F0600

G

Failure to Supervise Smoking Patio Resulting in Resident-on-Resident Assault and Facial Fracture

Chicago, 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 verbal and physical abuse by another resident and to follow its own abuse prevention and supervision policies. On the afternoon of 1/26/2026, two cognitively intact residents with independent community passes were on the facility’s smoking patio after signing out on pass. A verbal altercation began over a cigarette lighter, with both residents engaging in derogatory name calling. One resident (R3), who had a care plan noting potential for inappropriate behavioral problems and a need for supervised community access with restricted independent pass privileges, became agitated and punched the other resident (R2) multiple times in the right facial area. R2 and a witness (R5) both reported that there were no staff or security personnel present on the patio during the verbal escalation or the physical assault, and that no staff came outside to intervene.

As a result of the assault, R2 sustained a laceration and a closed fracture of the right anterior maxillary sinus. R2’s hospital records documented an assault with loss of consciousness, a comminuted, mildly impacted fracture of the right anterior maxillary wall, soft tissue swelling, and a facial laceration repaired with sutures. Progress notes from the LPN on duty described R2 returning from the patio with a right facial laceration and minimal bleeding, calling the police, and being transported to the emergency department. Upon return, documentation confirmed the diagnoses of closed fracture of the right maxillary sinus and facial laceration with two sutures below the right eye and a scratch on the right eyebrow. R2’s medical history included schizoaffective disorder, epilepsy, anxiety disorder, insomnia, restlessness and agitation, chronic pain, sleep apnea, nicotine dependence, and other conditions, with an MDS BIMS score of 15 indicating intact cognition.

Multiple staff interviews and observations showed that the facility did not provide active supervision of residents on the smoking patio, despite policies requiring resident monitoring and abuse prevention. On two separate observation dates, surveyors saw several residents smoking on the patio without any staff supervision. The security guard stated that supervised smokers should always have a staff member present on the patio, that unsupervised smokers with independent passes were mainly monitored by video cameras without audio, and that it would not be possible to hear verbal abuse or respond quickly enough to prevent a sudden physical assault. CNAs and nursing staff acknowledged that residents with behavioral issues could be aggressive or unpredictable and that someone should be supervising residents at all times to separate them before altercations escalate, but also stated that residents on the patio were not always supervised. The Psychiatric Rehabilitation Services Director, DON, Administrator, and Activity Director all confirmed that no staff witnessed the incident, that there was no supervising staff outside on the patio at the time of the altercation, and that the facility is responsible for residents while on facility property. Facility policies on resident rights, abuse prevention, rounds, and smoking safety required prevention of abuse, hourly monitoring of residents, and maintenance of a safe environment, but these were not followed, resulting in a founded conclusion of verbal and physical abuse of R2 by R3 and physical harm to R2.

The facility’s abuse prevention policies defined abuse as the willful infliction of injury with resulting physical harm, including verbal and physical abuse, and required the facility to establish a resident-secure environment, supervise and monitor staff’s ability to meet residents’ needs, and correct inappropriate language or handling at the time situations occur. The Resident’s Rights policy affirmed residents’ right to be free from abuse. The Rounds Policy required daily rounds to ensure residents are monitored every hour or as needed, and the Smoking Safety Policy aimed to provide a safe and healthy living environment recognizing potential harm from careless smoking. Despite these written policies, the facility did not ensure that staff were physically present to supervise residents on the smoking patio, did not ensure that a resident with known behavioral risks and a care plan calling for supervised community access was appropriately supervised, and did not intervene during the verbal escalation that preceded the physical assault. The Administrator and other leaders acknowledged that the smoking patio should be monitored at all times and that staff presence could have de-escalated the situation and prevented the abuse, and the facility’s own final incident investigation concluded that abuse was founded.