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F0550
D

Failure to Protect Resident Rights and Dignity Due to Repeated Room Intrusions

Monmouth, Illinois Survey Completed on 07-01-2025

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 a resident's right to a dignified existence and safety by not preventing repeated intrusions and inappropriate behaviors from another resident. One cognitively intact resident reported multiple incidents where another resident entered her room without permission, struck her with a shoe, threw water at her, and defecated and urinated on her floor and bed. Despite the resident expressing fear and reporting these incidents to the Administrator and Director of Nursing multiple times, the only intervention implemented was placing a lock on the shared bathroom door, which did not prevent further unauthorized entries through the main room door. Nursing progress notes and interviews confirm that the resident continued to experience distressing and undignified situations, including being awakened to find the other resident standing over her, taking her clothing, and soiling her living space. Staff and social services were aware of the ongoing issues, and the resident continued to express fear and discomfort due to the lack of effective measures to prevent these intrusions and maintain her right to a safe and homelike environment.

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