F0600

G

Failure to Protect a Resident From Verbal and Mental Abuse by Social Services Staff

Toluca, Illinois Survey Completed on 12-30-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident’s right to be free from mental and verbal abuse by staff, as required by its Abuse Prevention and Reporting Policy and Resident Rights Policy. The facility’s policies define abuse as the willful infliction of intimidation, punishment, or mental anguish, and specifically describe mental and verbal abuse as conduct that can cause humiliation, intimidation, fear, shame, agitation, or degradation. The policies also require staff to treat residents with courtesy, professionalism, and respect at all times, and emphasize staff training on resident rights, what constitutes abuse, and the obligation to report suspected abuse.

The incident centers on one resident with multiple medical and psychosocial conditions, including anxiety disorder, depression, hepatic encephalopathy, psychoactive substance abuse, vertebral disc degeneration with discogenic back pain, heart failure, liver disease, fall history, abnormal gait, lack of coordination, abnormal posture, impaired visual function, and a care plan identifying an activities of daily living performance deficit and risk for abuse/neglect. The resident’s care plan notes that the resident is at risk for abuse/neglect and is to be cared for in a safe manner and to verbalize any incidences of abuse or neglect. On the day of the incident, a CNA delivered the resident’s lunch tray, and the resident requested a salad. The CNA went to the kitchen, found it closed, and reported back that a salad was not available. The resident became angry, told the CNA to get out of the room, and, according to staff statements, called the CNA derogatory names, including “piece of s***,” and allegedly threw a tray. The CNA then informed the Social Service Director that the CNA did not want to return to the room alone.

The Social Service Director then went to the resident’s room. According to multiple staff and resident statements, the Social Service Director approached the resident with an angry attitude, got very close to the resident’s face, and used profane and degrading language. A Certified Occupational Therapy Assistant, who was in the bathroom providing therapy to the roommate, reported overhearing the Social Service Director tell the resident, “You have to quit being an a****** to my staff,” and that the Social Service Director argued with the resident, stating the resident could go get their own salad and could not yell at staff, emphasizing that the CNA was the only CNA on the unit. The COTA described the Social Service Director as aggressive, rude, and berating, using “a lot of other bad words,” and reported that the resident was very upset. The Director of Nursing reported being told by the COTA that the Social Service Director told the resident, “do not be a f****** a****** to my staff,” and immediately reported this to the Administrator.

The resident stated that they had an “explosive attitude” and acknowledged not being nice to the CNA, but reported that the Social Service Director came into the room right after the conflict with the CNA, got inches from the resident’s face, and was “cussing and screaming,” telling the resident to “f*** off” and calling the resident an “a******.” The resident reported feeling belittled, humiliated, helpless, and like an “idiot,” and expressed that the Social Service Director, who was supposed to help with discharge planning, instead degraded them. Other staff, including the Therapy Director and Resident Council President, reported hearing that the Social Service Director had been fired for cursing at the resident and described prior concerns and complaints about the Social Service Director’s behavior toward residents and staff. The facility’s own final abuse investigation documented that the Social Service Director was overheard telling the resident not to be an “a******” to staff and acknowledged unprofessional conduct by cursing during the conversation, although the facility’s internal conclusion stated that verbal abuse did not occur. These actions and interactions, as documented by multiple witnesses and the resident, constitute the basis for the cited deficiency related to failure to protect the resident from mental and verbal abuse.