F0600

G

Failure to Prevent Resident-to-Resident Physical and Verbal Abuse

Petersburg, Illinois Survey Completed on 02-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision to prevent verbal and physical resident-to-resident abuse, resulting in one resident physically assaulting another. The facility’s Abuse Prohibition Policy, dated 1/29/2026, states that all residents have the right to be free from verbal, sexual, physical, and mental abuse, as well as neglect and exploitation, and defines physical and verbal abuse. One resident (R1) was an older adult with Alzheimer’s disease, dementia with agitation, major depressive disorder, and anxiety disorder, with an MDS indicating moderate cognitive impairment and behaviors occurring every one to three days. R1’s care plan documented behaviors including yelling out, being demanding, making inappropriate sexual comments, touching staff, and, most recently, physical behavioral symptoms.

Another resident (R2) was an older adult with osteoarthritis, cardiomyopathy, aortic aneurysm, hypertensive heart disease with heart failure, and idiopathic peripheral autonomic neuropathy, and was cognitively intact and self-propelled in a wheelchair. On the evening of 2/7/26, R1 and R2, who shared a common bathroom, became involved in a verbal altercation in that bathroom. According to the final abuse report, police report, and interviews, R1 and R2 argued, and R1 then struck R2 in the face with closed fists and hit R2’s legs multiple times with R1’s walker. A CNA (V3) reported hearing someone yell for help, entering R2’s room, and observing R1 in the bathroom punching R2 in the chin with closed fists while holding onto R2’s wheelchair, requiring the CNA to physically separate them.

R2 reported that R1 had been in the bathroom repeatedly singing a phrase that R2 found embarrassing and aggravating, leading R2 to yell at R1 and call him a derogatory name, after which R1 slammed the walker into R2’s legs repeatedly and punched R2 in the face. Emergency department documentation noted an abrasion to the left side of R2’s face and bilateral hematomas to the shins from being hit multiple times with the walker, with R2 receiving tramadol for pain. Police photographs showed a laceration to R2’s left upper cheek and a softball-sized dark purple hematoma to the right lower leg, and discoloration to R1’s right hand. On later observation, R2 still had an open area on the left shin with a dressing and a large dark red hematoma on the right shin, and R2 stated that the shins remained swollen and painful every day. These events occurred despite the facility’s abuse prohibition policy and R1’s known history of behavioral symptoms, demonstrating a failure to adequately supervise and prevent resident-to-resident abuse.