F0607

D

Failure to Thoroughly Investigate Verbal Abuse Allegation and Remove Alleged Perpetrators from Care

Peoria, Illinois Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its Abuse, Neglect, Exploitation Policy by not conducting a thorough investigation and not adequately removing alleged perpetrators from resident care after an allegation of verbal abuse. The policy requires immediate investigation of suspected abuse, including identifying and interviewing all involved persons, documenting the investigation, and protecting residents from harm, including room or staffing changes as needed. A moderately cognitively impaired female resident with COPD, anxiety disorder, bipolar disorder, osteoporosis, and generalized muscle weakness reported to the ADON that two CNAs had used foul language toward her and called her a derogatory term. The ADON reported the allegation to the DON, who directed her to notify corporate leadership covering for the Administrator.

Corporate staff then interviewed the resident, during which they concluded the situation did not qualify as an abuse allegation after the resident’s account was perceived as changing. They reassigned the two CNAs to a different hallway but did not suspend them, did not document the incident, and did not conduct or document a complete investigation, including interviews of other staff or residents. The resident later reiterated that she had told corporate staff that two CNAs had called her the derogatory term, while both CNAs confirmed they were informed of the allegation and simply reassigned to another hall without being sent home. These actions and omissions demonstrate the facility’s failure to complete a thorough abuse investigation and to fully remove the alleged perpetrators from resident care while the investigation was underway, contrary to its written policy requirements.