Failure to Investigate and Report Multiple Abuse Allegations and Protect Residents
Penalty
Summary
The facility failed to follow its Abuse Prevention Program policy by not promptly investigating and reporting multiple allegations of abuse and by not ensuring resident protection during the investigation period. An alert and oriented resident (R9) reported that during a verbal altercation on 12/14/25, staff ripped his shirt and placed a knee on his neck. A CNA confirmed that R9 showed her the ripped shirt that night and that she reported the incident to the Administrator and DON. The Administrator acknowledged that R9 had reported staff being physically aggressive and that the incident occurred on 12/14/25, but did not begin investigating until 12/23/25, after R9 reported the allegation to the state agency. The initial report to the Illinois Department of Public Health was made nine days after the incident and did not include the allegation that staff ripped R9’s shirt. The facility also failed to investigate and report other abuse allegations involving alert and oriented residents. One resident (R5) reported that another resident (R1) held a knife to her neck and threatened her; a CNA stated she heard R1 threatening R5 with a knife and later found a knife, drill, hammer, and lighters in the room. Another CNA reported that, the next day, she was instructed by the DON to search R1’s room and found a taser and pocketknife under the bed, and another CNA confirmed that R5 reported being threatened with a knife and being scared. The Administrator verified that the confiscated items belonged to R1 but stated she did not investigate or report R5’s abuse allegation. In a separate incident, R5 reported that a CNA told her he would have let her choke after another CNA assisted her while she was choking; the Administrator acknowledged receiving this report but did not investigate or report it, stating it occurred before her start date. These actions and inactions were inconsistent with the facility’s policy requiring immediate investigation, separation of the alleged perpetrator, assurance of resident safety, and completion of an incident report for any alleged abuse.
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