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F0600
G

Failure to Protect Resident from Physical Abuse by CNA

Chicago, Illinois Survey Completed on 10-10-2025

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 certified nursing assistant (CNA) physically abused a resident with severe cognitive impairment in the facility's dining room. The CNA was observed on video grabbing and pulling the resident's ear, forcibly removing the resident from a chair, causing the resident to fall to the ground, and then picking the resident up and pushing him out of the dining room. The incident resulted in the resident sustaining bruising on both upper arms and a scratch on the ear. The resident, who has a history of dementia, cognitive communication deficit, and other neurological and psychiatric conditions, was at high risk for confusion and wandering. The abuse was not immediately witnessed by other staff, but signs of injury were noted over the following days. A CNA noticed a scratch and bleeding on the resident's ear, and a registered nurse trimmed the resident's nails, suspecting self-inflicted injury. The next day, bruising was observed on the resident's arms during a shower, and the nurse was informed. The resident initially stated he had bumped into a wall, but later reported that a man had touched or hit him, and subsequently refused to enter the dining room. These behavioral changes and physical findings prompted further investigation by facility management. Upon review of surveillance footage, the manager and administrator confirmed the abusive actions of the CNA. The CNA was not assigned to the resident but was responsible for monitoring the dining room. Staff interviews revealed no prior concerns or incidents involving the CNA, and the CNA had previously completed abuse prevention training. The abuse was substantiated through the facility's investigation, which included medical record review, staff statements, and direct observation of the video evidence.

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