F0600

G

Failure to Protect Cognitively Impaired Residents From Repeated Resident-to-Resident Abuse

Centralia, Illinois Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect cognitively impaired residents from abuse, specifically resident-to-resident physical and verbal aggression, resulting in two residents not being kept free from abuse. Resident R2, admitted with multiple diagnoses including dementia, a displaced fracture of the right humerus, muscle weakness, pain, and severe cognitive impairment (BIMS score of 03), was found on the floor near her bathroom door after yelling, following another resident’s command to “get out of bed.” Documentation shows that R2 reported that “a man pulled me out of bed,” and staff noted pain in her right arm, mid-back redness, and painful/limited ROM in the upper extremity, with refusal to move the right arm. Staff and event reports identified that another resident, R1, had been in R2’s room and was believed to have pulled R2 from bed.

R1 was also severely cognitively impaired (BIMS score of 04) with diagnoses including Alzheimer’s disease, dementia, seizures, major depressive disorder, anxiety disorder, and visual loss. R1’s care plan identified behavioral symptoms such as verbal, physical, and rejection-of-care behaviors, as well as exit-seeking, with approaches focused on snacks, drinks, independent activities, calling a friend, and inviting her to activities. Interviews with the Director of Memory Care and CNAs described R1 as having sporadic, often worsening evening behaviors, including trying to wake other residents, almost forcing them out of bed, telling residents to “go play in traffic” and to get out of “her house,” and becoming more argumentative with redirection. Multiple CNAs reported that R1 had tried to pull more than one resident out of bed, including being observed pulling another resident (R5) out of bed by the ankles, and that R1 could be very aggressive toward staff and residents, with threats and attempts to pick fights.

A separate incident involved R3, another resident with severe cognitive impairment (BIMS score of 03) and multiple diagnoses including dementia, end stage renal disease, metabolic encephalopathy, muscle weakness, and depression. In the dining room, while two residents were seated at adjacent tables, R1 was repeatedly speaking loudly and asking the same question, and R3 became visibly frustrated and poured cold coffee onto R1, striking R1’s face and right side of the head. Documentation indicates the coffee was cold and there was no redness or complaint of pain from R1. The facility’s abuse prohibition and reporting policy states that residents are to be protected from all kinds of abuse, including verbal, mental, and physical abuse, neglect, and other prohibited actions. Despite this policy and known behavioral histories, the facility did not prevent resident-to-resident physical contact and verbal aggression that resulted in R2 being pulled from bed and R1 having coffee thrown on her.

The survey findings, based on interviews, progress notes, event reports, and the facility’s own investigation, show that the facility was aware of R1’s ongoing aggressive and intrusive behaviors toward other residents, including attempts to pull residents from bed and verbal threats. Staff accounts confirm that R1’s behaviors were “all over the place,” could escalate quickly, and that redirection often did not work and sometimes worsened the situation. Nonetheless, R1 continued to have access to other residents in ways that allowed her to enter their rooms, get into their beds, and attempt to force them out, culminating in the incident where R2 was pulled from bed and sustained pain and observable physical findings. Additionally, R1’s loud, repetitive verbal behavior in the dining room led to R3’s frustrated act of pouring coffee on her. These events demonstrate that the facility did not effectively protect R1, R2, and R3 from abuse as required by its abuse prohibition policy.