F0610

D

Failure to Prevent and Investigate Alleged Resident-to-Resident Abuse Involving Repeated Bed-Entry and Pulling Incidents

Centralia, Illinois Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent and investigate alleged abuse related to a cognitively impaired resident with known behavioral issues entering other residents’ rooms and beds and attempting to pull residents out of bed. One resident with Alzheimer’s disease, dementia, severe cognitive impairment (BIMS 04), and documented behavioral symptoms had multiple progress notes describing her going into other residents’ rooms, lying in their beds, arguing with staff, and being difficult to redirect. Staff documented that this resident had previously been found in another resident’s bed without a shirt and that she had been moved to a different room due to going through a shared bathroom and disturbing another resident. Care plan approaches focused on redirection, snacks, activities, and independent activity supplies, but did not address the escalating pattern of entering other residents’ rooms and beds and attempting to pull residents from bed.

On the date of the key incident, another resident with dementia, severe cognitive impairment (BIMS 03), a right humerus fracture, muscle weakness, and pain was found on the floor near the bathroom door after staff heard a nearby resident say “get out of bed” and heard the resident yelling. The resident on the floor stated “a man pulled me out of bed,” and staff later documented that another resident had been in the room at the time and was redirected. A subsequent IDT root cause analysis note documented that staff heard the behaviorally impaired resident in the injured resident’s room telling her to get up, followed by the injured resident yelling and being found on the floor. Staff interviews confirmed that a CNA heard the behaviorally impaired resident scream, then the injured resident scream, and then found the injured resident on the floor with the behaviorally impaired resident standing next to her; the injured resident again stated that “that guy pulled me out of bed,” and staff noted a new red spot on her back.

Additional staff interviews revealed that CNAs had previously observed or been told that the same behaviorally impaired resident had tried to pull more than one resident out of bed, including an incident where she was seen holding another resident by the ankles and pulling her out of bed. Staff reported that the Director of Memory Care and the Administrator were aware of these prior incidents. Despite these reports and the facility’s written Abuse Prohibition and Reporting policy requiring interviews with all involved parties and use of an abuse investigation checklist when there is reasonable cause to suspect willful abuse, the Administrator stated that the incident between the two residents was not considered a resident-to-resident incident because it was not witnessed and the injured resident could not give a description of the event. The report does not describe that a full abuse investigation, as outlined in the facility’s policy, was conducted in response to the allegations and observed pattern of behavior.