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F0600
D

Failure to Protect Resident from Verbal Abuse by Staff

Marion, Illinois Survey Completed on 12-09-2025

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 deficiency occurred when a resident, who had diagnoses including osteomyelitis, type 2 diabetes with skin complications, traumatic amputation, hyperlipidemia, bipolar disorder, and hypertension, was subjected to verbal abuse by a dietary aide/cook. The resident, who was cognitively intact, requested a grilled cheese sandwich as an alternative meal. The dietary aide responded with profanity, refused to prepare the sandwich, and dismissed the resident's request in a derogatory manner. Multiple staff statements corroborated that the aide used inappropriate language and refused service to the resident, and that similar issues had occurred with this staff member previously. The incident was promptly reported by the resident to a nurse, who then notified the dietary manager and the administrator. The dietary manager collected statements from those involved and sent the staff member home. However, the administrator, who also served as the facility's Abuse Coordinator, did not report the incident as abuse, instead categorizing it as a customer service issue. No formal investigation into whether the incident constituted verbal abuse was conducted by the administrator, despite being notified of the situation and receiving documentation from the dietary manager and nursing staff. Facility policy defined verbal abuse as the use of disparaging or derogatory language toward residents. The administrator acknowledged being aware of the incident and the staff member's conduct but did not review the collected statements or initiate an abuse investigation. The lack of appropriate response and failure to report the incident as required by policy resulted in the facility not ensuring the resident was free from verbal abuse and intimidation.

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