F0609

D

Failure to Report Staff Altercation and Use of Unqualified CNA

Bement, Illinois Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report to proper authorities an altercation between staff that occurred in the presence of residents, and the discovery that an unqualified individual was working as a CNA. A sheriff’s deputy was dispatched to the facility after receiving 911 calls from two CNAs regarding threats made by one CNA toward another. One CNA reported that the other CNA told her to meet by the time clock so she could beat her, which made her feel uncomfortable and unsafe. This conflict arose after a dispute over which CNA was responsible for a resident who had not been cared for since early that morning. The reporting CNA also described an earlier verbal altercation that same shift between the same aggressive CNA and a different CNA, during which threats were made and had to be de-escalated. The aggressive CNA was reported to have yelled, accused coworkers of disrespect, and made racially derogatory comments.

The incident included yelling and screaming by the aggressive CNA in front of residents in the cafeteria and in a resident’s room, with at least one resident later confirming that two CNAs were yelling and having a disagreement in the resident’s room and that one CNA walked out. The administrator acknowledged knowing about the incident but did not report it. During the law enforcement contact, the administrator also stated that, upon checking the registry, it was discovered that the CNA who had been working from early morning until the time of the incident was not actually a CNA. Despite this, there is no indication in the report that the facility reported either the staff altercation in the presence of residents or the fact that an unqualified individual had been working as a CNA to the appropriate authorities.