F0609

D

Failure to Report Resident’s Allegation of Physical Abuse per Facility Policy

Wilmington, Illinois Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The facility failed to follow its abuse reporting policy when staff did not report a resident’s allegation of physical abuse to administration. The resident had multiple diagnoses including type 2 DM with hyperglycemia, unspecified dementia with moderate cognitive impairment, psychotic and mood disturbances, anxiety, cognitive communication deficit, recurrent moderate major depressive disorder, alcohol dependence with alcohol-induced disorder, and alcoholic cirrhosis. In December 2025, the resident told an insurance representative that he had been abused by a female staff member months earlier but could not provide a description or details. The administrator reported that this allegation was investigated by the state surveying agency with no findings, and the facility’s social service director and the resident’s case manager spoke with him about it. During that prior investigation, according to the administrator, no staff names were given by the resident.

On a later date, during an interview, the resident was lying in bed and answered only closed-ended questions. He stated that months ago a female staff member had physically abused him, saying she punched him, and he believed it was a staff member with a specific first name. He reported that he had told someone at the facility and that a male, whom he believed might be staff, had talked to him about it. When asked if he was afraid the staff member would do it again, he hesitated and said “probably.” The administrator was informed that the resident had now identified a staff first name, and she acknowledged that there were both a CNA and an RN with that first name, noting that the CNA was working that day and the RN was scheduled later. The administrator stated that previously no names had been provided in connection with the allegation.

Interviews with staff revealed that a CNA (V6) had been told of the abuse allegation by the resident months earlier but did not report it to administration as required by facility policy. V6 stated that while giving the resident a shower, he reported that months ago a CNA had beaten him and identified the first name shared by the CNA (V5) and RN (V7). V6 responded that she was sorry to hear it and did not notify the abuse coordinator or administration because the resident said it had happened months ago and had already been reported and “taken care of,” and because she believed it was an old, resolved case. V6 also stated she had heard about the allegation about eight months prior, believed it related to the unit where V5 worked, and thought the case was clear since V5 was still working there. V5 reported that she first heard of the allegation when V6 told her, after a shared shift, that the resident said someone with her first name had hit him; V5 said she did not take it seriously because she had never worked with the resident. The facility’s written policy required employees to immediately report any incident, allegation, or suspicion of potential abuse they observe, hear about, or suspect to the administrator or through designated channels, which did not occur in this case.