Failure to Timely Report Suspicious Death and Alleged Neglect Involving Choking and Cardiac Arrest
Summary
The deficiency involves the facility’s failure to timely report an alleged neglect-related incident and suspicious death to the State Agency within the required 2‑hour timeframe after an allegation or suspicion was formed. A male resident with end‑stage renal disease, bilateral lower extremity amputations, type II diabetes, dysphagia, impaired cognition (BIMS 7/15), reduced mobility, and need for assistance with personal care and eating was dependent on staff for transfers and required partial/moderate assistance with eating. His care plan and dietary assessments documented a mechanically altered, mechanical soft diet with thin liquids, monitoring for dysphagia signs (including choking), and staff assistance with eating due to weakness, dysphagia, and impaired cognition. An undated dashboard entry also instructed staff to assist the resident in eating due to inability to see. At a care plan meeting earlier in the month, the responsible party (RP) had voiced concerns that the resident was not being fed despite her ordering food, and the facility had indicated CNAs would attempt to feed him. On the evening of the incident, the assigned LVN spoke with the RP, who asked about ordering food; the resident declined delivery, and the LVN told the RP that the Dietary Manager was preparing food for the resident. The LVN then informed the assigned CNA that the Dietary Manager was bringing food and that the resident would need assistance with eating. Video footage later showed the LVN entering and exiting the resident’s room, followed by the Dietary Manager entering with a meal tray and leaving a few minutes later, with no other staff entering the room for approximately 24 minutes until the CNA went in. The Dietary Manager reported that she had found two untouched trays earlier, that the resident requested a turkey sandwich with cheese and mayonnaise, and that she removed the old trays, prepared the sandwich, and returned with the sandwich and a banana. She stated she placed the tray on a bedside table near the door, out of the resident’s reach, told him she would get a soda, and informed him that the CNA would be in shortly to assist with eating, but she was then diverted to another resident (her mother) with chest pain and remained there while EMS responded. When the CNA later entered the resident’s room to feed him, she observed a tray with half a sandwich pushed away from the bed, the other half of the sandwich in the resident’s hand, food sliding down the side of his mouth, and no response, respirations, or palpable pulse. Staff initiated CPR and EMS, who were already in the building for another resident, were brought to the room. EMS documented that the resident’s airway was completely obstructed by emesis, with large white, creamy chunks suctioned from the mouth, airway, and vocal cords, which EMS described as appearing to be food material, and EMS stated it was very likely the resident had been choking prior to cardiac arrest. Hospital records noted he arrived with CPR in progress and was later pronounced deceased. The RP reported to staff and EMS that she believed the resident had choked and expressed concerns about the staff’s response and the lack of supervision during eating, and EMS relayed to her that choking was suspected. Despite the RP’s expressed concerns, the resident’s known need for assistance with eating, the presence of food in his hand and mouth, and EMS’s findings of food‑like material obstructing the airway, the Administrator and DON concluded the resident had experienced cardiac arrest (or possibly pulmonary embolism), did not consider the death suspicious or neglect‑related, and determined the event was not reportable. As a result, the facility did not report the alleged neglect or suspicious death to the State Agency within the required 2‑hour timeframe, contrary to federal requirements and the facility’s own policy that all alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, be reported immediately within prescribed timeframes.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Report Allegation of Verbal Abuse: A resident with HTN, anxiety disorder, and hyperlipidemia reported that a staff member yelled at her during resident council. Facility records showed a nurse aide was disciplined and retrained on communication, but the allegation was not included in the abuse reports submitted to the State. The DON confirmed the required report was not filed.
Failure to Timely Report Alleged Abuse: The facility did not report an allegation of abuse involving a cognitively intact resident with stroke, coordination, and anxiety diagnoses to HHSC within the required 2-hour timeframe. The resident alleged that an CNA had bullied her during a smoke break, and the Administrator acknowledged the report should have been made within 2 hours but was not submitted until later that day.
Failure to Report Allegations of Verbal Abuse and Involuntary Seclusion: The facility did not report multiple grievances involving an RN and an LPN to the SA, including resident complaints of rude and disrespectful comments, yelling, scolding, and blocking residents from entering their rooms when they tried to self-transfer. Documentation showed incomplete grievance investigations, delayed administrator sign-off, and no timely reporting of the allegations as verbal abuse or involuntary seclusion.
A resident reported being frightened after another resident repeatedly entered the room, grabbed belongings, and acted aggressively, but the concern was not reported to the SA within 2 hours. In a separate incident, a cognitively intact resident returned from the ER with a minor labial tear/perineal laceration and minimal bleeding, yet the DON and administrator did not treat it as reportable abuse or an injury of unknown source and did not investigate it.
A facility failed to report an alleged mistreatment during a resident’s hair grooming to the State Agency within the required timeframe. The resident had dementia, depression, severe cognitive impairment, and was dependent on staff for grooming and hygiene. Records showed a matted area of hair was removed, leaving a reddened scalp, and staff later described the event as an abuse allegation that should have been reported.
Failure to Timely Report Injury of Unknown Origin: A resident with dementia and multiple medical diagnoses developed unexplained right elbow swelling, redness, warmth, and pain, later found to be a dislocation with fracture. An LPN notified the NP, DON, and family and a STAT x-ray was ordered, but the initial report to IDPH was not made within the required two-hour timeframe after the injury of unknown origin was identified.
Failure to Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to submit a report of an allegation of verbal abuse involving one resident. Facility policy stated that all allegations of abuse must be reported immediately to the Administrator and the applicable State agency, and verbal abuse was defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms. Review of the resident’s record showed diagnoses including hypertension, anxiety disorder, and hyperlipidemia. Resident council minutes documented that the resident told staff that a staff member had yelled at her, and facility investigation documents showed a disciplinary action for a nurse aide related to the incident along with retraining on effective communication. The allegation was discussed in resident council, but the grievance documentation did not show a related grievance and the reported incidents submitted to the State did not include the verbal abuse allegation. During interviews, the Activities Director stated the incident happened and that the Director of Human Resources spoke with the aide, while the Director of Human Resources did not recall retraining or discussing the allegation. The resident stated the matter had been taken care of and that she had cursed the aide back. The DON confirmed that the facility failed to submit the required report of the verbal abuse allegation.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving Resident #80 was reported to HHSC within the required timeframe. Resident #80 was a female resident with diagnoses including cerebral infarction (stroke), lack of coordination, and anxiety disorder. Her quarterly MDS indicated she could make herself understood and understand others, and her BIMS score was 15/15, showing she was cognitively intact. Her care plan noted a behavior problem with interventions to protect the rights and safety of others, speak in a calm manner, divert attention, and remove her from the situation as needed. Record review showed the allegation involving Resident #80 was learned about at 1:00 p.m. on 08/03/2026, but it was not reported to HHSC until 5:04 p.m. the same day. The provider investigation report stated Resident #80 alleged that CNA P had bullied her sometime during the prior week, around 6:30 p.m. during a smoke break, though she could not recall exactly what was said or the setting. During an interview, the Administrator stated he initiated the investigation at 1:00 p.m. and acknowledged the allegation should have been reported within 2 hours. CNA P stated she was not the resident’s assigned CNA and said she had helped push Resident #80’s wheelchair after a smoke break when the resident accused her of trying to push her out of the wheelchair.
Failure to Report Allegations of Verbal Abuse and Involuntary Seclusion
Penalty
Summary
The facility failed to report allegations of verbal abuse and threats of involuntary seclusion involving an RN and an LPN to the State Agency. One grievance involved a resident who reported the LPN was rude, stern, and spoke in a manner the resident felt was not nice. During the related interview, the LPN acknowledged making comments about the resident not taking direction well from women and said her word choice was not the best, while the concern was addressed only as unprofessional communication and education on professional conversation was documented. The administrator did not sign off on the report until months later, and there was no report made to the State Agency. A second grievance involved a resident who reported hearing the RN yelling loudly at another resident and then entering the resident’s room and saying she did not like him and that he was not a good patient. The RN denied yelling and said she was reminding the resident to ask for help. The resident who heard the exchange later stated she had no concerns about how the RN treated her, and the resident who was the subject of the yelling said he felt safe and that staff were treating him well. The grievance documentation did not identify the yelling as an allegation of verbal abuse, and it was not reported immediately to the State Agency or the administrator at the time it occurred. A third grievance involved a resident who reported the RN told her she was going into a time-out and said, "you don't know what you are doing," which made the resident feel inadequate. Additional interviews and an email described multiple residents being upset by the RN’s tone, yelling, and blocking residents from entering their rooms when they attempted to self-transfer. Staff described the RN as assertive and bossy, and one staff member reported the RN stood in front of a resident’s door and scolded him while preventing him from entering. The grievance record contained incomplete interviews, blank resolution and follow-up sections, and no indication that the allegations of verbal abuse or involuntary seclusion were reported to the State Agency as required.
Failure to Report Suspected Abuse and Unexplained Injury
Penalty
Summary
The facility failed to immediately report suspected resident-to-resident abuse to the state agency within 2 hours for a cognitively intact resident who reported being scared of another resident. The resident stated that the other resident had entered the room multiple times during the night, grabbed belongings, snarled at the resident, and left the room. Nursing documentation also showed the resident placed a walker in front of the door on two nights to keep the other resident out and stated, "I'm scared to death of him." The DON was notified of the situation, and staff interviews confirmed the concern was treated as a resident-on-resident altercation with possible abuse, but no state report was made because the facility did not believe it reached the level of potential abuse. The other resident involved had moderate cognitive impairment, vascular dementia with agitation, and Alzheimer's disease. The MDS indicated this resident paced and wandered daily and significantly disrupted the care or living environment of other residents. Progress notes described frequent roaming into other residents' rooms and frequent agitation toward staff and residents. During interviews, staff stated that any nursing staff could file a vulnerable adult report, and the DON acknowledged that a resident-on-resident altercation with concerns of abuse should be reported to the state agency within 2 hours of learning about it. The facility also failed to report and investigate a resident's unexplained perineal injury as potential sexual abuse or an injury of unknown source. The resident was cognitively intact, frequently incontinent, and required substantial to maximum assistance with activities of daily living and peri care. After an emergency room visit, the resident was found to have a very minor labial tear/abrasion at the 12 o'clock position with minimal blood present, and the AVS listed a diagnosis of laceration to the perineum. Staff asked the resident whether anyone had been rough or abusive during care, and the resident denied abuse. The DON and administrator stated they did not consider the injury reportable because they believed it was similar to a prior situation and did not feel the injury of unknown origin needed to be reported or investigated.
Failure to Report Alleged Mistreatment During Hair Grooming
Penalty
Summary
The facility failed to ensure an alleged mistreatment during grooming and hygiene was reported to the State Agency within two hours for one resident. The resident had diagnoses of dementia and depression, and a quarterly assessment showed a BIMS score of 3, indicating severe cognitive impairment. The assessment also showed the resident was dependent on staff for grooming and hygiene. A Concern/Grievance Report documented that a mat of hair was removed from the back of the resident’s head and a reddened area was noted afterward. A nurse’s progress note the same day stated the resident’s scalp was red and irritated and that the resident did not want to get up. The facility’s investigation records showed no documentation that the allegation of mistreatment during hair grooming was reported to the State Agency. During interviews, staff stated the resident had a matted area of hair that was brushed out, after which the resident was heard hollering in pain, and the administrator later stated the matter should have been reported as an abuse allegation.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its Injury of Unknown Origin Policy and did not report an injury of unknown origin within two hours of the incident to IDPH for one resident. The resident was 95 years old and had diagnoses including dementia with mood disturbance, major depressive disorder, anxiety disorder, Alzheimer's disorder, dislocation of the right ulnohumeral joint, essential hypertension, overactive bladder, and chronic kidney disease. Records and interviews showed the resident's right elbow became swollen, red, warm, and hard to touch, and the resident was yelling that the arm was broken. An LPN assessed the resident, gave pain medication, notified the NP, DON, and family, and a STAT x-ray was ordered. The x-ray results were received later that evening, and the resident was sent to the hospital early the next morning, where hospital documentation showed arrival at 7:11 AM and a diagnosis of right elbow dislocation with mildly displaced fracture of the tip of the coronoid and olecranon process. The Administrator stated the initial IDPH report was sent at 8:08 AM the following morning, but also stated the report should have been sent on the day the swelling was first identified because the source was unknown. The facility policy stated that any injury with an immediately undetermined cause, including swelling, fractures, and unexplained pain or tenderness, is to be treated as an injury of unknown origin, and the abuse policy required immediate reporting of reasonable suspicion of a crime against a resident, not later than two hours after the allegation when serious bodily injury results.
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