F0610

F

Failure to Substantiate Resident Abuse and Exploitation Allegations

Havana, Illinois Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to recognize and substantiate clear instances of abuse under its own Abuse Prevention and Reporting policy. The policy defines abuse as the willful infliction of injury, intimidation, or punishment causing physical harm, pain, or mental anguish, and mental abuse as verbal or nonverbal conduct that causes or has the potential to cause humiliation, intimidation, fear, shame, agitation, or degradation. It also defines exploitation as taking advantage of a resident for personal gain through manipulation, intimidation, threats, or coercion. Despite these definitions, the Administrator, who serves as the Abuse Coordinator, determined that two separate abuse allegations were not substantiated.

In the first incident, the facility’s Final Abuse Investigation dated 1/23/26 documented that a CNA (V5) raised her voice, used profanity, and pushed another CNA (V7) in the presence of residents, with residents witnessing the altercation and staff member screaming, cursing, and threatening anyone who tried to calm her down. Multiple residents (R1–R7) later described being present or affected: one resident recalled the CNA “beating up” the other CNA and described it as very scary; another resident, who described himself as able to care for himself, expressed concern for residents who could not protect themselves; another resident reported the building was tense afterward. Nursing notes documented residents as alert and oriented, with one having a sad and worried look, another having episodes of crying and verbalizing fear related to witnessing the altercation, and another stating he was struggling with having been a witness and was very angry about it. The Administrator acknowledged that five residents were in the hallway and witnessed the attack but concluded the allegation was not substantiated because no residents were physically involved, none were within arm’s reach of the aggressor CNA, and the CNA did not specifically threaten to harm a resident.

In the second incident, the facility’s Final Abuse Investigation dated 3/6/26 documented that a resident (R2) reported loaning a CNA (V3) $50, which she did not repay. R2, who manages his own finances and is described by the Administrator as alert, oriented, usually laid back, and not known to fabricate stories, stated he gave the CNA a $50 bill after she complained about her money situation. Another resident (R3), also described as alert, oriented, and not known to fabricate stories, reported that the same CNA had asked him for money, which he refused. The CNA in question refused to participate in interviews and made herself unavailable despite multiple attempts to contact her. Nonetheless, the Administrator determined the allegation was unsubstantiated, stating that R2 could not prove he had given the money or even possessed $50, and further asserted that it should not be considered abuse because the resident had offered the money on his own accord and, therefore, it was not misappropriation of funds.