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F0600
D

Resident Deprived of Personal Jacket Due to Exit-Seeking Behaviors

Toulon, Illinois Survey Completed on 09-17-2025

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 a resident from abuse by depriving him of his personal jacket, which he relied on for warmth due to his constant feeling of being cold. The resident's jacket was taken by a Certified Nursing Assistant (CNA) because the resident was exhibiting exit-seeking behaviors, and the CNA believed that having the jacket increased these behaviors. The jacket was placed in the shower room and not returned to the resident, despite his repeated requests and complaints of being cold. The resident was observed using a blanket to keep warm in the absence of his jacket, and both the resident and his family reported his ongoing discomfort and distress due to the missing jacket. Multiple staff members, including the Director of Nursing (DON) and other CNAs, were aware that the jacket had been taken and that the resident was left without it for several weeks. The facility's policy prohibits the deprivation of goods or services necessary for residents' well-being, yet no further investigation was conducted by the DON after being notified of the incident. The resident's family and Power of Attorney also raised concerns about the deprivation, but the jacket was never recovered, and the resident continued to experience discomfort as a result.

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