F0600

G

Failure to Protect Residents From Repeated Aggression by an Identified Assaultive Resident

Harrisburg, Illinois Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from abuse by not adequately managing and responding to a resident with known aggressive behaviors. One resident (R2) had documented diagnoses of anxiety disorder, depression, and dementia, with a BIMS score of 6 indicating severe cognitive impairment. R2’s care plan identified a focus area of potential for aggressive behavior related to dementia, with interventions such as encouraging activities, monitoring labs, observing location and aggression level, and removing the resident from areas when aggression increased. These interventions were all initiated on the same date with no further additions or revisions despite multiple subsequent aggressive incidents involving other residents.

The first substantiated incident occurred in R2’s room during the night, when staff heard yelling and found R2 on the floor holding onto the legs/foot of a roommate (R3), while R3 was hitting R2 in the head. R3 reported that R2 had come over and started “attacking” him by grabbing his foot and not letting go, and R3 stated he no longer wanted to room with R2. Both residents had dementia diagnoses, with R3’s BIMS score of 11 indicating moderate cognitive impairment. The facility’s investigation and report to the state agency characterized this as a resident‑to‑resident physical altercation and substantiated the allegation, but the care plan for R2 showed no new or revised interventions after this event.

A second substantiated incident involved another resident (R4), who had schizoaffective disorder, anxiety disorder, dementia, and depression, with a BIMS score of 12 indicating moderate cognitive impairment. In the dining room, CNAs reported that an agitated R2 became combative, swung fists and a board removed from the wall, struck a CNA, threw a heavy Christmas decoration, and then hit R4 on the top of the head with facility signage. R4 described the event as a “shock” and stated that R2 “does crazy things.” The investigation form documented an injury location as the top of the scalp at the time of incident, although no visible injuries were later observed. Despite this second substantiated resident‑to‑resident altercation, R2’s care plan still reflected only the original interventions from the earlier date, with no documented additions or modifications to address the repeated aggression toward other residents.

A third incident involved R1, who had COPD, panlobular emphysema, and dysphagia, and was cognitively intact with a BIMS score of 15. R1 and his family member (V9) reported that R2 approached R1 from behind in the dining room, rammed R2’s wheelchair into R1’s wheelchair, hit or punched R1 in the back, yelled at him, and pulled on his blanket until another resident verbally intervened. V9 stated she immediately reported the incident to the LPN on duty (V3), who then moved R2 away and, according to V9, instructed her to email the administrator with a full account, which V9 did that evening. Staff interviews indicated that R2 had a history of conflict and physical aggression with multiple residents, and that it was common for R2 to become aggressive. The administrator later acknowledged awareness of the prior substantiated incidents between R2 and R3 and between R2 and R4, but did not initially report the incident involving R1 and did not revise R2’s care plan beyond the original interventions, demonstrating a failure to identify patterns of abuse and to implement effective protective measures for other residents.

The facility’s own Abuse Prevention and Reporting policy stated that residents have the right to be free from abuse and that the facility would identify occurrences and patterns of potential mistreatment, promptly investigate all allegations, and make necessary changes to prevent future occurrences. In practice, the facility substantiated multiple resident‑to‑resident altercations involving R2 but limited its response to minimal, case‑specific actions and did not update or expand R2’s care plan interventions after the initial date. The administrator also delayed reporting the incident involving R1 until after receiving a letter from R1’s family member to corporate, despite the family member’s contemporaneous email describing the assaultive behavior. These actions and inactions resulted in multiple residents being subjected to physical aggression by R2 without adequate, timely, and comprehensive protective measures in place, contrary to the facility’s abuse prevention policy and the requirement to keep residents free from abuse.