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F0600
D

Failure to Prevent Resident-to-Resident Physical Abuse

Normal, 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 protect two residents from physical abuse, as evidenced by two separate incidents involving physical altercations between residents. In the first incident, a resident with a history of atherosclerotic heart disease and developmental delays reported being struck on the hand by another resident diagnosed with vascular dementia, agitation, autism, and dysphagia. The injured resident experienced pain and redness, and staff applied an ice pack to the affected area. Witness statements and a police report confirmed the altercation, with staff noting that the two residents were in close proximity and waving their arms at the time of the incident. In the second incident, a resident with severe unspecified dementia and major depressive disorder was scratched on the hand by another resident with moderate dementia, cognitive communication deficit, and dysphagia. Witness statements indicated that the resident who was scratched did not provoke the other resident. Both incidents were documented in care plans and reported to the appropriate authorities, but the facility's actions were insufficient to prevent these occurrences of physical abuse between residents.

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