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F0600
D

Failure to Protect Resident from Physical Abuse by Another Resident

Mount Zion, Illinois Survey Completed on 04-18-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with a history of depression, general anxiety disorder, PTSD, and prior experiences of abuse was physically assaulted by another resident diagnosed with dementia and severe cognitive impairment. The incident occurred when the resident with dementia approached the other resident in the dining room, demanded her seat, and, upon refusal, struck her in the left arm with a closed fist and attempted to pull her out of her chair. The assaulted resident called for staff, who intervened and separated the two individuals. The assaulted resident was visibly upset and reported feeling unsafe for several days following the incident. The care plan for the assaulted resident documented her vulnerability to abuse due to her medical and trauma history, including frailty and prior abuse. Staff interviews confirmed the sequence of events, and a witness corroborated that the physical assault took place. The facility's abuse policy requires staff to ensure residents remain free from abuse, but the incident demonstrated a failure to protect the resident from physical harm by another resident.

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