Failure to Timely Report Multiple Abuse Allegations to State Agency
Penalty
Summary
The facility failed to timely report multiple allegations of abuse to the Illinois Department of Public Health as required by its Abuse Prevention Program policy. An alert and oriented resident (R5) reported that another resident (R1) held a knife to her neck and threatened her on 12/7/25. A CNA (V4) stated she heard R1 threatening R5 with a knife and observed R1 standing over R5, and staff found knives, a drill, a hammer, and lighters in R5's room that night. The next day, another CNA (V3) searched R1's room at the direction of the DON (V2) and found a taser and a pocketknife under R1's bed. Various potentially dangerous items, including a drill, hammer, scissors, razor blades, and lighters, were later observed in the medication room and then removed to the Administrator's office. The Administrator (V1) verified the objects belonged to R1 and acknowledged that R5's allegation of being threatened with a knife on 12/7/25 was not reported to the Illinois Department of Public Health. A second incident involved an alert and oriented resident (R9) who alleged that during a verbal altercation with staff on 12/14/25, staff ripped his shirt and had a knee on his neck. R9 reported the ripped shirt and physical aggression to a CNA (V5) and a nurse, and V5 confirmed that R9 showed her the ripped shirt and that she reported the allegation to the Administrator and DON. The facility did not submit its initial report to the Illinois Department of Public Health until nine days after the incident and the report omitted the allegation that staff ripped R9's shirt. In a third incident, R5 reported that while she was choking and a CNA assisted her, another CNA (V17) stated he would have let her choke; R5 reported this to the Administrator, who acknowledged receiving the report but did not report it to the Illinois Department of Public Health because R5 said it occurred before the Administrator started working at the facility. These actions and inactions demonstrate failures to immediately report allegations of staff-to-resident and resident-to-resident abuse as required by facility policy.
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