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F0550
F

Failure to Maintain Resident Dignity Due to Staff Altercation

Washington, Illinois Survey Completed on 06-25-2025

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

The facility failed to maintain an environment free from inappropriate staff behavior, specifically failing to provide respect and dignity for residents. Documentation and interviews revealed that certified nursing assistants (CNAs) engaged in verbal arguments in resident areas, with multiple residents and staff reporting that such incidents were observed and created discomfort. Resident council meeting minutes and concern forms documented ongoing issues with staff approach and professionalism, and residents reported feeling uncomfortable due to staff arguing and unprofessional conduct. On a specific occasion, two CNAs were involved in a physical altercation in a hallway where residents reside. Video evidence and staff interviews confirmed that one CNA approached another in an assigned area, leading to a verbal argument that escalated when one CNA pushed the other. The altercation was witnessed by residents and staff, and both CNAs had prior disciplinary records for attendance and conduct issues. The incident occurred in a public area of the facility, directly impacting the environment experienced by residents. The facility's own policies and job descriptions require staff to treat residents and each other with respect and dignity, and to maintain a safe, homelike environment. Despite these requirements, the documented staff conflict and lack of effective intervention prior to the altercation resulted in a failure to uphold residents' rights to a dignified existence and a respectful environment. The deficiency had the potential to affect all residents in the facility.

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