Loft Rehab of Rock Springs: Resident-on-Resident Assault - IL
A resident at Loft Rehab of Rock Springs accused her roommate of wearing clothing that belonged to her. Then she started hitting.
The resident who got hit, identified in inspection records as R6, was a woman managing end-stage renal disease, stage five chronic kidney disease, congestive heart failure, type two diabetes, and hypertensive heart disease. She told inspectors what happened when her roommate, R7, came at her. R7 grabbed her and punched her in the left arm. R6 hit back. She also threw a glass of water at R7, trying to get distance between them. When inspectors spoke with her on December 23, 2025, R6 pointed to her right upper arm and described the bruise she was left with after the fight.
R7 told a different version. She said R6 started hitting first. She said she hit back, then walked away to find staff and report it. She couldn't remember the exact date, but she remembered it was the day she got moved to another floor.
Both women agreed on the basic facts: a physical fight broke out between two nursing home residents sharing a room, over a piece of clothing, and it ended with punches thrown in both directions.
Federal inspectors who arrived at the facility on December 23, 2025, as part of a complaint investigation, cited the facility for failing to protect residents from physical abuse. The inspection report identifies the altercation as having occurred on or around August 8, 2025, based on the date on the facility's own abuse investigation file. That means more than four months passed between the fight and the day inspectors walked in to review what had happened.
R7's records are important context here. Her Minimum Data Set assessment documents a brief interview mental status score of 12, which indicates moderate cognitive impairment. Her care plan, dated November 17, 2025, specifically addresses physical aggression toward other residents. That care plan entry came more than three months after the August altercation. R7 had been a resident at the facility since August 21, 2024, admitted following a cerebral infarction that caused hemiplegia and hemiparesis on her left, non-dominant side. She also had hyperlipidemia and chronic obstructive pulmonary disease.
A care plan that flags a resident for physical aggression toward others is only useful if it exists before someone gets hurt, or at minimum, before someone else gets hurt again.
The administrator, identified in the report as V1, confirmed to inspectors on December 23 that physical contact had occurred between the two residents. V1 said staff separated them immediately and moved R7 to a room on a different floor right after the altercation. The separation happened. The room change happened. What inspectors were examining was whether the facility had done enough, before and after, to protect the residents in its care.
The facility's own abuse policy, dated June 8, 2020, defines abuse to include certain resident-to-resident altercations, and commits the facility to protecting residents from physical and psychological harm during and after any abuse investigation. The policy is explicit: residents are to be shielded from additional abuse while the facility is still looking into what happened the first time.
R6's condition makes the stakes of that commitment concrete. A woman with end-stage renal disease and stage five chronic kidney disease, with congestive heart failure layered on top, is not a resident with much physical reserve. A bruise on her arm may have been the extent of the visible injury. It does not describe the extent of the risk.
The inspection report rates the level of harm as minimal harm or potential for actual harm, the lower end of CMS's harm scale. Two of the three residents reviewed for abuse in the sample were identified as affected: R6 and R7. The third was not.
What the inspection record does not show is any indication that the facility identified R7's known history of physical aggression as a factor that should have shaped how and with whom she was housed. The November 2025 care plan entry addressing aggression came after the August fight. Whether the facility had any documentation of aggressive behavior from R7 before she was placed in a shared room with R6, the report does not say. What it says is that R6 was punched hard enough to bruise, and that the facility's response was reactive: separate them, move one resident, open an investigation file.
The investigation file itself was dated August 8, 2025. Inspectors reviewed it on December 23, 2025. That file contained R6's statement that she was grabbed and punched in the left arm. It contained the documentation that R6 hit back. It contained the record of the room change.
What the inspection record does not describe is what the facility did between August and December to ensure that R7's aggression, now documented in an abuse investigation file, was being adequately managed in her new placement. The November care plan update suggests the aggression was still a recognized issue three months later. Whether anyone on a different floor, in a different room, was aware of that history before the care plan was updated is not addressed in the report.
R6 is still at the facility. When inspectors spoke with her on the morning of December 23, she recounted the incident herself, unprompted by anything other than an interview about abuse. She remembered where she was hit. She remembered the bruise. She remembered throwing the water.
She also said the facility moved R7 to another floor immediately after the fight. She said it as though that were the resolution.
For R6, a woman with end-stage renal disease and heart failure living in a shared nursing home room, the resolution was that her roommate was moved. The bruise healed. The investigation file was dated and filed. Four months later, a federal inspector came to review it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Loft Rehab of Rock Springs, The from 2025-12-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 17, 2026 · Our methodology
LOFT REHAB OF ROCK SPRINGS, THE in DECATUR, IL was cited for violations during a health inspection on December 29, 2025.
A resident at Loft Rehab of Rock Springs accused her roommate of wearing clothing that belonged to her.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.