirmed through staff interviews and review of documentation, with both initial reportables submitted well after the mandated period.

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