F0610

D

Failure to Investigate Resident-to-Resident Physical Altercation

Clinton, Illinois Survey Completed on 03-21-2026

Penalty

No penalty information released

Summary

The facility failed to investigate an allegation of resident-to-resident physical abuse involving two residents with known histories of aggression and cognitive impairment. The facility’s Abuse Prevention and Reporting Policy, revised 10/24/22, states that all incidents will be documented whether or not abuse is alleged or suspected, and that any incident or allegation involving abuse will result in an investigation. Nursing notes dated 2/25/2026 document that one resident (R2) had an alleged physical altercation with another resident, and another note from the same date by an LPN documents that a second resident (R5) had an alleged altercation with R2. The nurse’s note for R5 does not document any notification to the abuse coordinator.

R2’s care plans, initiated 8/25/2025 and 3/2/2026, identify a problematic manner of acting characterized by ineffective coping and verbal/physical aggression related to cognitive impairment and physiological brain changes, as well as a potential to be physically aggressive related to anger, dementia, depression, history of harm to others, and poor impulse control. R2’s MDS shows a BIMS score of 02, indicating severely impaired cognition. R5’s care plans, both initiated 3/3/2026, document problematic behavior characterized by ineffective coping, verbal/physical aggression, and inappropriate behavior such as hoarding and rummaging, related to cognitive impairment, onset of Alzheimer’s, mood disorder, vascular dementia, anxiety, and inability to differentiate between personal and others’ belongings. On interview, the Administrator stated that the incident on 2/25/2026 between R2 and R5 was not investigated because the Administrator was not aware of it and staff had not reported it, resulting in no investigation of the alleged abuse as required by policy.