F0600

D

Failure to Protect Residents From Repeated Resident-to-Resident Physical Abuse

Chicago, Illinois Survey Completed on 03-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents were free from abuse and physical assault, specifically resident-to-resident abuse. One resident with right heart failure, schizoaffective disorder, hypertension, and type 2 diabetes, and with intact cognition (BIMS 14), had a documented history of aggressive and maladaptive behavior, including conflicts and verbal or physical aggression toward staff and loud, intimidating behavior toward a roommate. Progress notes state that this resident physically attacked a peer unprovoked, and was observed hitting and pushing another resident out of his wheelchair. The facility’s internal investigation later substantiated that this resident was physically aggressive toward the peer.

Another resident involved in multiple incidents had quadriplegia, schizophrenia, traumatic brain injury, and moderately impaired cognition (BIMS 11). This resident’s care plan identified a risk for violence related to schizophrenia, with goals that the resident would maintain safe behavior and do no harm to self or others, and that staff would closely monitor behavior. Despite this, progress notes document that this resident was involved in an altercation with a peer that became physical, and in a separate incident, another cognitively intact resident reported being hit twice in the face by this resident without provocation while sitting in the hallway. A nurse documented being called to the scene of the fight between the two roommates and another staff member stated that this resident “tries to hit people all the time,” noting that staff usually intervened but were unable to do so before both residents hit each other during the incident.

Additional incidents involved a resident with schizophrenia, heart failure, insomnia, pulmonary hypertension, and moderate cognitive impairment (BIMS 11), who had documented hallucinations and delusions and a history of aggressive or agitated behavior and abuse/neglect as either recipient or perpetrator. Screening assessments showed this resident’s aggressive behavior and abuse history progressed from a moderate to a significant problem. Progress notes document that this resident hit a roommate, resulting in redness to the roommate’s face and a scratch on the nose, and that the roommate, who had Alzheimer’s disease, atrial fibrillation, diabetes, hypertension, osteoarthritis, and moderate cognitive impairment (BIMS 8), indicated that this resident had hit him in the arm and face while he was in bed. CNAs reported that the aggressive resident had a pattern of aggressive behavior toward other residents, including getting in their faces, screaming, cursing, verbally threatening them, and being particularly aggressive toward female staff. The facility’s internal investigation substantiated the altercation between these two residents. The facility’s own policies state that residents have the right to be free from abuse, neglect, and mistreatment and that the facility aims to prevent abuse by establishing a resident-sensitive and secure environment, yet multiple substantiated incidents of resident-to-resident physical abuse occurred.

The administrator, who serves as the abuse coordinator, stated that regulatory requirements for abuse include immediately separating residents involved, notifying the administrator, physician, and family, and reporting to the state agency, and also stated that screaming and yelling is a form of abuse. Staff interviews confirmed that residents and staff were aware of ongoing aggressive behaviors, including frequent attempts by one resident to hit others and another resident’s repeated verbal aggression and threats toward peers and staff. Despite care plans and risk assessments identifying aggression and risk for violence, and staff awareness of ongoing aggressive behaviors, multiple residents experienced physical assaults by peers, with injuries such as redness and scratches documented, demonstrating that residents were not consistently protected from abuse as required by facility policy and resident rights.