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F0609
D

Failure to Timely Report Alleged Verbal Abuse to Authorities

Marion, Illinois Survey Completed on 12-09-2025

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 an allegation of verbal abuse involving a resident and a staff member to the State Agency and local law enforcement within the required 24-hour timeframe. The incident involved a resident with diagnoses including osteomyelitis, type 2 diabetes mellitus with skin complications, traumatic amputation of the right great toe, hyperlipidemia, bipolar disorder, and hypertension, who was cognitively intact. The resident requested a grilled cheese sandwich from a dietary aide, who responded with profane language and refused the request. Multiple staff members, including a nurse and the dietary manager, were made aware of the incident, and statements were collected from those involved and witnesses. Despite the facility's policy requiring immediate reporting of potential abuse, the administrator, who also served as the Abuse Coordinator, did not report the incident. The administrator was notified of the situation the night it occurred but considered it a customer service issue rather than verbal abuse, despite staff indicating otherwise. The dietary manager, who believed the incident constituted verbal abuse, was instructed by the administrator not to terminate the staff member for abuse to avoid mandatory reporting to public health authorities. The dietary manager ultimately resigned due to concerns about the handling of the situation. A review of facility records revealed that no report of the incident was made to the State Agency or law enforcement, and the required documentation was not present. The facility's abuse prevention policy outlines clear steps for reporting and investigating allegations of abuse, including immediate notification of authorities and documentation of actions taken. These procedures were not followed in this case, resulting in a failure to comply with regulatory requirements for reporting suspected abuse.

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