F0610

E

Failure to Remove Accused CNA From Resident Contact During Abuse Allegation

Chrisman, Illinois Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its Abuse Prevention Program by not immediately removing from resident contact an employee accused of verbal abuse and by not documenting or initiating an abuse investigation when first informed of the allegation. The facility’s October 2022 Abuse Prevention Program states that visitors are encouraged to report suspected abuse immediately to the administrator or an immediate supervisor, who must then report to the administrator, and that employees accused of abuse will be removed from resident contact immediately and not permitted to return to work until the administrator reviews the investigation results and determines the allegation is unsubstantiated. A cognitively intact resident (R6), per a recent Minimum Data Set, reported that about a week prior, a CNA (V41) assisted with a bedpan during the night and responded to the resident’s comments about being too hot or too cold by stating that the resident needed to make up their mind because the CNA was not going to keep coming into the room every five minutes and was only required to come every two hours. R6 described this interaction as scolding, belittling, and abusive, and stated they did not like being treated that way and believed it was a dignity issue and abuse.

R6 believed this concern had been reported to a corporate marketer (V42) the previous Thursday, yet when surveyors reviewed the facility’s abuse log on 3/17/26, there were no documented allegations involving R6. The allegation was reported to the DON (V2) on 3/17/26 at 12:10 PM. V2 stated that V42 had spoken with R6 the day before and that R6 reportedly did not recall the incident, so abuse was not suspected, and V2 had not yet spoken with V41. Despite the facility policy requiring immediate removal of accused staff from resident contact pending investigation, V41 reported working the previous evening from 6:00 PM to 6:00 AM on Hall 1 of the 200 unit and answering call lights on other halls, including assisting R6 onto the bedpan that night. Timecard records confirmed V41 worked from 5:47 PM on 3/16/26 until 5:57 AM on 3/17/26. The Resident List Report for that date shows that residents R13–R21 reside on Hall 1 of the 200 unit, indicating that during the period when the allegation was known to at least one staff member, the accused CNA continued to have access to multiple residents.