F0689

D

Failure to Supervise Legally Blind Resident During Ambulation Leading to Resident Altercation

Crestwood, Illinois Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and assistance with ambulation for a resident with severe visual impairment, resulting in an avoidable accident and resident‑to‑resident altercation. One resident (R1) was diagnosed with category five blindness in the right eye, category four blindness in the left eye, and atrophy of the right globe, with the MDS documenting severely impaired vision but cognitively intact status. The MDS Section GG documented that R1 required supervision or touching assistance for walking at least 10 feet, and the care plan noted an ADL self‑care performance deficit related to legal blindness, specifying that R1 used a white cane for ambulation and required assistance with ambulation and transfers as necessary, with an intervention to ensure R1 used his white cane when up and about. Despite this, R1 reported that on the day of the incident he was walking without his cane and no staff were helping him return his coffee cup.

On the day of the incident, R1 attempted to return his coffee cup to a kitchen window area and bumped into another resident (R2) seated in a wheelchair, which R1 stated he did not see due to his visual impairment. R1 reported that he almost fell, asked R2 why he was sitting there, and then R2 punched him in the chest, after which R1 hit R2 two or three times with his cane. R1’s written statement indicated he bumped into R2’s chair, tried to apologize, and was verbally cursed at before being hit, leading him to hit back. R2 stated that R1 hit him in the mouth with his cane, causing a busted lip, and denied hitting R1; staff documentation noted a superficial scratch/red raised area on R2’s upper lip consistent with this account. A social service note documented that R1 was seen trying to get past another peer and lost his step, hitting the peer with his cane.

Multiple witnesses described a physical altercation between the two residents in a common area without immediate staff intervention at the moment of escalation. A medical records staff member (V6) reported hearing an uproar and seeing R1 striking R2 with his walking stick while R2 covered his head, and an activity aide (V4) reported hearing arguing, seeing R1 (described as legally blind) asking R2 why he was sitting there, hearing R2 respond with profanity, and then observing R1 hit R2 several times in the mouth with his cane. A social service aide (V3) stated he heard cursing and then saw R1 physically altercating with R2, with blood coming from R2’s mouth. Another resident (R3) stated that R1 fell into R2’s wheelchair, became entangled, and that R2 hit R1, after which R1 took his folded cane from his pocket and hit R2; R3 also reported that R1 stumbles over residents and walks into their wheelchairs daily and tends to walk forward rather than backing up when entangled. The DON (V2) stated that if a resident requires supervision with ambulation, staff should be within arm’s reach, and if touching assistance is required, staff should physically touch the resident, but also stated that R1 did not need anyone to walk with him. The administrator (V1) acknowledged there was no written supervision policy and that the incident could have been prevented with supervision, while existing education materials stated that all staff are expected to monitor residents to prevent incidents and altercations.