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F0600
D

Failure to Prevent Resident-to-Resident Physical Abuse

Galesburg, Illinois Survey Completed on 04-10-2025

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-to-resident physical abuse incident occurred when one resident with a history of severe mental illness, but no recent aggressive behavior, threw a canister at another resident, hitting him in the knee, and then punched him in the chest. The incident took place near the drink station by the patio door, and was partially captured on facility camera footage, although the video was blurry and lacked audio. The resident who was struck was assessed for injuries, with no injuries or redness noted, and declined further medical attention. The incident was reported to the facility administrator and physician. Witness accounts confirmed that the aggressor slapped a cup of coffee out of the other resident's hand and then hit him in the chest, accompanied by a verbal statement. Staff, including an LPN, responded immediately after being notified by another resident who witnessed the event. The aggressor refused to be interviewed by the surveyor and was not observed near the victim following the incident. The facility's policy prohibits all forms of abuse, including resident-to-resident altercations, but the event demonstrates a failure to prevent such abuse in this instance.

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