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F0550
E

Staff Conflicts and Disruptive Behavior Compromise Resident Dignity and Quality of Life

West Frankfort, Illinois Survey Completed on 09-16-2025

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 that promotes the maintenance and enhancement of residents' quality of life, as evidenced by multiple incidents of staff members engaging in loud arguments, yelling, and using inappropriate language in the presence of residents. Interviews and record reviews revealed that staff conflicts, particularly among CNAs on the evening shift, were frequent and disruptive, with staff members yelling and cursing at each other in hallways and near the nurses' station. These altercations were witnessed by residents and other staff, and were described as ongoing and creating a chaotic atmosphere within the facility. One resident, who was cognitively intact and had a history of mental health diagnoses including bipolar disorder, schizophrenia, and anxiety, reported that staff frequently got loud and fought in front of residents, which contributed to agitation and restlessness. Staff interviews corroborated these accounts, with one CNA describing being harassed and verbally abused by coworkers to the point of feeling unsafe and needing to leave work early. Other staff, including an activity director and agency LPNs, confirmed that yelling and drama among staff were common occurrences, and that these behaviors were audible throughout the north and south halls where a large number of residents resided. Documentation showed that the facility's own policy required staff to treat residents, family members, coworkers, and visitors with respect, kindness, and professionalism at all times. Despite this, the environment described by both residents and staff was one of frequent conflict and lack of professionalism, directly impacting the residents' right to a dignified existence and a quality living environment.

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