Failure to Report Resident-to-Resident Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report to the state an allegation of resident-to-resident abuse involving two residents. The facility’s abuse prohibition policy, revised 1/29/2026, requires that any incident involving alleged abuse be immediately reported to the Administrator, and that the Administrator provide the Illinois Department of Public Health with initial notice of the alleged abuse via the OHCR Portal, email, or fax, with alleged violations of abuse or those resulting in serious bodily injury to be reported immediately but no later than two hours after the allegation is made. R4’s health status note dated 12/27/25 documents that R4 allegedly had a physical altercation with another resident that resulted in R4 falling to the ground and being sent to the emergency room for evaluation. An event note dated 12/28/25 in R4’s EMR documents that R4 was pushed by another resident, and progress notes from the same date show that R4 returned to the facility with a soft cast to the right hand due to a wrist fracture following the incident. A health status note dated 12/28/25 documents that V4, an LPN, notified V1, the Administrator, about the incident. During an interview on 2/19/26, V4 stated she called the Administrator and reported the incident, and on 2/20/25 at 3:00 p.m., the Administrator stated he did not notify the State Agency about the incident involving R4 and R6, acknowledging that he should report all allegations of abuse incidents.
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