F0602

D

Unauthorized Resident Transport and Misappropriation of Funds by CNA

Normal, Illinois Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

Facility staff failed to protect a resident from misappropriation of money and unauthorized transport off premises by a CNA. On 12/11/25, a CNA (V6) transported a resident (R13) in the CNA’s personal car approximately 30 miles from the facility to the resident’s home so the resident could obtain clothing. The resident reported being away from the facility from 7:30 a.m. to 11:30 a.m. and stated that the CNA was off duty and had been told several times that the resident was planning to go home. The resident gave the CNA $50.00 as compensation for the trip. The facility file documented that the CNA informed the nurse only after returning to the facility. There was no physician order authorizing the resident to leave the facility, and the resident’s progress notes did not document that the resident was out of the facility at any time.

The resident’s MDS dated 12/3/25 documented no cognitive impairment, but the MDS section GG dated 12/2/25 showed the resident ambulated with a wheelchair and required maximum assistance from staff for transfers. The resident’s care plan documented hemiplegia related to a stroke and an increased risk for falls. The facility’s Abuse Prevention and Reporting Policy defined exploitation as taking advantage of a resident for personal gain through manipulation, intimidation, threats, or coercion. The facility’s Transportation for Residents Policy required all personnel to be trained prior to transporting residents, and the Incidents and Accidents Policy required a report and nursing documentation, including 72-hour documentation, for residents leaving the premises without authorization. The CNA had no facility training related to transportation of residents, and no incident report or required nursing documentation was completed for this unauthorized absence.