Failure to Recognize and Report Resident’s Abuse Allegation to State Agency
Penalty
Summary
The facility failed to recognize and report an allegation of abuse to the State Agency after a resident complained about the conduct of a CNA. The grievance tracking log for November 2025 shows that the resident filed a grievance on 11/06/25, but the log contains no additional information about the nature of the grievance. A Grievance Concern/Compliment Form dated the same day documents that the Housekeeper/Laundry Supervisor received the report and recorded that the resident stated a CNA, described as a heavier-set girl of a specified race, threw clothes at the resident and told the resident to get dressed and into the wheelchair independently. The resident’s MDS showed a Brief Interview of Mental Status score of 13/15, indicating no cognitive impairment. Despite this, the Administrator/Abuse Prevention Coordinator did not report the grievance to the Illinois Department of Public Health, stating he considered it a customer service issue rather than abuse at the time. In an interview, the resident recounted that the CNA tossed clothes to her, told her to dress herself, and that she then had to get into her wheelchair on her own. The resident reported feeling upset and described the CNA as rude and in a hurry, and stated that no one deserves to be rushed or treated rudely. The Housekeeper Supervisor later stated that the resident appeared anxious and somewhat agitated, with a facial expression suggesting she was holding back tears, and that the resident reported the CNA had thrown her clothes and told her to dress and get into her wheelchair by herself. The Housekeeper Supervisor also stated that this concern was reported immediately to the Administrator/Abuse Prevention Coordinator and that the resident stated she felt abused. The facility’s Abuse Prevention and Reporting policy, revised 10/24/22, requires that any allegation of abuse be reported to the Illinois Department of Public Health immediately, but no later than two hours after the allegation, or within 24 hours for incidents not involving abuse and not resulting in serious bodily injury. The Administrator acknowledged that the resident’s grievance should have been reported as an abuse allegation in accordance with this policy.
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