F0600

D

Failure to Protect Resident From Abuse and Delay in Reporting Pillow-Over-Face Incident

Freeport, Illinois Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from abuse when one severely cognitively impaired resident was found placing a pillow over the face/head area of her severely cognitively impaired roommate. In the early morning hours, two CNAs entered the shared room to perform a bed check and observed one resident standing over the other holding a pillow over her face, or a large pillow already over the resident’s face. The resident in bed, who had dementia and severe cognitive impairment and required supervision with mobility, was initially sleeping and did not appear in distress; when awakened, she became agitated, questioned the CNA’s actions, and grabbed the CNA’s arm before calming after reorientation. The resident who placed or was holding the pillow had Alzheimer’s disease with severe cognitive impairment and a history of wandering at night and being redirected back to bed.

The CNAs reported difficulty locating a nurse at the time of the incident and each believed another CNA was reporting the event, resulting in a delay in notifying supervisory staff. The Memory Care Director and DON were not informed until later that afternoon, several hours after the incident occurred, despite the facility’s abuse policy requiring that any employee or agent who becomes aware of alleged abuse or neglect immediately report the matter to the administrator. A nurse who was on the unit around the time of the event stated she was not told of the incident. The facility’s own abuse investigation documented the conflicting CNA accounts about whether the pillow was being held over the resident’s face or already covering it, and confirmed that the incident was not promptly reported as required by policy.