Failure to Report and Investigate Resident-to-Resident Abuse Allegation
Summary
The facility failed to follow its abuse prevention and management policy regarding timely reporting and investigation of a resident-to-resident allegation of physical abuse. Resident 1, who had hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, dysphagia, and heart failure, was cognitively moderately impaired and required maximal assistance to dependent for ADLs. On the date of the incident, an SBAR documented that another resident (Resident 2) accidentally bumped into Resident 1’s right face, hitting the right upper cheek, and that Resident 2 was apologetic. However, during an interview, Resident 1 reported that Resident 2 was yelling and arguing, then hit Resident 1 in the face with both fists, and ended up on top of Resident 1’s bed after Resident 1 tried to push the bedside table to push Resident 2 away. Resident 1 stated there were no staff present when this occurred and that he later explained the incident to staff. LVN 1 reported that Resident 2 returned from an out pass yelling, walking wobbly, and smelling of alcohol, and that he assumed Resident 2 had been drinking based on a brown paper bag with a can inside. LVN 1 stated he directed Resident 2 back to his room, where Resident 1 was also present, and then heard a loud crashing sound. Upon entering the room, LVN 1 found Resident 2 on top of Resident 1 and observed that Resident 1 subsequently had a black eye. When questioned, Resident 1 told LVN 1 that Resident 2 fell on top of him and asked that Resident 2 not be allowed to return to the room. LVN 1 stated he did not witness the actual contact and that Resident 2, who was intoxicated, could not clearly explain what had happened. LVN 1 reported the incident to RN 1. RN 1 documented in Resident 2’s progress notes that Resident 2 returned from pass, was yelling and cursing, and that while walking toward his bed, Resident 2 grabbed the bedside table for support and his elbow accidentally touched Resident 1’s right cheek, with staff supporting Resident 2 to prevent a fall. During interview, RN 1 acknowledged she had not witnessed this and that she should not have documented the event as an accidental elbow contact without further investigation. The Administrator later stated he was not in the facility when the incident occurred and that he had just seen Resident 1 with a black eye and needed to further investigate and interview staff and residents. Despite the facility’s written policy requiring the Administrator or designee to immediately initiate an investigation upon receiving an abuse allegation and to notify law enforcement and submit written SOC341 reports to the Ombudsman, law enforcement, and CDPH within two hours, the facility did not implement these reporting and investigative requirements for this resident-to-resident allegation of physical abuse and did not submit a conclusion report of investigation within five days or in accordance with state or federal law.
Penalty
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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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