F0600

G

Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Head Injury

Momence, Illinois Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The facility failed to protect a resident from abuse when one resident struck another in the head with a cane, causing a head injury and laceration that required sutures. On 12/26/25, staff progress notes documented that the injured resident was observed bleeding from below the right eye and that another resident had hit him. A subsequent hospital report confirmed a head injury and a laceration requiring three sutures, and later observation on 12/31/25 showed a bruise to the upper right cheek below the eye and three sutures on the right eyelid. The facility’s incident report to the state agency described that the two residents engaged in inappropriate physical contact, and the Administrator stated it had been reported that one resident hit the other in the head with his cane. The injured resident had a care plan dated 12/24/25 noting a history of suspected abuse with an intervention to assure he was in a safe environment, while the other resident’s care plan, focused on inappropriate sexual behavior, did not include an assessment for potential physical abuse against others, despite the facility’s Abuse Prevention Program policy prohibiting and seeking to prevent resident abuse and neglect, including physical abuse such as hitting.