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F0600
D

Failure to Protect Resident from Physical Abuse by Peer

Frankfort, Illinois Survey Completed on 06-17-2025

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 resident with a history of schizoaffective disorder, depressive type, and other medical and behavioral diagnoses was involved in multiple incidents of physical aggression toward peers within the facility. The resident was noted to have moderate cognitive impairment and had previously exhibited aggressive behaviors, including striking other residents and being non-redirectable, which resulted in interventions such as counseling, administration of as-needed medication, and transfers to the hospital for psychiatric evaluation. Despite these interventions, the resident continued to display aggressive behavior toward others in the facility. On the date of the incident, the resident physically struck another resident in the mouth after perceiving that the peer had cut in front of him at the water cooler. The assaulted resident sustained a swollen and abraded lip, which required first aid and was reported to the physician. Witness accounts and progress notes confirmed that the aggressor had a pattern of similar incidents, including previous altercations with both staff and other residents, and that the behavior was escalating despite prior interventions. The facility's policy affirms the right of residents to be free from abuse, including physical abuse inflicted by anyone. However, the facility failed to protect the assaulted resident from physical abuse by another resident, as evidenced by the repeated aggressive incidents and the lack of effective measures to prevent further harm. The incident was reported to the appropriate authorities, and the aggressor was ultimately transferred out of the facility, but the deficiency centers on the failure to prevent the physical abuse from occurring.

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