F0609

D

Failure to Timely Report Resident’s Allegation of Verbal Abuse to State Agency

Chicago, Illinois Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report an allegation of abuse to the state survey agency within two hours of the initial allegation. The resident involved, R44, has multiple diagnoses including COPD with acute exacerbation, gait and mobility abnormalities, anxiety disorders, depressive episodes, psychoactive substance abuse, and hypertension, with a BIMS score of 12 indicating moderate cognitive impairment. R44’s care plan notes a history of suspected abuse/neglect and behavioral symptoms, including involvement in other residents’ care and difficulty with adjustment and mood. On the evening of 01/04/26, R44 wrote a letter to the Administrator/Executive Director describing an incident in which a CNA (V17) allegedly spoke hostilely to R44’s roommate, told R44 to “shut up,” blocked R44’s path, threatened to throw R44 out of the window, and bumped R44 as the CNA left the room. R44 reported feeling like a “nervous wreck” and physically shaking, and stated she went to the nurse’s station and then downstairs to report the incident and write the letter, which the receptionist placed in the administrator’s mailbox.

On 01/06/26, during an interview, R44 again described the incident, stating that the CNA refused to immediately change the roommate, used profanity toward R44, blocked her from leaving the room, and threatened to throw her out the window, causing significant fear and shaking. R44 reported that she informed the nurse at the nurse station, then went downstairs, where the receptionist provided pen and paper for her to write a letter that was placed in the administrator’s mailbox. R44 also stated she told the Executive Director and the Social Worker about the incident. The Social Worker (V6) confirmed that R44 complained that a staff member was very abusive and that V6 reported this to the Executive Director. The receptionist (V7) confirmed that R44 came downstairs, complained that someone had threatened to push her out the window, and wrote a letter that V7 placed in the administrator’s mailbox; V7 acknowledged that this could be considered an allegation of abuse and that she did not follow protocol, treating it more as a complaint.

The Executive Director (V2) stated that R44 interrupted him on 01/05/26 and gave a generalized account of a confrontation with a CNA who had dropped off food and was to care for the roommate. V2 checked the schedule and identified that the CNA was on duty, and acknowledged that R44 said the CNA threatened her. V2 reported that he considered the situation abuse and that he “probably should have reported it yesterday,” explaining that he initially thought R44 was having psychosis based on her care plan. The facility’s Abuse Report Initial Form, dated 01/06/26 at 12:10 PM, documents that the facility became aware of the incident at 10:30 AM on 01/06/26, lists the Administrator as the first staff aware, and characterizes the allegation as verbal/mental abuse by an unknown CNA. The facility’s Abuse and Neglect policy requires that all allegations of abuse be reported to the Administrator immediately and that all allegations be reported to the state agency immediately, not exceeding two hours after the initial allegation is received. Despite multiple notifications and the written letter on 01/04/26, the allegation was not reported to the state agency within the required two-hour timeframe, resulting in the cited deficiency.