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F0609
D

Failure to Timely Report Alleged Abuse to State Agency

Rockford, Illinois Survey Completed on 06-23-2025

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 immediately report an allegation of abuse involving a resident with a history of mental illness and prior abuse. The resident, identified as being at risk for abuse and/or neglect, returned from the hospital and made a statement accusing a staff member of assault. This statement was heard by a CNA, who relayed it to an LPN shortly after the resident's return. The LPN then texted the Administrator/Abuse Coordinator about the allegation, but did not receive a response. The Administrator was not informed in person until the following day and acknowledged that the report to the state survey agency was delayed. The Director of Nursing later confirmed that there was no record of a timely report being sent to the state agency regarding the abuse allegation, and the initial report was only sent several days after the incident. The facility's policy required immediate reporting of all abuse allegations, but this protocol was not followed in this instance.

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