F0600

D

Failure to Prevent and Manage Resident-to-Resident Abuse and Threats Involving a Sharp Object

Cahokia, Illinois Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent resident-to-resident abuse and to adequately manage known behavioral risks between two cognitively intact male residents with significant psychiatric and neurological diagnoses. One resident (R3) had documented dementia, parkinsonism, bipolar disorder, and a history of being verbally and physically inappropriate and abusive with staff and other residents, including prior physical aggression and attempts to cut other residents’ hair with clippers. His care plan identified him as short-tempered with impaired cognition, at risk for being verbally/physically inappropriate and for psychosocial/mental abuse, and noted a recent altercation with another resident from whom he needed to be kept apart in common areas. The other resident (R2) had schizophrenia, diabetes, and a right below-knee amputation, and his care plan documented potential for verbal and physical aggression related to schizophrenia and potential to experience psychosocial/mental abuse, with interventions to analyze triggers and remove residents to a calm, safe environment when conflict arose.

On one occasion, an altercation occurred between these two residents in the dining room. The state incident report documented that staff reported an alleged resident-to-resident altercation at approximately 7:35 AM, during which the residents were found in a physical confrontation. One account stated that R3 was propelling himself through the dining room and asked R2 to move; R2 allegedly yelled and pushed R3’s wheelchair, and R3 fell from his wheelchair while reaching out to stop it. Another account from a former Business Office Manager described staff running into the dining room and finding R3 on the floor after a fist fight, with witnesses stating that R3 was wiping off a table, R2 approached, words were exchanged, and both residents hit each other, resulting in R3 falling and sustaining a small bruise under his chin. R2’s progress note documented that staff heard arguing, entered the dining room, and found both residents with one on the floor, hitting and kicking each other before they were separated and taken to their rooms. Despite these events, R3’s progress notes contained no documentation of this altercation.

A separate series of events involved R3’s possession and use of a box-cutter type tool in the dining room and threats made toward R2. The state incident report documented that R3 was observed using a box-cutter type tool to scrape dirt from dining room tables, and that he refused to relinquish the tool when asked by the Administrator and Social Services Director. Interviews documented that R3 stated he was scraping sticky tables and that R2 was cussing in front of visiting children; R3 admitted telling R2 he would “get him one way or another” and described hostile statements about wishing he could put R2 “back in the sewer” and ensure he did not come back up. Multiple residents reported that R3 had a box cutter, that he had threatened another resident with it, and that they did not feel safe living in the facility. R2 reported that R3 threatened him with the box cutter in the dining room, that R3 said the tool was for him, and that he did not feel safe and could not get away from R3 due to his mobility limitations. Another resident witness stated that R3 brought a razor knife to the dining room, used it on the tables, and, when asked why he had it, pointed to R2 and said it was for him. Staff interviews confirmed that R3 had a box-cutter-like object in the dining room and that R2 and R3 frequently did not get along, with escalating verbal exchanges. R2’s progress notes contained no documentation of the incident involving the box cutter and the reported threat. These events occurred despite the facility’s written Abuse Prevention Program, which prohibits abuse and defines physical abuse and willful actions, and despite care plan directives to separate residents during conflict and ensure a calm, safe environment.