F0609

E

Failure to Timely Report and Investigate Resident-to-Resident Verbal Abuse Allegations

Bement, Illinois Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s repeated failure to timely report allegations of resident-to-resident verbal abuse to the Illinois Department of Public Health (IDPH) as required by its abuse prevention policy. One resident (R18) had a BIMS score of 12/15, indicating moderate cognitive impairment, and another resident (R15) had a BIMS score of 15/15, indicating no cognitive impairment. R18 reported that approximately one week prior to the survey, R15 yelled, cussed, and repeatedly used the f*** expletive toward her, causing R18 to feel afraid and fearful of retaliation. R18 stated she had been R15’s roommate and was moved to a separate room after this incident, and she described R15 as regularly using offensive language and a confrontational tone.

Staff interviews revealed that facility leadership was aware of at least one verbal altercation between these two residents before the surveyor’s notification, but no investigation or required external reporting was initiated at that time. The Social Service Director (V10) stated that on the day before the survey, the psychotherapist/LCSW (V7) reported that R15 and R18 had a verbal altercation, and V10 directed V7 to report this to the Administrator/Abuse Prevention Coordinator (V1). V1 later confirmed that V7 had reported that R15 called R18 a derogatory name (“d*****s”) on that date, but V1 did not initiate an investigation, did not interview residents or staff, and did not notify IDPH at that time, despite acknowledging that the allegation should have been investigated and reported.

Further, a CNA (V9) reported that about a week prior to the LCSW’s report, there had been another incident in which R15 yelled at R18, with both residents eventually arguing back and forth. V9 stated that R18 was initially very upset and that V9 intervened to de-escalate the situation, then immediately reported the incident to the Administrator and that another CNA reported it to a nurse. V9 stated that no one interviewed her about the incident and that the residents were not moved to separate rooms until several days later. The facility’s undated Abuse Prevention Policy requires accurate and timely investigative reports and mandates that when an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation is made, the Administrator or designee must immediately notify the Department of Public Health’s regional office. Despite these policy requirements and multiple staff reports of verbal altercations, the facility did not timely investigate or report the allegations of verbal abuse involving R15 and R18 to IDPH until after the surveyor brought the issue to the Administrator’s attention.