F0600

G

Failure to Protect Cognitively Impaired Residents From Repeated Abuse by an Aggressive Resident

Flora, Illinois Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent repeated verbal, physical, and sexual abuse by one resident (R7) toward multiple cognitively impaired residents (R1, R6, R8, and R9), despite R7’s known history of aggressive behaviors. R7 was admitted with dementia with agitation, lack of coordination, anxiety, and depression, and had a care plan focus for behavior problems related to verbal/physical aggression and wandering/elopement risk. The care plan’s only reference to a resident-to-resident altercation was a single entry noting an altercation and referral to behavioral health, without further detail on specific protective interventions for other residents. Facility policy stated that residents who allegedly abused another resident should be immediately evaluated to determine suitable care approaches and placement, and that the facility would take all steps necessary to ensure resident safety, including separation of residents.

In one incident, R7 approached R8, who had severe cognitive impairment due to Alzheimer’s disease and other psychiatric and neurologic diagnoses, while she was in the dining room talking out loud to herself. A CNA (V13) observed R7 walk to his usual dining spot where R8 was seated, then step back and slap her across the left side of her face while calling her a “stupid b**ch” and attempting to slap her again. R7 later stated he was annoyed by R8’s yelling and that he slapped her to “shut her up,” adding that he would have slapped her again if staff had not intervened. R8, who also had severe cognitive impairment, was unable to provide a description of the event. This incident was documented in resident-to-resident altercation forms and in a final report to the state agency.

In another incident, R7 entered R1’s room, where R1, who had moderate cognitive impairment, major depressive disorder, generalized anxiety, dementia with behavioral disturbance, and unsteadiness on her feet, was in her wheelchair. A CNA (V12) responded to R1’s call light and found R7 holding the wheelchair handles and attempting to tip R1 out of the wheelchair while yelling and cursing at her. Documentation noted that earlier that day R7 had been very agitated, banging doors, attempting to exit the building, and verbally distressing other residents and staff in the dining room. R7 was reported to have walked out of R1’s room cursing and stating, “next time I will hurt her.”

A further incident involved R7 and R9, who had severe cognitive impairment with diagnoses including Parkinson’s disease with dyskinesia, Alzheimer’s disease, chronic pain syndrome, and depression. While R9 was eating in the dementia unit dining room, staff reported that R7, who had been agitated and “bickering” and “mouthing” at others most of the day, stood up, went toward R9, grabbed him by the throat, and pushed him in his wheelchair out of the dining room into the hallway. A CNA (V9) stated she removed R7’s hand from R9’s neck and called for assistance. Facility documentation described R7 as visibly agitated and noted that staff had to separate the residents.

In a separate event on the same date as the incident with R9, R7 sexually abused R6, a resident with severe cognitive impairment, anxiety disorder, anoxic brain damage, catatonic disorder due to a physiological condition, and depression, who was care planned as being at risk for abuse/neglect. A CNA (V10) reported that R7, who had been agitated and “targeting” R6 by following her around throughout the day, walked up behind R6, reached around from her back, and grabbed her breast. V10 stated she told R7 to let go, he initially said no, and she then removed his hand from R6’s breast and redirected him. R6 was unable to provide a description of the incident. These repeated episodes of physical, verbal, and sexual abuse by R7 toward multiple vulnerable residents occurred despite the facility’s abuse prevention policy and R7’s known behavioral history, demonstrating a failure to protect residents from abuse by another resident.