F0600

D

Failure to Protect Residents From Physical and Verbal Abuse

Kewanee, Illinois Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from physical and verbal abuse. In one incident, a male resident with dementia, anxiety, chronic pain, and moderate cognitive impairment wandered from a shared bathroom into his roommate’s room during the night. The cognitively intact roommate, who was new to the facility, reacted by placing his arm loosely around the first resident’s neck while both ended up on the floor. Staff heard shouting and found the two residents on the floor, with one resident’s arm around the other’s neck in a choke hold and the other resident pulling hair and yelling to be released. Staff separated and assessed the residents, and the administrator later confirmed that the physical altercation was substantiated and that the cognitively impaired resident had wandered into the roommate’s room.

In a separate incident, the facility failed to prevent verbal abuse and threatening behavior between a cognitively intact male resident and a dietary staff member. The resident, who had diagnoses including edema, type 2 diabetes, antisocial personality disorder, bipolar disorder, and major depression, admitted to calling the dietary staff member racial slurs. Multiple staff witnesses reported that the resident was screaming racial slurs at the staff member, who responded by shouting back, using profanity, and moving toward the resident as if to strike him, while verbally challenging the resident and stating that nobody talks to him like that. Another staff member intervened by stepping between them with hands raised to keep them separated and de-escalate the situation. The facility’s abuse policy affirms residents’ rights to be free from abuse, including physical and verbal abuse, but the described events show that residents were subjected to both physical and verbal mistreatment.