F0600

D

Failure to Prevent Resident-to-Resident Physical and Sexual Abuse

Peoria, Illinois Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent physical and sexual abuse among residents with known behavioral and psychiatric histories. One resident with schizophrenia and bipolar disorder reported being slapped in the face in the dining room and later stated that another resident had grabbed her breast there. A CNA heard the resident yell for the other resident to stop touching her and observed the peer touching her breast and lower back. The same day, the peer resident walked behind her, made a suggestive verbal remark, and attempted to kiss the top of her head, prompting the resident to yell and staff to intervene. The peer resident’s care plan documented a history of inappropriate sexual behavior, yet the incidents occurred in a common area where contact and sexualized behavior were observed by staff.

Additional incidents of physical abuse occurred between other residents with documented behavioral risks. In one event, a resident with a criminal history including domestic battery, aggravated battery, and battery admitted to hitting another resident in the mouth with an open hand after complaining about the other resident’s statements; staff heard the victim yell that she had been hit and then separated the two. In another event in a dining room, a resident with schizoaffective disorder, daily yelling behaviors, hallucinations, and a history of potential physical aggression punched another resident in the mouth with a closed fist, causing a lip laceration and swelling. Staff statements and care plans confirmed that this resident frequently yelled out, could be physically aggressive, and was resistant to redirection, yet the assault still occurred in a common area where both residents were present.