Landmark of Itasca: Abuse Allegation Ignored for Months - IL
The incident at Landmark of Itasca Rehabilitation and Nursing Center, a skilled nursing facility at 535 South Elm in Itasca, came to light during a complaint inspection completed April 29, 2026. What inspectors found was not a complicated case. There was a resident who said she was hit. There was a witness in the next room. There was a police visit to the facility the same night. And there was an administrator who looked at all of that and concluded it did not meet his definition of abuse.
The resident, identified in inspection records as R4, told an inspector on April 23, 2026 what happened on the night of December 3, 2025. She had returned from dinner to find that the certified nursing assistant, identified as V26, had taken dishes R4 had left on the bathroom sink she shares with her neighbor. When R4 confronted V26 about it, V26 hit her with a garbage bag.
R4 called the police. Officers came to the facility that night.
The next morning, the administrator, identified in the report as V1, spoke with R4. She told inspectors he did nothing about it.
R4's medical record showed she has diagnoses including depression, chronic obstructive pulmonary disease, and gastroesophageal reflux disease. Her most recent assessment, dated March 29, 2026, documented that her cognition was intact and that she was independent in her daily activities. She was not a confused resident making an uncertain claim. She was a woman who knew what had happened to her, called the police over it, and then watched the person who hit her keep coming to work.
The neighbor, R9, whose room shares the bathroom where the dishes had been left, told inspectors on April 24 that she witnessed V26 hitting R4 with the garbage bag. R9's own assessment showed intact cognition and independence in daily activities. Two residents, both cognitively intact, describing the same event.
V26 was not removed from the floor. No investigation was opened. The facility did not notify the Illinois Department of Public Health.
When an inspector asked the administrator directly on April 23, 2026 whether he had reported the incident, V1 said he had not, because he did not believe it met the facility's definition of abuse. He acknowledged the incident was not reported to IDPH until April 22, 2026 — the day before inspectors interviewed R4, and nearly five months after the night R4 called the police. He said an internal investigation had been initiated at that point. He also confirmed that V26 had continued working at the facility throughout.
The Director of Nursing, V2, and the Assistant Director of Nursing, V3, told inspectors the following day that the facility had overlooked the incident and that the abuse allegation should have been addressed in a timely manner. That was the extent of the explanation offered by facility leadership: they overlooked it.
The facility's own written policy on abuse prevention, last revised in January 2019, states that the facility will not tolerate resident abuse, will define how investigations of abuse allegations are conducted, and will outline the process for reporting, investigating, and reaching conclusions about allegations. The policy existed. The administrator knew it existed. He chose not to apply it.
What the inspection report describes is a sequence of decisions, not a single oversight. Someone had to decide, on December 3, that the police coming to the facility was not enough to trigger a report. Someone had to decide, on December 4, that speaking with R4 and taking no action was sufficient. Someone had to decide, over the weeks that followed, that V26 could keep working. Someone had to decide, again and again through January, February, March, and into April, that none of this required a call to the state. V1 was that person, and he told inspectors plainly that he made those decisions because he did not believe the incident met his definition of abuse.
The inspection cited the deficiency as causing minimal harm or potential for actual harm, affecting few residents. That is the regulatory classification. It does not capture what it meant for R4 to live next door to the person she says hit her, in a facility that had decided her account did not rise to the level of something worth investigating.
Facilities that receive Medicare and Medicaid funding are required to report abuse allegations to state health departments promptly and to protect residents during investigations, which typically means removing the accused employee from resident contact while the investigation is underway. Neither happened here. V26 remained on the job. The report went unfiled for 141 days.
The facility's plan of correction was not included in the inspection documents reviewed. Inspectors noted that for information on the nursing home's plan to address the deficiency, the public should contact the facility or the state survey agency directly.
R4's neighbor witnessed what happened to her. The police came. The morning after, the administrator spoke with R4 and, by her account, did nothing. By the time inspectors arrived in April, the facility had just filed the report it should have filed in December, and the certified nursing assistant who allegedly swung a garbage bag at a resident had been working at Landmark of Itasca for five months since.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Landmark of Itasca Rehabilitation and Nursing Cent from 2026-04-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 7, 2026 · Our methodology
Landmark of Itasca Rehabilitation and Nursing Cent in ITASCA, IL was cited for abuse-related violations during a health inspection on April 29, 2026.
What inspectors found was not a complicated case.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.