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F0600
D

Failure to Prevent Resident-to-Resident Physical Abuse and Staff-to-Resident Verbal Abuse

Peoria Heights, Illinois Survey Completed on 12-11-2025

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 prevent both resident-to-resident physical abuse and staff-to-resident verbal abuse involving four residents. In one incident, two residents with a history of anxiety disorder, major depression, and chronic pain engaged in a physical altercation in the smoking area and dining room. One resident sustained a hematoma above the right eye after a verbal disagreement escalated to physical contact, including chest bumping and pushing. Witness statements from staff and residents confirmed the sequence of events, with both parties acknowledging their involvement in the altercation. In a separate incident, two other residents argued over a borrowed phone, which led to one resident throwing a plate and physically striking the other. Staff present during the altercation intervened to separate the residents, and the missing phone was later found in the possession of the resident who initiated the physical contact. Additionally, the facility failed to prevent staff-to-resident verbal abuse. A staff member (receptionist) was reported to have yelled at a resident, used profane language, and made derogatory comments about the resident's mother after the resident returned from an outing. Another staff member witnessed the verbal abuse and intervened, confirming that inappropriate language was used and reporting the incident to nursing staff. These events demonstrate that the facility did not effectively implement its abuse prevention and reporting policy, resulting in multiple instances of abuse and failure to protect residents from harm.

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