F0600

G

Failure to Protect Residents From Abuse, Mental Distress, and Possible Exploitation

Havana, Illinois Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from abuse, including mental abuse and exploitation, as required by its Abuse Prevention and Reporting policy. The policy defines abuse as the willful infliction of injury, intimidation, or punishment causing physical harm, pain, or mental anguish, and mental abuse as verbal or nonverbal conduct that causes or has the potential to cause humiliation, intimidation, fear, or agitation. Despite this policy, a certified nurse aide (V5) engaged in a loud, profane, and aggressive altercation with staff in a resident care area, with residents present in the hallway and within hearing distance in their rooms.

On the date of the incident, a registered nurse (V8) directed V5 to report to the dining room, which escalated into V5 yelling, cursing, and using profane, degrading language toward V8 in an area where residents were present and could hear. Another CNA (V7) intervened by telling V5 to stop yelling because she was scaring the residents. V7 reported that V5 then grabbed her by the throat, lifted her off the ground, slammed her into a door, and threw her to the floor. V8 similarly reported that V5 grabbed V7 by the throat, slammed her into a doorway, and flung her to the ground. The facility’s Final Abuse Investigation Report acknowledged that V5 raised her voice, used profanity, and pushed V7 with residents present, but concluded the allegation was not substantiated because no residents were physically involved in the altercation.

Multiple residents later described fear, distress, and ongoing emotional impact from witnessing or being aware of the altercation. One resident recalled V5 beating up V7 and stated that the yelling and cursing were very scary. Another resident, who described himself as generally able to take care of himself, reported seeing V7 on the ground holding her neck and crying and expressed concern for residents who could not protect themselves. Nursing notes documented a resident with a sad and worried look, another resident crying and verbalizing fear after witnessing the altercation, and a resident stating he was struggling with having been a witness and was very angry about it. The administrator acknowledged that the whole building was in an uproar over the incident. In a separate matter, a resident reported loaning a CNA (V3) $50 after she complained about her money situation, and another resident reported that V3 had asked him for money but he refused; the administrator deemed this allegation unsubstantiated because the resident could not prove he had given the money, despite the facility’s policy defining exploitation as taking advantage of a resident for personal gain through manipulation, intimidation, threats, or coercion.