F0609

D

Failure to Report Alleged Resident-to-Resident Abuse After Fall From Bed

Centralia, Illinois Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report an allegation of resident-to-resident abuse to the Illinois Department of Public Health as required by facility policy. One resident (R2), with severe cognitive impairment and multiple diagnoses including dementia, fracture of the right humerus, diabetes, muscle weakness, and major depressive disorder, was admitted on 12/11/25. Another resident (R1), also with severe cognitive impairment and diagnoses including Alzheimer’s disease, dementia, seizures, and major depressive disorder, had documented behavioral symptoms such as verbal, physical, and exit-seeking behaviors, with care plan approaches focused on redirection, snacks, and activities. The facility’s abuse prohibition and reporting policy required notification to the state agency within specific timeframes when alleged abuse or serious bodily injury occurs.

On 01/20/26 at approximately 10:06 PM, an LPN documented that while passing medications on the 200 hall, a resident in the room next to R2’s was heard saying “get out of bed,” followed by R2 yelling. A CNA entered R2’s room and found R2 on the floor near the bathroom door. R2 stated that “a man pulled me out of bed,” and neuro checks were initiated; R2 was moved to a recliner and given PRN pain medication. An event report for this incident documented that R2 had been in bed prior to the fall, that she believed she fell because “a man pulled me out of bed,” and that staff had heard another resident in the adjacent room telling someone to get out of bed before R2 was found on the floor.

A subsequent progress note on 01/22/26 documented an IDT root cause analysis of the 01/20 fall, stating that R2 had been in bed, staff heard R1 in R2’s room telling her to get up, then heard R2 yelling and found her on the floor, with R2 again stating that a man pulled her out of bed. Staff interviews further described R1’s history of aggressive and intrusive behaviors toward other residents, including trying to wake them, forcing them out of bed, getting into bed with them, threatening them, and an instance where R1 was reported to have partially pulled another resident (R5) out of bed. A CNA reported that during the incident in question, she heard R1 screaming and then R2 screaming, and found R2 on the floor with R1 standing next to her, and noted a new red spot on R2’s back. A family member stated the facility had informed him that R2 was pulled out of bed by another resident. Despite these observations and statements, as of 02/10/26 there had been no report of resident-to-resident abuse related to this incident submitted to the Illinois Department of Public Health, constituting the failure to report the alleged abuse.