F0609

D

Failure to Recognize and Report Resident Abuse Allegations

Decatur, Illinois Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to recognize and report resident allegations of abuse, including rough and belittling care, to the Administrator/Abuse Prevention Coordinator as required. One resident (R1), with moderate cognitive impairment, limited upper extremity range of motion, and total dependence for most ADLs, reported that a CNA with a ponytail was rough during care and transfers, causing bruises on both forearms and neck pain. R1 showed the surveyor quarter- and nickel-sized bruises with yellow halos on both forearms and described being grabbed behind the neck during a transfer, which made her cough and feel scared it could happen again. R1 stated she had told a “lady up in the front offices,” later identified as the Social Service Director (V4), who noticed the bruises and was told about the rough care, but no one followed up with R1 afterward.

The facility’s January Concern Log documented a grievance from R1 on 01/14/26, recorded by V4 and the Business Office Manager, describing a “mean” CNA on night shift who was rough with care and that R1 wanted to discharge home. The concern was categorized as “Care-Staff Approach,” assigned to the Interim Administrator/Abuse Prevention Coordinator (V1), and marked resolved the same day. However, when the surveyor reported R1’s detailed allegation of rough care, physical abuse, and bruising on 01/16/26, V1, the DON (V2), and the Regional Nurse Consultant (V3) all stated they were not aware of any abuse allegations involving R1. Later, V4 confirmed she had received and logged R1’s grievance, including allegations that the CNA caused bruising and neck pain, and stated she reported it to V1, while a county Community Support Services Manager (V7) corroborated being present when R1 described the rough transfer, bruises, neck pulling, and fear of future rough care.

A second resident (R3), cognitively intact and receiving aftercare following joint replacement surgery, also reported concerns about staff conduct that were not properly recognized or reported as possible abuse. The January Concern Log showed a grievance from R3 about a CNA on the phone during care, categorized as “Care-Staff Approach” and assigned to Social Service, with same-day resolution. V4 later stated that R3 had reported the CNA was on her phone, rude, and rough with care, and that she identified the CNA as V11. V4 acknowledged she only addressed the phone use with the CNA, did not consider the situation abuse because she knew the CNA personally, and did not report the rough care allegation to the Administrator. R3 told the surveyor he reported the incident to prevent other residents from receiving rushed or rough care and described the CNA belittling him by calling him lazy and saying he did not need the help. An LPN (V16) and a Physical Therapy Assistant (V14) both confirmed awareness of R3’s allegations of verbal and physical abuse but did not report them to the Administrator, citing uncertainty about who the Interim Administrator was at the time. The DON and Interim Administrator later confirmed they were not informed of R3’s grievance or abuse allegations.