F0609

D

Failure to Timely Report Alleged Physical Abuse Between Cognitively Impaired Roommates

Freeport, Illinois Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report an allegation of physical abuse when one severely cognitively impaired resident was found with a pillow being held over her face by her severely cognitively impaired roommate. In the early morning, around 5:30 AM, two CNAs entered the shared room during 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. One CNA removed the pillow and the other removed the aggressor from the room. The resident in bed, who had dementia and severe cognitive impairment and required supervision with mobility, was initially sleeping, became agitated when awakened, and then calmed after being reassured. The roommate, who had Alzheimer’s disease with severe cognitive impairment and required supervision with mobility, had been wandering earlier and had been redirected back to bed.

Despite witnessing this event, the CNAs did not immediately report the incident to a nurse or other appropriate authority. One CNA stated she never told the nurse what she had witnessed, and the other CNA reported that she did not report the incident at the time and only called the Memory Care Director later that afternoon after waking up from sleep. Staff who worked the following morning shift, including a CNA and an RN, reported they were not informed of the incident in report. The DON and Administrator both stated they were notified later in the afternoon, and the DON indicated the incident should have been reported when it occurred. The facility’s abuse policy requires that any employee or agent who becomes aware of alleged abuse or neglect immediately report the matter to the facility administrator, which did not occur in this case.