Deficiency in Fall Management and Resident Transportation
Summary
The facility's administration failed to address significant concerns regarding fall management and the transportation of residents within the facility. This deficiency was highlighted by the case of a resident who experienced multiple falls, with the most severe occurring on November 1, 2024, resulting in a major injury. The resident was admitted to an acute care hospital with serious injuries, including fractures and a laceration, following the fall. Despite these incidents, the facility did not conduct a thorough investigation or root cause analysis to understand and mitigate the risks associated with these falls. The Administrator, who had been in the position for two years, did not complete a full investigation into the fall incident on November 1, 2024, as the former Director of Nursing (DON) advised that it was not a reportable incident. The Administrator's inquiry was limited to asking the Activities Director about the incident, without interviewing other staff members who were present at the time. This lack of comprehensive investigation and analysis contributed to the facility's failure to implement necessary changes to prevent future occurrences. The facility's administration also did not ensure that a therapy assessment and psychosocial harm assessment were completed for the resident post-fall. Additionally, there was a lack of staff education on safely transporting residents within the facility, which further contributed to the risk of accidents. These oversights and failures in addressing the fall management and transportation procedures led to the determination of noncompliance with federal, state, and local regulations governing long-term care centers.
Removal Plan
- A therapy screen was done for R13 by the Physical Therapist. A Physical Therapy assessment was completed for R13. The Social Worker completed a behavioral assessment. No changes were identified for R13. A care plan conference was held with R13 and her family with the Social Worker, Registered Nurse, Licensed Practical Nurse, Restorative Nurse, Dietary Manager, Charge Nurse LPN, and CNA. R13 stated she had no problems or concerns. Speech Therapy completed an assessment for R13. The Occupational Therapy department evaluated R13 for positioning and wheelchair review. A 16x18 inch cushion was placed in the wheelchair providing more even support to hips and the footrests were exchanged for more appropriate length allowing Bilateral Lower Extremity flexibility. The Registered Dietitian assessment was done for R13 weight loss, with a new order for a nutritional supplement (one carton by mouth every day was ordered. Continue weekly weight. Speech Therapy to evaluate and treat. No recommendation currently. A Medical Doctor assessed R13, with no concerns noted. The Psych Physician conducted an evaluation post-fall for R3, no recommendation at this time. The plan of care was reviewed and updated by an LPN, and by an RN for R13.
- Newly hired DON began a new root cause analysis. The root cause was completed for R13.
- An ad hoc Quality Assurance Process Improvement and performance improvement plan was developed and initiated. The meeting discussion included plan development and citations. In attendance at the meeting were the Division President, Administrator, Divisional Nurse, DON, LPN, Medical Director, Social Worker, Financial Controller, Maintenance Director, RAI nurses, Wound Care Nurse, Environmental Services Director, AD, health information manager Environmental/ laundry supervisor, Admission Nurse, HR Partner Service, Scheduler, for the accident. The existing Fall Management policies and concluded no revisions were needed.
- Division President and Divisional Nurse provided education to the Administrator, DON, and the Social worker on job description, roles and responsibilities, and duties to ensure the safety of all residents. Education provided on the falls management policy included that nurses should observe and interview the patient and/or witnesses to determine the possible cause of the fall and complete the Initial Event in the EHR to capture the investigation of the fall and assessment of the patient and how to use the QAPI tool The 5 Whys and that nursing is to complete therapy referral in EHR upon admission/readmission and post-fall as indicated. Nursing to follow up with therapy to ensure timely review of referral. Therapy to complete an assessment post-fall as indicated to include completion of an evaluation of the wheelchair to determine if the wheelchair was appropriate for the patient. Resident transport safety to prevent falls/injuries. Nursing and social services to follow up and assess patients for psychosocial harm post-fall to determine if behavioral health services are needed.
- Oversight was provided by the Divisional Nurse to ensure the DON completed a root cause analysis of residents with falls. Oversight by the Divisional Nurse to ensure that eight of eight therapy referrals were completed by RAI coordinator was completed. Oversight by Divisional Nurse of Social Worker to confirm that eight of eight social visits were completed to ensure no evidence was noted of further treatment psychosocial harm post fall, to include weight loss, increased anxiety, or further decline. One of eight patients identified with weight loss post-fall was reviewed by the Regional Dietitian.
- The Division President and the Divisional Nurse made observational rounds to supervise the administrator, DON, and Social Worker of the day-to-day operations including adhering to the falls policy and that oversight was being provided by the administration to ensure patients were being transported safely. The Divisional Nurse attended the clinical meeting to ensure that falls were being reviewed per the guideline to include performing a root cause analysis and 72-hour observations were completed to include observation of signs of psychosocial harm. The Division President and the Divisional Nurse confirmed that education had been completed with staff for falls and safety transportation.
- Quality Assurance Plans to monitor facility performance to ensure corrections are achieved and are permanent. A quality improvement data collection grid 3 tool was developed and initiated by the Administrator and is being utilized daily to monitor the implementation of the Plan of Correction. The DON or Assistant DON will be responsible for ensuring the completion of this tool. The results of the monitoring completed under this plan of correction will be validated by the Division President and /or Divisional Nurse and submitted daily to the QAPI committee for review and further follow-up. The quality improvement data collection grid will continue until the QAPI committee deems it is no longer necessary.
- The facility alleges that the IJ was removed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to maintain effective wandering and elopement safeguards for cognitively impaired residents. One resident with Alzheimer’s disease and severe cognitive impairment exited through an unsecured maglock door and was found by police hours later, while another resident’s wander alert bracelet failed to alarm when tested. Staff, including the DON, ADM, and DOR, reported there was no policy or documented process for testing the current wander alert system or monitoring bracelet function, and the facility had no system for checking the maglock doors before the incident.
A facility failed to report an alleged sexual abuse incident to DOH and law enforcement within the required timeframe after a resident told an LPN they had been raped by a CNA. The resident, who had intact cognition and significant neurologic and urinary diagnoses, later described intimate care that involved pain and burning, and said they felt embarrassed and ashamed when a male NS and male officers were present. The facility also allowed the male NS to complete an assessment without another staff member present and did not provide SW involvement or psychosocial interventions despite the resident being emotionally distraught and not sleeping well.
The NHA and DON failed to manage the facility effectively to ensure allegations of abuse were reported timely and that interventions were implemented to protect residents from abuse. Review of job descriptions, facility documentation, and staff interviews showed the facility did not meet its responsibilities to protect residents from potential abuse, resulting in an Immediate Jeopardy situation.
Failure to Monitor Wandering and Elopement Safety Systems: The NHA and DON did not effectively oversee systems intended to protect a resident at risk for wandering/elopement. A resident with a history of removing an electronic monitoring device and expressing intent to leave, smoke, and return home exited through an exterior door without staff knowledge or supervision and entered an unsafe outdoor environment.
Failure to prevent resident elopement occurred when the NHA and DON did not effectively manage the facility to protect residents from exiting unsupervised, and a resident left the building without supervision. The report states this created an Immediate Jeopardy situation for one of 29 cognitively impaired residents.
Staff were observed and reported using personal cell phones in resident care areas, including a CNA sitting in a resident common area with a personal phone in hand. Residents stated aides were often on their phones while working, and one resident reported being told they were rude for interrupting a staff member who was on the phone with her boyfriend. Resident Council minutes also noted concerns that some aides were on their phones too much, despite the handbook prohibiting cell phone use in the work area.
Unsafe wandering and elopement safeguards were not effectively managed
Penalty
Summary
The facility was cited for not being administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of residents because it failed to ensure a safe environment for cognitively impaired residents who wander or are at risk for elopement. The report identified two separate events involving wandering safety systems and noted that the deficiency affected seven residents identified as at risk for unsafe wandering and elopement. Resident #1 had diagnoses including Alzheimer's disease, alcohol abuse, and COPD, and the Minimum Data Set dated 06/08/2026 assessed the resident as having severe cognitive impairment. On 06/04/2026, the resident was located by local police approximately 12 hours later and about three miles away. Staff interviews indicated that the resident exited through a door associated with the third-floor east stairwell area, and the Maintenance Assistant stated the maglock may have slipped and disengaged, causing the door to inactivate and the alarm not to sound. The Director of Maintenance stated the third-floor east wing stairwell door used a keypad and magnetic locking system, that the first-floor exit door near the parking lot had no alarm system, and that the facility had no system for checking the doors prior to the incident. Resident #2 had diagnoses including hypertension, diabetes mellitus, and depression. The Minimum Data Set documented the resident as independent with chair/bed-to-chair transfers and wheelchair mobility and as having no wandering behaviors. During testing on 06/29/2026, the resident's wander alert device failed to alarm. Staff interviews further revealed there was no documented policy for testing the wander alert system or resident bracelets, and the facility had no current system for monitoring bracelet functionality weekly per manufacturer recommendations. The Director of Maintenance stated they could not find a policy for the wander alert system and only obtained manufacturer guidance after contacting the manufacturer, while the Administrator stated they assumed the system monitored bracelet functionality.
Failure to Report Alleged Sexual Abuse and Address Resident Distress
Penalty
Summary
The facility failed to report an alleged sexual abuse incident involving a resident immediately or within 2 hours to the Department of Health and local law enforcement after the allegation was made. The resident was admitted with diagnoses including obstructive and reflux uropathy, hemiplegia, and hemiparesis following cerebral infarction, and had a BIMS score of 15 indicating intact cognition. A facility incident report documented that the resident told an LPN that they had been raped by a CNA, and the resident later described that the CNA was providing brief care, applying cream to the hip and then to the anus and vaginal area, and that they felt something enter the anus and vagina. The resident stated they told the CNA they were hurting them, that the CNA apologized and made a moaning sound, and that they later felt burning in the vaginal area. The facility also failed to protect the resident during the response to the allegation by allowing a male nursing supervisor to perform a nursing assessment with no other staff member present after the rape allegation. The resident and family member stated that when law enforcement arrived, male officers and the male nursing supervisor were present, and the resident said they felt embarrassed and ashamed and did not want to discuss the rape. The resident stated they only reported that the CNA was rough with them. The family member stated the resident was hysterically crying and said a staff member had raped them, and the family member contacted law enforcement and requested hospital transfer. The facility further failed to provide social work involvement or psychosocial interventions after the allegation. The resident stated they were not sleeping well after the incident and were emotionally distraught and tearful during the interview. The administrator stated the facility did not report the alleged rape to the state because the resident later changed the story to rough handling, and stated they did not think the resident required social work or psychosocial interventions. The primary care physician stated the facility should call law enforcement and the Department of Health if the resident alleged they were raped.
Failure to Ensure Timely Abuse Reporting and Protective Interventions
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) did not effectively manage the facility to ensure residents were free from abuse by ensuring staff reported allegations of abuse in a timely manner and by implementing interventions to prevent abuse. Review of the NHA job description showed the NHA is responsible for ensuring the facility operates in compliance with local, state, and federal regulations, and review of the DON job description showed the DON is responsible for leading the Nursing Department to provide quality care based on best practices and regulatory guidelines. Facility documentation and staff interviews showed the facility failed to ensure allegations of abuse were reported timely and that interventions were implemented to protect residents from potential abuse. This failure placed residents at risk for serious injury from abuse and resulted in an Immediate Jeopardy situation. Based on the deficiencies identified, the NHA and DON failed to fulfill essential duties and responsibilities of their positions, contributing to the Immediate Jeopardy situation.
Failure to Monitor Wandering and Elopement Safety Systems
Penalty
Summary
The facility failed to provide effective administrative oversight and to implement and monitor systems intended to protect residents identified as being at risk for wandering or elopement. The Nursing Home Administrator’s job description stated the administrator was responsible for managing the facility in accordance with policies, procedures, and applicable standards, while the Director of Nursing’s job description assigned responsibility for directing nursing services, collaborating with the Administrator and Medical Director, conducting daily rounds, reviewing nursing documentation, monitoring resident care, and assuming daily operations in the Administrator’s absence. Despite these responsibilities, the facility did not effectively use available resources to identify and correct system problems related to resident safety. On June 19, 2026, Resident CR1 exited the facility through an exterior door without staff knowledge or supervision and entered an unsafe outdoor environment while holding a cigarette. The resident had a documented history of removing safety devices, including the electronic monitoring device intended to activate the exit alarm system, and had repeatedly stated an intent to leave the facility, smoke, and return home. Even with these known risk factors, administrative oversight did not ensure effective systems were in place to identify when required safety interventions were absent or to prevent the resident from leaving the building unnoticed.
Failure to Prevent Resident Elopement
Penalty
Summary
The Nursing Home Administrator and Director of Nursing failed to effectively manage the facility to protect residents from elopement, resulting in Resident R1 exiting the building unsupervised. Review of the facility job descriptions showed the NHA was responsible for directing overall operations in accordance with applicable regulations to ensure the highest level of care, and the DON was responsible for managing and directing resident care within the nursing department to maintain standards of resident care and ensure each resident functioned at his or her highest level. The facility failed to prevent residents from exiting the facility unsupervised, and during an interview the NHA and DON confirmed that administration failed to effectively manage the facility to protect residents from elopement. The report states this created an Immediate Jeopardy situation for one of 29 cognitively impaired residents.
Staff Used Personal Cell Phones in Resident Care Areas
Penalty
Summary
The facility failed to ensure staff did not use personal cell phones in resident care areas. Resident interviews indicated that staff were often seen using personal phones while working, including one report that a staff member told a resident they were being rude for interrupting while the staff member was on the phone with their boyfriend. Other residents reported seeing staff walking by their rooms while on their cell phones, and one resident stated staff members working in the facility were often seen using personal cell phones. During observation on 06/24/26 at 5:25 A.M., CNA #838 was observed sitting in a darkened corner of a resident common area with a personal cell phone in hand, with the phone light illuminating the CNA's face. When approached by the surveyor, the CNA dimmed the phone and placed it in the pocket of scrub pants. The CNA stated she was unsure of the facility's policy on personal cell phones but knew they were prohibited during work hours, and confirmed she did not have a work cell phone. Resident Council meeting minutes also documented resident concerns that some aides were on their phones too much, and the employee handbook stated that cell phone use in resident areas may violate regulations and was prohibited in the work area.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.