Brandel Health and Rehab: Abuse Prevention Failures - IL

The failures emerged during a September 12 complaint inspection, when federal surveyors found that the facility had not completed trauma screenings upon admission for multiple residents, had not updated those screenings after abuse allegations were made, and had not developed individualized abuse prevention care plans for residents with cognitive impairment and behavioral issues who were at elevated risk. The residents are identified in inspection records by number. What the records show, case by case, is a pattern that nobody caught until inspectors arrived.

Resident 3 had cognitive impairment and behavioral issues. No abuse prevention care plan was initiated upon admission. An abuse allegation was filed on August 25, 2025. No trauma screening had been done. No care plan was developed after the allegation. The facility's Social Services Director, identified in the report as V3, told inspectors she had been on vacation when the incident occurred. The Memory Care coordinator, V14, had been in charge in her absence.

Resident 4 had no trauma screening done upon admission. An abuse allegation was filed on September 1, 2025. Again, no trauma screening. No abuse prevention care plan. The Social Services Director was on vacation. V14 was in charge.

Resident 5 had cognitive impairment and behavioral issues. No trauma screening upon admission. No abuse prevention care plan. An abuse allegation was filed on March 26, 2025. The Social Services Director was on vacation when that incident occurred too.

Then there is Resident 6.

Resident 6 had no care plan for abuse prevention and no trauma screening upon admission. On May 23, 2025, Resident 6 was sent to the hospital for shortness of breath and was admitted with a diagnosis of hypoxia and rib fractures. The facility completed and reported an injury of unknown origin the following day, May 24. By the time inspectors arrived in September, no abuse prevention care plan had been developed.

The inspection report does not explain how Resident 6 fractured their ribs. It does not need to. What it documents is that a vulnerable resident sustained injuries serious enough to require hospitalization, that the facility classified those injuries as being of unknown origin, and that no abuse prevention care plan existed before or after.

The Social Services Director's repeated absences appear throughout the report like a refrain. Three of the four residents with abuse allegations had their incidents occur while she was on vacation and V14 was covering. When inspectors interviewed V14, the Memory Care coordinator, on September 10, she offered an explanation for how screenings were handled. She said that upon admission, staff completed a trauma screening, but that they used a "trauma assessment" rather than an "abuse screening," and had been told to do it only once. She said she did not update a resident's trauma assessment after an allegation of abuse was made.

That explanation did not satisfy the facility's own staff. On September 9, both the Director of Nursing and the Social Services Director told inspectors that trauma screening assessments should be done upon admission, that a trauma assessment should be completed after any allegation of abuse, and that an abuse prevention care plan should be developed following any such allegation. They also said that cognitively impaired residents with behavioral issues should have abuse prevention care plans because those residents can react negatively to other residents, and other residents can react negatively to them.

The MDS Coordinator and Care Plan Coordinator, interviewed separately on September 10, said the same things. Social services should complete a resident trauma assessment and develop an abuse prevention care plan when an abuse allegation is reported. Vulnerable residents who are cognitively impaired with behavioral issues should be care planned for abuse prevention.

Everyone, in other words, knew what should have been done. Nobody had done it.

The facility's own policy on trauma-informed and culturally competent care, revised in August 2022, stated that staff should perform universal screening of residents upon admission, including a brief identification of possible exposure to traumatic events, and should develop individualized care plans that address past trauma in collaboration with the resident and family. The policy existed. The screenings did not happen. The care plans were not developed.

A separate facility policy on the Abuse Prevention Program, revised July 12, 2023, did not include screening of residents as required under the State Operating Manual, inspectors noted. The facility had updated that policy less than two years before the inspection. The screening requirement still was not in it.

On September 10 at 2:30 in the afternoon, inspectors informed the administrator and the Director of Nursing of their findings.

What the inspection report describes is not a single lapse or a staffing crisis on one bad night. It is a structural failure, repeated across at least four residents over a span of months, from March through September of 2025. Residents with cognitive impairment and behavioral challenges, residents the facility's own care coordinator acknowledged could react negatively to others and prompt reactions in return, went without the basic protective documentation that the facility's own staff said was required. When abuse allegations came in, the response was the same each time: no updated screening, no care plan, and a note in the record that the Social Services Director had been away.

Resident 3 waited. Resident 4 waited. Resident 5 had waited since March. Resident 6 came back from the hospital with fractured ribs and a diagnosis of hypoxia, and waited too.

The inspection was classified as causing minimal harm or potential for actual harm. The surveyors noted that some residents were affected. Resident 6 had already been to the hospital by then.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Brandel Health and Rehab from 2025-09-12 including all violations, facility responses, and corrective action plans.

Additional Resources

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