F0607

D

Failure to Identify and Substantiate Verbal Abuse Toward a Resident

Toluca, Illinois Survey Completed on 12-30-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to identify and substantiate verbal and mental abuse toward a resident in accordance with its Abuse Prevention and Reporting Policy. The policy defines abuse as including willful mental abuse and verbal abuse, such as harassing, insulting, yelling, or threatening a resident, and requires staff to promptly investigate and report all allegations. An incident occurred involving the former Social Service Director (V4) and a resident (R1) after R1 became upset when a Certified Nursing Assistant (V17) could not obtain a requested salad because the kitchen was closed. R1 reacted by telling V17 to get out of the room, calling V17 derogatory names, and allegedly throwing a tray. V17 then reported to V4 that V17 did not want to return to R1’s room alone.

Multiple staff and the resident provided statements describing V4’s subsequent interaction with R1. The Certified Occupational Therapy Assistant (V13), who was in the bathroom providing therapy to R1’s roommate, reported overhearing V4 approach R1’s bedside with an attitude, get close to R1’s face, and berate R1 using profanity, including calling R1 an “a******” and telling R1 not to be a “f****** a******” to staff. V13 stated that V4 was aggressive, rude, and degrading toward R1 and immediately reported the incident to the Director of Nursing (V2). R1’s own written and verbal statements corroborated that V4 entered the room right after the conflict with V17, got inches from R1’s face, screamed and cursed, told R1 to “f*** off,” and called R1 an “a******,” which R1 described as belittling, humiliating, and degrading.

Despite these statements, the facility’s Final Abuse Investigation, completed by the former Administrator/Abuse Coordinator (V18), concluded that verbal abuse did not occur and characterized V4’s conduct only as unprofessional use of profanity not directed at the resident. The investigation documented that V4 used profane language during the conversation but did not substantiate abuse, even though staff statements and R1’s account indicated cursing and degrading language directed at R1. V2 later stated that, based on the information and statements collected, V4 did mentally and verbally abuse R1 and that the investigation could have reached a more thorough determination by substantiating the abuse. The failure to recognize and substantiate this conduct as abuse, despite corroborating evidence, represents the facility’s failure to follow its own abuse policy and to properly identify abuse for one of three residents reviewed for abuse investigations.