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F0610
D

Failure to Immediately Investigate and Suspend Staff After Abuse Allegation

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 investigate an allegation of abuse and did not immediately suspend the alleged perpetrator while the investigation was ongoing for one resident. The resident, who had a history of mental illness and prior abuse, returned from the hospital and made a statement identifying a staff member as the person who assaulted her. This statement was relayed to a nurse, who then informed the administrator via text message, but the administrator did not respond at that time. The nurse did not interview the resident for further details, and the administrator did not speak to the resident about the allegation upon being notified the next day. The alleged perpetrator continued to work until later in the day when they were identified and sent home. Documentation shows that the staff member involved wrote a statement about the incident, and the resident's care plan indicated a risk for abuse, instructing staff to follow facility policy for all suspected or reported instances. Despite these protocols, the facility did not act immediately to investigate the allegation or remove the alleged perpetrator from duty, as confirmed by interviews with staff and review of time cards. The initial and final abuse allegation investigations were sent to the state agency several days after the incident.

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