F0609

D

Late Submission of Final Abuse Investigation Report to State Agency

Chicago, Illinois Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to submit a final investigation report of alleged staff-to-resident abuse to the Illinois Department of Public Health (IDPH) within the required five business days. The facility’s own Abuse Prevention Program policy, dated 01/2019, states that the final investigation report will be completed within five working days of the reported incident and that the Administrator is responsible for forwarding a final written report of the results of the investigation and any corrective action taken to IDPH within that same timeframe. The Administrator (V1), who serves as the facility’s abuse coordinator, confirmed that once abuse is reported, an initial report must be submitted to IDPH within two hours and the final report within five business days.

The incident under investigation involved R6, a cognitively intact resident with multiple medical diagnoses including atherosclerotic heart disease, chronic diastolic heart failure, COPD, hypertension, hyperlipidemia, polyneuropathy, chronic kidney disease, schizoaffective disorder bipolar type, rheumatoid arthritis, gout, nicotine dependence, major depressive disorder, and anemia. R6 uses a wheelchair and is dependent on staff for transfers and has a care plan noting a history of suspected abuse, neglect, exploitation, past trauma, and other factors increasing susceptibility to abuse/neglect, with an expectation to be treated with respect and dignity and to reside free from mistreatment. R6 reported that while wheeling himself down the hallway toward the designated smoking area with an unlit cigarette in his mouth, an LPN (V21) snatched the cigarette from his mouth, broke it, threw it at him, and told him he should not have it in his mouth, and further threatened to call the police on him.

Two CNAs (V22 and V23) corroborated R6’s account, stating that R6’s cigarette was unlit and in his mouth only so he could use both hands to propel his wheelchair, and that V21 abruptly got up from the nurses’ station, snatched the cigarette from R6’s mouth, broke it, and then verbally threatened him by saying she would call the police, which they characterized as intimidating and verbally/mentally abusive. R6 reported the incident to the Administrator on 12/09/25, stating it had occurred on 12/07/25. The facility submitted the initial report to IDPH on 12/09/25 at 5:23 PM. However, the final report was not submitted until 12/19/25 at 3:40 PM, which the Administrator acknowledged was late, noting that it should have been submitted by 12/16/25. This delay in forwarding the final written investigation report to IDPH beyond the five-business-day requirement constitutes the cited deficiency.