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F0600
G

Failure to Protect Residents from Verbal and Physical Abuse

Hazel Crest, Illinois Survey Completed on 09-18-2025

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 residents from verbal and physical abuse, as evidenced by two separate incidents involving two residents. In the first incident, a cognitively intact resident was subjected to inappropriate and profane language by a staff member during an argument about returning from a smoke break. Multiple interviews and documentation confirmed that the staff member used hostile and unprofessional language, including profanity, towards the resident. Witnesses described the staff member as agitated and hostile, and the resident reported feeling disrespected, childlike, and angry as a result of the interaction. The facility's abuse policy, which prohibits such behavior, was not followed in this case. In the second incident, a resident with severe cognitive impairment and a diagnosis of schizophrenia was reportedly subjected to both verbal and physical mistreatment by a certified nursing assistant (CNA). Multiple residents and a nurse reported that the CNA was verbally aggressive, used disparaging language, and was excessively loud when providing care. Witnesses also reported hearing the CNA give harsh commands and a thud against the wall, and the resident herself stated that the CNA hit her on the head and pushed her. The resident expressed a desire not to be cared for by this CNA and reported feeling mistreated on several occasions. The facility's investigation included multiple interviews and statements corroborating the resident's claims of mistreatment. Both incidents demonstrate a failure to ensure that residents were free from all forms of abuse, including verbal, mental, and physical abuse, as required by the facility's own policies and federal regulations. The actions of the staff members involved resulted in residents experiencing fear, intimidation, and emotional distress. The facility did not prevent or adequately address the abusive behaviors at the time they occurred, leading to substantiated findings of mistreatment and abuse.

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