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F0600
G

Failure to Protect Resident from Physical Abuse by CNA

Evanston, Illinois Survey Completed on 12-07-2025

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 cognitively intact resident with diagnoses including Parkinson's Disease, spinal stenosis, and scoliosis, who requires staff assistance for all activities of daily living, was subjected to physical abuse by a Certified Nursing Assistant (CNA) during care. The resident reported that the CNA hit her arm and hand multiple times while using a sit-to-stand machine, causing immediate pain and emotional distress. Despite the resident's pleas for the CNA to stop due to pain from improper use of equipment, the CNA continued, slapped the resident, and yelled at her to stop screaming. The incident was witnessed by a Registered Nurse (RN) who responded to the resident's cries for help and observed the CNA at the bedside. The resident also reported a history of the CNA being rough and rushing through care, though previous incidents had been overlooked. The RN reported the incident to the Director of Nursing (DON), who instructed that the CNA be sent home immediately after confirming the resident's allegation of abuse. The facility's executive director did not respond to initial communications regarding the incident, and the CNA was ultimately terminated for not meeting service standards. The facility's policy prohibits any form of resident abuse and requires staff to report and identify inappropriate behaviors, but the incident demonstrates a failure to protect the resident from physical abuse and to ensure staff adhered to abuse prevention protocols.

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