Failure to Timely Report Elopement-Related Neglect to State Agency
Summary
The deficiency involves the facility’s failure to timely report alleged neglect related to elopement to the State Agency within 24 hours, and failure to report subsequent actual elopements. A male resident with diagnoses including cerebral infarction, osteoarthritis, and a documented dementia diagnosis in the care plan was admitted in October 2025 and discharged in December 2025. His care plan, initiated and revised in October and November 2025, identified him as at risk for elopement based on an Elopement Evaluation risk score, with impaired cognitive function/dementia, use of Donepezil for dementia, and psychiatric diagnoses including schizophrenia, depression, and anxiety. The care plan also documented that he was a potential safety risk when leaving the facility, with a history of leaving facilities independently and self-admitting to hospitals. However, the care plan revised on 11/27/2025 did not reflect his elopement attempt and actual elopements on 10/24/2025, 11/02/2025, and 11/26/2025. Elopement risk evaluations showed inconsistencies and incomplete assessments. On 10/13/2025, the resident was assessed as a moderate elopement risk, cognitively impaired, and able to ambulate or propel himself. On 11/02/2025 and 11/27/2025, the evaluations were locked as completed but only the “No Risk” section was filled out, and questions that would have evaluated him as moderate or imminent risk were not completed, despite additional information stating he was at risk for elopement. These later evaluations also contained discrepancies regarding his ability to make decisions and ambulate. Progress notes documented that on 10/24/2025 security called nursing staff because the resident was at the gate wanting to go home; he was redirected back into the building and placed on two-hour monitoring. On 11/02/2025, notes described two episodes of elopement from the facility, aggressive and combative behavior when he insisted on leaving, inability to articulate a destination, involvement of police, and transfer to a psychiatric hospital, with notifications made to the physician, administrator, DON, and family. Further documentation showed that on 11/26/2025 the resident again left the facility and independently checked himself into a local hospital, with no injuries reported. A subsequent progress note characterized this as consistent with his baseline pattern of independently leaving prior facilities and seeking his own care, and stated he was aware of his needs and able to make decisions regarding his care and safety. Psychiatry/therapy notes from November 2025 indicated he was referred for depression, confusion, elopement, adjustment disorder, and high-risk behavior, and described him as an unreliable historian who did not remember attempting to elope, disoriented to situation, and endorsing cognitive impairment symptoms such as decreased concentration and forgetfulness. Interviews with staff and family revealed that the resident had a history of dementia, wore a medical bracelet listing dementia and stroke, had previously left the facility through the gate or fence, and that family sometimes learned of his departures from him or from hospitals or police. The RNC reported striking out the dementia diagnosis on 11/27/2025 after a high BIMS score and discussion with the MD, who confirmed he discontinued the dementia diagnosis based on the BIMS score and was not aware of the resident’s exit-seeking or elopement behaviors. Interviews with nursing staff, the DON, social worker, and the administrator clarified the facility’s internal reporting practices and the failure to report these elopements to the State. RN E stated that elopements were reportable to the State, that nurses did not report directly, and that the administrator was responsible for reporting. The previous social worker recalled the 11/26/2025 elopement, stating that facility staff notified the administrator that the resident was not in the facility, and she then located him at a local hospital and contacted the family. The DON stated that staff reported incidents to her and the administrator, and that the administrator was responsible for deciding if an incident was reportable to the State, emphasizing that reporting was important for regulatory compliance and resident safety. The administrator stated that he was responsible for reporting incidents, that elopements without injury were to be reported within 24 hours, and that staff were to report to him immediately so he could investigate. He also asserted that the 11/02/2025 notes were not accurate, that there were no elopements, and that the resident was not an elopement risk because of a high BIMS score and lack of dementia. The facility’s Abuse Prevention and Prohibition Program policy required reporting allegations of abuse, neglect, exploitation, and other qualifying incidents, including neglect, to the state survey agency and other authorities within 2 hours if involving abuse or serious bodily injury, and within 24 hours if not, and specified that failure to file reports within required time frames could result in disciplinary action. Despite these policies and the documented elopement-related events, the facility did not immediately report the alleged neglect and actual elopements to the State Agency within the required 24-hour timeframe. The facility’s written policy designated the administrator as responsible for coordinating and implementing the abuse prevention program, including investigation and reporting of abuse, neglect, and related incidents. It specified that all mandated reporters must report reasonable suspicion of neglect and that the administrator would submit initial and follow-up written reports of investigations to appropriate agencies. Interviews with staff confirmed that they relied on the administrator to determine reportability and submit reports. However, in this case, the administrator did not report the resident’s elopement attempt and actual elopements as required, and instead disputed that elopements had occurred or that the resident was an elopement risk, despite documentation in progress notes, care plans, and interviews describing exit-seeking behavior, elopement episodes, and involvement of police and hospitals. This failure to follow the facility’s own abuse/neglect reporting policy and federal/state reporting requirements constituted the cited deficiency.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Report Allegation of Verbal Abuse: A resident with HTN, anxiety disorder, and hyperlipidemia reported that a staff member yelled at her during resident council. Facility records showed a nurse aide was disciplined and retrained on communication, but the allegation was not included in the abuse reports submitted to the State. The DON confirmed the required report was not filed.
Failure to Timely Report Alleged Abuse: The facility did not report an allegation of abuse involving a cognitively intact resident with stroke, coordination, and anxiety diagnoses to HHSC within the required 2-hour timeframe. The resident alleged that an CNA had bullied her during a smoke break, and the Administrator acknowledged the report should have been made within 2 hours but was not submitted until later that day.
Failure to Report Allegations of Verbal Abuse and Involuntary Seclusion: The facility did not report multiple grievances involving an RN and an LPN to the SA, including resident complaints of rude and disrespectful comments, yelling, scolding, and blocking residents from entering their rooms when they tried to self-transfer. Documentation showed incomplete grievance investigations, delayed administrator sign-off, and no timely reporting of the allegations as verbal abuse or involuntary seclusion.
A resident reported being frightened after another resident repeatedly entered the room, grabbed belongings, and acted aggressively, but the concern was not reported to the SA within 2 hours. In a separate incident, a cognitively intact resident returned from the ER with a minor labial tear/perineal laceration and minimal bleeding, yet the DON and administrator did not treat it as reportable abuse or an injury of unknown source and did not investigate it.
A facility failed to report an alleged mistreatment during a resident’s hair grooming to the State Agency within the required timeframe. The resident had dementia, depression, severe cognitive impairment, and was dependent on staff for grooming and hygiene. Records showed a matted area of hair was removed, leaving a reddened scalp, and staff later described the event as an abuse allegation that should have been reported.
Failure to Timely Report Injury of Unknown Origin: A resident with dementia and multiple medical diagnoses developed unexplained right elbow swelling, redness, warmth, and pain, later found to be a dislocation with fracture. An LPN notified the NP, DON, and family and a STAT x-ray was ordered, but the initial report to IDPH was not made within the required two-hour timeframe after the injury of unknown origin was identified.
Failure to Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to submit a report of an allegation of verbal abuse involving one resident. Facility policy stated that all allegations of abuse must be reported immediately to the Administrator and the applicable State agency, and verbal abuse was defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms. Review of the resident’s record showed diagnoses including hypertension, anxiety disorder, and hyperlipidemia. Resident council minutes documented that the resident told staff that a staff member had yelled at her, and facility investigation documents showed a disciplinary action for a nurse aide related to the incident along with retraining on effective communication. The allegation was discussed in resident council, but the grievance documentation did not show a related grievance and the reported incidents submitted to the State did not include the verbal abuse allegation. During interviews, the Activities Director stated the incident happened and that the Director of Human Resources spoke with the aide, while the Director of Human Resources did not recall retraining or discussing the allegation. The resident stated the matter had been taken care of and that she had cursed the aide back. The DON confirmed that the facility failed to submit the required report of the verbal abuse allegation.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving Resident #80 was reported to HHSC within the required timeframe. Resident #80 was a female resident with diagnoses including cerebral infarction (stroke), lack of coordination, and anxiety disorder. Her quarterly MDS indicated she could make herself understood and understand others, and her BIMS score was 15/15, showing she was cognitively intact. Her care plan noted a behavior problem with interventions to protect the rights and safety of others, speak in a calm manner, divert attention, and remove her from the situation as needed. Record review showed the allegation involving Resident #80 was learned about at 1:00 p.m. on 08/03/2026, but it was not reported to HHSC until 5:04 p.m. the same day. The provider investigation report stated Resident #80 alleged that CNA P had bullied her sometime during the prior week, around 6:30 p.m. during a smoke break, though she could not recall exactly what was said or the setting. During an interview, the Administrator stated he initiated the investigation at 1:00 p.m. and acknowledged the allegation should have been reported within 2 hours. CNA P stated she was not the resident’s assigned CNA and said she had helped push Resident #80’s wheelchair after a smoke break when the resident accused her of trying to push her out of the wheelchair.
Failure to Report Allegations of Verbal Abuse and Involuntary Seclusion
Penalty
Summary
The facility failed to report allegations of verbal abuse and threats of involuntary seclusion involving an RN and an LPN to the State Agency. One grievance involved a resident who reported the LPN was rude, stern, and spoke in a manner the resident felt was not nice. During the related interview, the LPN acknowledged making comments about the resident not taking direction well from women and said her word choice was not the best, while the concern was addressed only as unprofessional communication and education on professional conversation was documented. The administrator did not sign off on the report until months later, and there was no report made to the State Agency. A second grievance involved a resident who reported hearing the RN yelling loudly at another resident and then entering the resident’s room and saying she did not like him and that he was not a good patient. The RN denied yelling and said she was reminding the resident to ask for help. The resident who heard the exchange later stated she had no concerns about how the RN treated her, and the resident who was the subject of the yelling said he felt safe and that staff were treating him well. The grievance documentation did not identify the yelling as an allegation of verbal abuse, and it was not reported immediately to the State Agency or the administrator at the time it occurred. A third grievance involved a resident who reported the RN told her she was going into a time-out and said, "you don't know what you are doing," which made the resident feel inadequate. Additional interviews and an email described multiple residents being upset by the RN’s tone, yelling, and blocking residents from entering their rooms when they attempted to self-transfer. Staff described the RN as assertive and bossy, and one staff member reported the RN stood in front of a resident’s door and scolded him while preventing him from entering. The grievance record contained incomplete interviews, blank resolution and follow-up sections, and no indication that the allegations of verbal abuse or involuntary seclusion were reported to the State Agency as required.
Failure to Report Suspected Abuse and Unexplained Injury
Penalty
Summary
The facility failed to immediately report suspected resident-to-resident abuse to the state agency within 2 hours for a cognitively intact resident who reported being scared of another resident. The resident stated that the other resident had entered the room multiple times during the night, grabbed belongings, snarled at the resident, and left the room. Nursing documentation also showed the resident placed a walker in front of the door on two nights to keep the other resident out and stated, "I'm scared to death of him." The DON was notified of the situation, and staff interviews confirmed the concern was treated as a resident-on-resident altercation with possible abuse, but no state report was made because the facility did not believe it reached the level of potential abuse. The other resident involved had moderate cognitive impairment, vascular dementia with agitation, and Alzheimer's disease. The MDS indicated this resident paced and wandered daily and significantly disrupted the care or living environment of other residents. Progress notes described frequent roaming into other residents' rooms and frequent agitation toward staff and residents. During interviews, staff stated that any nursing staff could file a vulnerable adult report, and the DON acknowledged that a resident-on-resident altercation with concerns of abuse should be reported to the state agency within 2 hours of learning about it. The facility also failed to report and investigate a resident's unexplained perineal injury as potential sexual abuse or an injury of unknown source. The resident was cognitively intact, frequently incontinent, and required substantial to maximum assistance with activities of daily living and peri care. After an emergency room visit, the resident was found to have a very minor labial tear/abrasion at the 12 o'clock position with minimal blood present, and the AVS listed a diagnosis of laceration to the perineum. Staff asked the resident whether anyone had been rough or abusive during care, and the resident denied abuse. The DON and administrator stated they did not consider the injury reportable because they believed it was similar to a prior situation and did not feel the injury of unknown origin needed to be reported or investigated.
Failure to Report Alleged Mistreatment During Hair Grooming
Penalty
Summary
The facility failed to ensure an alleged mistreatment during grooming and hygiene was reported to the State Agency within two hours for one resident. The resident had diagnoses of dementia and depression, and a quarterly assessment showed a BIMS score of 3, indicating severe cognitive impairment. The assessment also showed the resident was dependent on staff for grooming and hygiene. A Concern/Grievance Report documented that a mat of hair was removed from the back of the resident’s head and a reddened area was noted afterward. A nurse’s progress note the same day stated the resident’s scalp was red and irritated and that the resident did not want to get up. The facility’s investigation records showed no documentation that the allegation of mistreatment during hair grooming was reported to the State Agency. During interviews, staff stated the resident had a matted area of hair that was brushed out, after which the resident was heard hollering in pain, and the administrator later stated the matter should have been reported as an abuse allegation.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its Injury of Unknown Origin Policy and did not report an injury of unknown origin within two hours of the incident to IDPH for one resident. The resident was 95 years old and had diagnoses including dementia with mood disturbance, major depressive disorder, anxiety disorder, Alzheimer's disorder, dislocation of the right ulnohumeral joint, essential hypertension, overactive bladder, and chronic kidney disease. Records and interviews showed the resident's right elbow became swollen, red, warm, and hard to touch, and the resident was yelling that the arm was broken. An LPN assessed the resident, gave pain medication, notified the NP, DON, and family, and a STAT x-ray was ordered. The x-ray results were received later that evening, and the resident was sent to the hospital early the next morning, where hospital documentation showed arrival at 7:11 AM and a diagnosis of right elbow dislocation with mildly displaced fracture of the tip of the coronoid and olecranon process. The Administrator stated the initial IDPH report was sent at 8:08 AM the following morning, but also stated the report should have been sent on the day the swelling was first identified because the source was unknown. The facility policy stated that any injury with an immediately undetermined cause, including swelling, fractures, and unexplained pain or tenderness, is to be treated as an injury of unknown origin, and the abuse policy required immediate reporting of reasonable suspicion of a crime against a resident, not later than two hours after the allegation when serious bodily injury results.
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