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F0610
F

Failure to Investigate Alleged Abuse After Unauthorized Intrusion and Filming

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 thoroughly investigate an allegation of abuse after a group of unauthorized men entered the building, engaged in disruptive and inappropriate behavior, and included two residents in a music video without their consent. The men entered the facility by distracting the receptionist and proceeded to walk through the halls, smoking marijuana, using obscene language, and filming. Staff and residents witnessed the incident, and at least one resident reported feeling unsafe and fearful as a result. The video was later posted on social media and viewed by thousands. Interviews revealed that staff, including CNAs, dietary aides, and the receptionist, observed the men in the facility and felt unsafe but did not take immediate action to stop the intrusion or protect the residents. The receptionist did not call the police due to fear for her own safety, and it was a resident who ultimately contacted law enforcement. The Director of Nursing and the police arrived after the men had exited the building. The incident was reported to the administrator only after the video surfaced online, and the administrator confirmed that no staff or residents knew the men or had given permission for filming. The facility's investigation was limited in scope, as only alert and oriented residents on one hall were interviewed, despite the potential impact on all 91 residents. The facility's abuse prevention policy requires thorough investigation and reporting of all allegations of abuse, but the response to this incident did not meet those standards. The investigation did not include all potentially affected residents, and the initial response by staff did not adequately address the safety and well-being of residents during or after the event.

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