F0609

D

Failure to Report Resident-to-Resident Abuse Allegation to State Agency

West Chicago, Illinois Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report an allegation of abuse to the Illinois Department of Public Health (IDPH) as required by its Abuse Prevention Policy. A resident (R1) reported that another resident (R2) threatened her, including threats to hit her with a walker, shove the walker up her anus, and kill her. Staff interviews and written witness statements confirm that R1 told the Psychiatric Rehabilitation Services Counselor and the Assistant Administrator that R2 approached her in the dining room, grabbed her walker, made explicit verbal threats of physical harm and death, and that R1 stated she was scared and did not know what R2 was going to do. An investigation assessment and investigation document completed by the former Administrator describe the incident, including review of video footage showing R2 walking up to R1, speaking toward her, placing both hands on R1’s walker, lifting it slightly off the ground, and pushing it toward R1.

The facility’s Abuse Prevention Policy requires employees to report any incident, allegation, or suspicion of abuse to the Administrator immediately and requires the Administrator or designee to notify the Department of Public Health’s regional office immediately by telephone or fax when an allegation of abuse has been made. While the Assistant Administrator reported the allegation internally to the former Administrator and an internal investigation was conducted, the investigation documentation does not show that the allegation was reported to IDPH. The current Administrator reviewed the investigation report and stated that, based on the threats made toward R1, the incident should have been reported to IDPH and that she had no evidence that such a report was made by the facility.