F0609

D

Failure to Timely Report Resident-to-Resident Abuse Allegation

Harrisburg, Illinois Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report an allegation of resident-to-resident abuse to the state survey agency and other required authorities, as required by its abuse reporting policy. One resident (R1), who was cognitively intact with a BIMS score of 15 and had diagnoses including COPD, panlobular emphysema, and dysphasia, alleged that another resident (R2), who had anxiety disorder, depression, dementia, and a BIMS score of 6 indicating severe cognitive impairment, physically assaulted him in the dining room. R1 stated that while he was sitting in his wheelchair after the evening meal talking with his family member (V9), R2 came up behind him, rammed R2’s wheelchair into R1’s wheelchair, and began punching him in the back. R1 reported that another male resident yelled at R2 to stop, after which R2 rolled away, and that his family member immediately went to get a nurse, leading R1 to assume the facility was aware of the incident.

V9, R1’s family member, reported that she had previously been told by various staff that R2 could become physically aggressive and that staff had described R2 as combative, aggressive, and dangerous, with one staff member stating it was inevitable someone would get hurt with R2 in the building. V9 described that on the date of the incident, R2 rolled up behind R1 in the dining room, hit R1’s wheelchair with his own, and when R1 did not move, R2 began punching R1 in the back and pulling on his blanket while yelling at him. Another resident (R7) verbally intervened, and V9 went to get staff assistance. V9 stated that LPN V3 responded, assisted R2 back to his room, and instructed V9 to report the incident directly to the Administrator (V1). That same evening, V9 sent an email to V1 at 9:55 PM describing that R1 had been attacked or harassed twice that day by R2, including being pushed, slapped/hit, yelled at, and having his blanket yanked, and noted that V3 had asked her to report directly to V1.

Despite this contemporaneous email report, the Administrator did not initiate timely external reporting. V1 later stated she was not aware of the 12/16/25 incident until 1/6/26, when V9 came to speak with her, and that she did not report the incident at that time because she believed it was unfounded. Email documentation shows that on 1/6/26, V9 forwarded the original 12/16/25 email to V1, copying the DON (V2), and explained that she had assumed the matter was addressed because the aggressor was absent from the facility the following days. The facility’s own Abuse Prevention and Reporting policy requires that when an allegation of abuse occurs, the resident’s representative and the Department of Public Health regional office be informed by telephone or fax, and that if there is suspicion a crime has been committed without serious bodily injury, a report to local law enforcement and the Department of Public Health must be made as soon as possible but within 24 hours of when the suspicion was formed. Contrary to this policy, the Administrator did not report the allegation to the Illinois Department of Public Health until 02/03/26, as documented on the Report to IDPH marked Initial & Final, which listed the incident date as 02/03/2026 and summarized that R1’s daughter had reported weeks after the incident that R2 grabbed R1’s blanket and hit his back. V1 acknowledged that she ultimately reported the 12/16/25 incident on 2/3/26 only after V9 sent a letter to corporate, demonstrating that the facility failed to timely report the abuse allegation in accordance with regulatory and policy requirements.

The facility’s abuse policy further requires that an initial report to the Department of Public Health include the resident’s name, age, diagnosis, mental status, type of abuse reported, and the date, time, location, and circumstances of the alleged incident, and that a complete written final investigation report be submitted within five working days of the report. In this case, the initial external report was delayed for several weeks after the alleged incident and after the Administrator had been made aware of the allegation through direct communication from the resident’s representative. The Administrator’s decision not to report when first informed, based on her belief that the allegation was unfounded, and the failure to act upon the original 12/16/25 email describing a physical assault, are the actions and inactions that led to the cited deficiency for failure to timely report suspected abuse as required by the facility’s own policy and state and federal regulations.