F0600

G

Failure to Prevent and Report Verbal and Mental Abuse by Nursing Staff

Aviston, Illinois Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect multiple residents from verbal and mental abuse by a staff nurse and the failure of other staff to report witnessed or suspected abuse, resulting in emotional harm and distress. One resident with malignant neoplasm of the left breast, depression, generalized anxiety, unspecified mood disorder, mild cognitive impairment, and a BIMS score of 5 (severely cognitively impaired) repeatedly asked for her mother. The Director of Physical Therapy (V15) stated that an LPN (V11) turned to this resident and loudly told her that her mother was dead, which V15 characterized as hateful, verbally, and mentally abusive. V15 reported that the resident became very upset and cried after this statement. Although V15 believed the interaction was abusive, she did not report this incident to administration or the DON at the time it occurred, despite the resident’s care plan identifying her as at risk for abuse/neglect and directing staff to address complaints promptly and report suspected abuse immediately.

Another resident with Alzheimer’s disease, unspecified dementia, major depressive disorder, insomnia, and a BIMS score of 5 (severely cognitively impaired) was also involved in alleged verbal abuse. Nursing staff (V3 and V4) reported that the same LPN (V11) was verbally mean and not nice to residents, and specifically that she yelled at this resident, who liked to sleep in, from the hallway telling her she needed to get out of bed and that she was getting up. V3 stated she did not report this behavior because she felt it would put a target on her back. V4 reported that on one occasion this resident was crying and asking to call her son, and V11 would not call him; V4 eventually called the son herself, which calmed the resident. V4 also described an incident where the resident was sitting near the nurse’s station and V11 was yelling at her in a very loud and rude manner, which upset the resident. The resident herself reported poor memory and uncertainty about whether staff had yelled at her, but did recall being very upset and mad when she was not allowed to use the phone to call her son. Her care plan, like that of the first resident, identified risk for abuse/neglect and directed staff to address complaints and report suspected abuse immediately.

A third resident with cerebral palsy, paraplegia, vascular dementia, bipolar disorder, major depressive disorder, anxiety disorder, unspecified intellectual disabilities, and a BIMS score of 11 (moderately impaired) reported being forced to get out of bed for a shower when she normally received bed baths. She stated that the LPN (V11) told her in a loud voice that she had to get up and take a shower, despite her back and spine problems and her fear of the mechanical lift due to a prior fall from a lift sling at another facility. The resident reported that staff, at V11’s direction, got her up with the mechanical lift for the shower, and she was crying, very upset, and stated she was unhappy at the facility because they made her do things she did not want to do and raised their voices at her. Another LPN (V4) corroborated that V11 instructed staff to get this resident up for a “real shower” despite the resident’s refusals and fear of the lift, and that the resident was crying and screaming, very upset during the process. A CNA (V9) confirmed that she gave the resident a shower at V11’s direction despite the resident’s refusal to get out of bed, and another CNA (V21) reported hearing the resident yelling and screaming during the shower, noting it was the first time she had seen the resident get up out of bed for a shower. The resident’s care plan did not include a focus area for abuse, and staff who witnessed or were aware of these events did not report them to the administrator or DON at the time.

Multiple staff interviews further described a pattern of verbally rude or mean behavior by the LPN (V11) toward residents, including telling another resident who was yelling out to stop because no one needed to hear that. The DON (V2) acknowledged that she had previously spoken to V11 about being rude to a resident but had not received additional reports until the surveyor’s inquiry, and stated that if the resident who feared the lift did not want a shower, V11 should not have made her get one, and that no staff should yell at any resident or prevent a resident such as the second resident from calling her son. The facility’s Abuse Prevention Program policy states the facility desires to prevent abuse, neglect, or misappropriation of property by establishing a resident-sensitive and resident-secure environment. Despite this, the reported incidents show residents being subjected to loud, rude, or coercive interactions by an LPN, residents becoming upset, crying, or emotionally distressed, and staff failing to promptly report suspected abuse as required by resident care plans and facility policy.