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F0600
L

Failure to Prevent Mental Abuse and Unauthorized Access

Cahokia, Illinois Survey Completed on 07-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to prevent mental abuse by allowing a group of unauthorized men to enter the building, where they engaged in disruptive and abusive behavior, including smoking marijuana, shouting obscenities, and swinging a leather belt while filming a music video. The men entered the facility by distracting the receptionist and bypassing visitor screening procedures. Staff members, including CNAs and dietary staff, observed the men in the hallways and common areas, but did not immediately intervene to stop the intrusion or prevent the filming. The video, which included footage of two residents without their consent, was later posted on social media and viewed by tens of thousands of people. One resident, who was cognitively intact and required assistance with daily care, reported being awoken by the commotion and expressed feeling unsafe and fearful, noting that neither he nor other residents could defend themselves. Another resident, with moderate cognitive impairment and multiple medical conditions, also appeared in the video without permission. Both residents stated they did not consent to being filmed or having their images shared online. Additional residents and staff reported feeling unsafe and uncomfortable as a result of the incident, with some residents expressing ongoing fear and anxiety about their safety in the facility. The facility's own investigation confirmed that the men were not affiliated with any staff or residents and had gained entry by providing false information to the receptionist. Staff and residents witnessed the men recording themselves, but there was a lack of immediate and effective response to remove the intruders or protect residents' privacy and well-being. The facility's abuse prevention policy was not effectively implemented, as the incident resulted in mental and psychosocial harm to residents, who reported feeling unsafe in their home environment.

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