F0600

E

Failure to Protect Residents From Sexual, Verbal, and Physical Abuse by Other Residents

Dwight, Illinois Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect multiple residents from abuse by other residents, including sexual, verbal/mental, and physical abuse, as defined in the facility’s Abuse Prevention and Reporting policy. In one incident, a CNA observed a cognitively impaired female resident with severe impairment, hallucinations, wandering behavior, and no capacity for sexual consent standing in a male resident’s room with her feet on his bed, holding up her nightgown without a bra, while the male resident, who has moderate cognitive impairment and a documented history of sexually inappropriate behaviors and poor self-regulation, had his hand on her bare breast. The CNA questioned both residents, but neither responded. Subsequent interviews showed that both residents did not recall the incident, and the social services director confirmed that the female resident lacked capacity to consent to sexual relationships, while the male resident was assessed as having capacity but also did not recall the event.

The deficiency also includes the facility’s failure to protect a severely cognitively impaired resident from ongoing verbal/mental abuse by a moderately cognitively impaired roommate. Housekeeping and CNA staff reported witnessing repeated episodes over a period of weeks in which the more cognitively intact roommate yelled at and cursed the other, including calling the roommate a “f****** dummy” and using other profanities when the severely impaired resident was confused or forgetful. Staff reported these interactions to nursing and suggested a room change, but the verbal exchanges continued, with staff again observing the more intact resident yelling profanities at the roommate. At the time of survey, the two residents were still sharing a room, and the severely impaired resident either minimized the interactions or did not recall them.

Additional incidents involved physical contact between residents that met the facility’s definition of physical abuse. In one case, a cognitively intact resident reported that another resident with moderate cognitive impairment pushed the wheelchair despite being told not to, leading the intact resident to grab the other resident’s nose; the cognitively impaired resident then grabbed or pushed the other resident’s hand or arm away. A CNA later had the cognitively impaired resident demonstrate what occurred, and the resident reenacted the nose grab. In another incident, a cognitively intact resident witness and interviews indicated that an anxious resident in the lobby bumped another resident’s wheelchair, leading to mutual yelling and each resident grabbing the other’s wrist or arm. These events, involving residents with varying levels of cognitive function and documented behavioral issues, show repeated resident-to-resident physical contact and altercations without effective prevention or protection by the facility.