Failure to Report Multiple Allegations of Sexual Abuse and Violations of Dignity
Summary
The deficiency involves the facility’s failure to report multiple allegations of sexual abuse and violations of dignity and privacy involving four cognitively intact residents to required external authorities, despite its own policy mandating immediate reporting of suspected abuse, neglect, exploitation, or misappropriation. The facility’s policy, dated August 21, 2025, required that the administrator or the individual making the allegation immediately report suspicions to the state licensing agency, local/state ombudsman, the resident’s representative, adult protective services, law enforcement, the attending physician, and the medical director. Surveyors found no documented evidence that these entities were notified regarding the allegations against a male nurse aide (Nurse Aide 1), and interviews with the Nursing Home Administrator and acting Director of Nursing confirmed that they did not report the incidents because they did not believe abuse had occurred. One cognitively intact resident (Resident 14), who was documented as always continent of urine and requiring minimal help with daily care, filed a grievance stating that around 5:00 a.m. a male nurse aide entered her room while she was sleeping and put his hand inside her pants to see if she was wet, without explaining what he was doing. She reported that he touched her genitalia inappropriately and that she felt violated, especially because she had no history of incontinence and could have been asked. She stated she requested to speak with a nurse immediately, but an LPN did not come until about 7:30 a.m., at which time she reported the incident to LPN 2. LPN 2 reported that she immediately informed the Director of Nursing, but that the Director of Nursing did not take the allegation seriously and the aide continued working. Another cognitively intact resident (Resident 6), who required assistance with incontinence care and was usually incontinent of urine and bowel, filed a grievance describing an incident during nighttime incontinence care with the same aide. She reported that he initially refused timely care, told her she was not allowed to defecate, commented that she had “pooped everywhere,” removed her nightgown and brief, and left her naked on the bed with the door and curtain open while he left the room twice to gather supplies. She stated he asked if she slept nude at home, said he liked looking at naked women while looking at her, and mentioned another woman he liked to look at naked. She also reported that he told her a coworker had accused him of touching her inappropriately and that he was supposed to be suspended, but staffing needs prevented a proper suspension. She stated she was not afraid for herself but feared for residents who could not speak for themselves. A third cognitively intact resident (Resident 7), who required help to get in and out of the bathroom and was always incontinent of urine and bowel, reported that she did not want the same aide to provide care because he startled her awake by sticking his hand inside her brief to check for wetness instead of asking her, as other staff did. She stated she did not like him putting his hand in her brief and did not want him back in her room. A fourth cognitively intact resident (Resident 1), who required observation for ambulation and was frequently incontinent of urine and bowel, was the subject of a grievance initiated by her daughter-in-law and Power of Attorney. The family member reported that the resident called her at about 1:00 a.m. crying, stating that the aide had put his hand inside her brief while she was sleeping and that his fingers penetrated her vagina, and that this had occurred two or three other times, causing the resident to fear she would be raped. Staff interviews corroborated that Resident 1 reported digital penetration by the aide to multiple staff members. A nurse aide (Nurse Aide 3) stated that Resident 1 told him that the male night-shift aide put his hand in her pants and touched her private area, and he immediately reported this to LPN 4. LPN 4 reported that Resident 1 told her the male aide put his hand inside her brief and his fingers penetrated her vagina, and LPN 4 immediately reported this to RN 5. RN 5 stated she then reported to the Director of Social Services that Resident 1 said the aide put his hand in her brief and his finger inside her vagina, and was told by the Director of Social Services and the Assistant Director of Nursing that they were already aware of the allegation, so she took no further action. Another RN (RN 6) reported that when staff asked if the aide would be working after the allegations, she approached the Nursing Home Administrator about replacing him on the night shift and informed him that a resident said the aide had “fingered her” two nights earlier; the Administrator stated he was not aware of the allegation. The Nursing Home Administrator and acting Director of Nursing stated in interview that they did not consider the allegation involving Resident 1 and the aide to be abuse and treated it only as a grievance. The acting Director of Nursing stated she was not aware of any sexual abuse allegations. The Administrator stated that when he became aware of the allegation, he had the Director of Social Services speak with Resident 1 and was told that the resident’s story had changed, so they concluded the incident did not occur. The Director of Social Services emphatically denied that any abuse occurred, stated she knew there was no abuse and wished people would stop saying that, and denied being told by the family member, RN 5, or the Administrator that the aide had touched the resident’s crotch or digitally penetrated her. Despite multiple resident grievances, resident and family reports of inappropriate genital touching and digital penetration, and staff reports up the chain of command, there was no documentation that these allegations were reported to the Department of Health, ombudsman, resident representatives, adult protective services, law enforcement, attending physicians, or the medical director, in violation of facility policy and state regulatory requirements.
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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