The incident at Stonebrooke Rehabilitation Center happened on October 15, but the facility's executive director didn't learn about the alleged verbal abuse until the next day — violating federal requirements for immediate reporting of suspected abuse.
Resident C, who has chronic pain syndrome and major depressive disorder but remains cognitively intact according to her September assessment, became upset and tearful after receiving care from CNA 9 that morning.
CNA 2 witnessed the incident. During an October 23 interview with federal inspectors, she described how CNA 9 "hushed Resident C when she was apologizing for being wet, making hand gestures for her to shut her mouth and stop talking, and throwing dirty linens on the floor."
The coworker wrote out a statement about what she saw and placed it under every director's door that night. The directors found the reports when they arrived at work October 16.
"CNA 2 indicated she should have notified the Executive Director sooner," inspectors noted.
But CNA 2 wasn't the only staff member who knew something was wrong.
An occupational therapist arrived in Resident C's room later that same day for a therapy treatment. The resident was still tearful and told the therapist what had happened during her morning care.
Resident C described how "CNA 9 had rushed in and out of her room earlier that day, hushed her during care and made hand gestures for her to shut her mouth when she was apologizing for being wet."
The occupational therapist immediately sought out the Social Service Director to report the resident's distress. She found the director in a family meeting.
The Social Service Director told the therapist she would notify the Executive Director once the meeting ended.
She didn't.
Instead, the Social Service Director went to check on Resident C that afternoon. During their conversation on October 15, the resident didn't mention the morning incident with CNA 9.
It wasn't until the next day, October 16, that Resident C told the Social Service Director what had actually happened during her care.
By then, the Director of Nursing had already discovered CNA 2's written statement under her office door when she arrived at work that morning.
"The DON indicated once she read CNA 2's statement, she notified the ED who was off of work, who then reported the incident to IDOH reporting care concerns," inspectors wrote.
The Executive Director was not at the facility when the incident occurred on October 15. She told inspectors she "did not know it was an alleged abuse allegation until she began investigating the incident and spoke with Resident C."
Federal regulations require nursing homes to immediately report suspected abuse to administrators. The facility's own policy states that "any individual who witnesses abuse, or has suspicion of abuse, shall immediately notify the charge nurse of the unit, which the resident resides and to the Executive Director."
The policy uses the word "immediately" twice in describing reporting requirements.
Yet multiple staff members knew about the incident on October 15 — CNA 2 who witnessed it, the occupational therapist who heard about it from the distressed resident, and the Social Service Director who was told to notify the Executive Director.
None of them followed the immediate reporting requirement.
The occupational therapist told the Social Service Director, who said she would handle it but didn't. CNA 2 wrote statements and left them under doors, but didn't directly contact the Executive Director as policy required.
The delay meant the Executive Director couldn't begin investigating the alleged abuse until October 16, more than 24 hours after it occurred.
During that delay, Resident C remained in the facility receiving care from the same staff, including potentially the same nursing assistant who had allegedly abused her the day before.
The inspection report doesn't indicate what disciplinary action, if any, the facility took against CNA 9 after the investigation began.
It also doesn't specify whether CNA 9 continued providing care to residents during the period between the incident and when the Executive Director finally learned about it.
Federal inspectors found the facility failed to timely report the incident of alleged verbal abuse to the Executive Director, affecting one resident reviewed for reporting abuse.
The violation carried a determination of "minimal harm or potential for actual harm" affecting "few" residents.
But for Resident C, who was already dealing with chronic pain and major depression, the impact was immediate and visible. She spent the day tearful and upset, telling her occupational therapist about the morning's humiliation hours after it occurred.
The resident had been apologizing for something she couldn't control — incontinence that required assistance from nursing staff. Instead of receiving compassionate care during a vulnerable moment, she was told to shut up and subjected to staff complaints about having to clean up after her.
The incident highlighted a breakdown in the facility's reporting system that left a cognitively intact resident's abuse allegations unaddressed for more than a day while she continued receiving care in the same environment.
Multiple staff members knew something serious had happened to Resident C on October 15. Each had opportunities to immediately alert the Executive Director as policy required.
Instead, they passed responsibility to each other while the resident who had been humiliated during intimate care waited another day for someone in authority to take her seriously.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stonebrooke Rehabilitation Center from 2025-10-23 including all violations, facility responses, and corrective action plans.
Additional Resources
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