F0607

D

Failure to Implement Abuse Policy and Investigate Alleged Staff-to-Resident Abuse

Macomb, Illinois Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its abuse policy and thoroughly investigate an allegation of staff-to-resident physical/sexual abuse. The facility’s written policy on residents’ right to freedom from abuse, neglect, and exploitation states that all associates must not use verbal, mental, sexual, or physical abuse and that, when abuse is identified, the facility will take steps to prevent further potential abuse, report alleged violations within required timeframes, and conduct thorough investigations of all allegations. The policy further specifies that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of resident property must be reported and thoroughly investigated.

During an interview, one resident (R12) reported that a male CNA (V12) smacked her behind while assisting her with toileting, and she stated she was very angry and bothered by the incident and had informed facility staff. The Administrator in Training (V1), who also serves as the facility’s abuse coordinator, initially stated there were no abuse investigations for the past six months and was unaware of any prior allegations or where such investigations would be kept. Later, V1 confirmed there had been an incident between this resident and the CNA in December 2025 but acknowledged there were no interviews or documentation related to investigating the allegation that the CNA hit the resident on the behind. V1 stated he had only interviewed the CNA about other staff issues, had not interviewed other residents about this employee, and had no investigation or related documentation to provide regarding this incident, demonstrating a failure to follow the facility’s abuse policy and to conduct and document a thorough investigation of the allegation.