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F0600
D

Failure to Protect Resident from Verbal Abuse and Report Allegation

Chicago, Illinois Survey Completed on 12-26-2025

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 facility failed to protect a resident from verbal abuse by a staff member, did not provide required abuse prevention training to the alleged perpetrator, and did not report an allegation of abuse to the Illinois Department of Public Health (IDPH) within the required timeframe. The incident involved a resident with multiple diagnoses, including hyperlipidemia, type 2 diabetes, repeated falls, anxiety disorder, dysphagia, major depressive disorder, spinal stenosis, pain, fibromyalgia, morbid obesity, and generalized anxiety disorder. The resident was cognitively intact, as indicated by a BIMS score of 15, and had a care plan specifying the need for a safe environment and protection from mistreatment. During a medical clinic visit, the resident's escort was reported by two clinic staff members to have verbally abused the resident by telling him to "shut the f_ _k up" after a brief exchange regarding appointment wait times. The resident became quiet and appeared sad following the incident. The clinic manager reported the incident to the facility, but the office manager and administrator did not believe the allegation and did not report it to IDPH as required by facility policy. The administrator later acknowledged not being aware of the abuse allegation at the time and admitted that the escort's abuse training documentation could not be located. Interviews revealed that the escort did not recall receiving abuse training and was unaware of the abuse coordinator. Facility policy required immediate reporting of abuse allegations and documentation of abuse prevention training for all employees. The lack of timely reporting, failure to provide or document abuse training, and the staff's disbelief of the allegation contributed to the facility's failure to protect the resident's rights and comply with abuse prevention protocols.

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