F0609

D

Failure to Timely and Accurately Report Resident-to-Resident Abuse Allegation

Wilmington, Illinois Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely and accurately report an allegation of resident-to-resident abuse to the state surveying agency and law enforcement. On the morning of March 12, 2026, a nurse (V9) was approached by R1, who propelled his wheelchair down the hallway stating, "he hit me, he hit me." V9 followed R1 to his room, attempted to clarify what happened, and assessed R1 for injuries, finding none and with R1 denying pain. V9 then spoke with R2, who reported that R1 had gotten in his face and that he pushed R1 away, demonstrating a flat-handed pushing motion. Recognizing this as an abuse allegation under facility protocol, V9 notified the Administrator (V1) at approximately 6:40–6:45 AM that R1 alleged R2 had hit him and that R2 admitted to pushing R1.

V1, in turn, notified the Social Service Director (V18) and the DON (V2) via text message that morning, describing that R2 allegedly pushed R1 in the dining room because R1 was yelling at him. V1 and V18 reviewed the dining room camera footage later that morning. The view was partially blocked, but they observed R1 approaching R2, yelling and waving his arms, and R2 becoming agitated and pushing R1 away. V18 documented a behavioral progress note in R1’s EMR at 10:11 AM, describing R1 approaching R2, yelling and waving his arms, R2 reporting that R1 grasped his arm, and R2 pushing R1 away. The note also documented that the camera view was partially blocked and they could not verify whether R1 grasped R2’s arm. Despite this information and the facility’s policy that an allegation of abuse, such as a resident pushing another resident, must be reported to the state surveying agency within two hours, V1 did not submit an initial abuse allegation notification or notify the police on March 12, 2026.

On March 13, 2026, R1 reported to surveyors that on the previous morning in the dining room, R2 approached him, yelled at him, and suddenly pushed him out of his wheelchair, with no staff present and no staff witnessing the event. R1 stated he felt bad that someone attacked him in his place of residence and that he had asked a nurse to call the police, which he said was refused, and that he had reported the incident to V1 around 11:00 AM on March 12. R2 also told surveyors that he had gotten into a fight with his roommate in the dining room and that he pushed him, causing him to fall out of his wheelchair and get up on his own. When V1 eventually submitted the Facility Reported Incidents form to the state surveying agency on March 13, 2026, the report inaccurately listed the occurrence date as March 13 instead of March 12 and described the event as both residents alleging a resident-to-resident behavior to a surveyor, rather than reflecting the original allegation and occurrence date. The facility’s Abuse and Retaliation Prevention and Reporting Policy required any allegation of abuse to be reported immediately, but not more than two hours after the allegation, which was not followed in this case.