Failure in Administration, Care Planning, Abuse Prevention, and Reporting
Summary
The deficiency involves the facility’s failure to administer operations effectively to meet residents’ needs in the areas of care planning, protection from abuse, and immediate reporting of alleged abuse. The facility admitted a resident with schizophrenia who, according to multiple psychiatric evaluations and behavioral nursing notes beginning in mid‑August 2025, exhibited escalating aggressive and sexually inappropriate behaviors and was identified as being at risk for sexually acting out. Despite this documented pattern of behavior during the look‑back period for the resident’s annual MDS assessment dated late August 2025, the facility did not identify behavioral symptoms toward others on the MDS, and the behavioral care area did not trigger for care planning. The comprehensive care plan created from that assessment did not include a problem or interventions related to behaviors, and no behavioral care plan was developed until January 9, 2026, after a serious incident had already occurred. During this period without a behavioral care plan, the resident continued to display aggressive behavior, mood instability, irritability, and psychotic symptoms, as documented in subsequent psychiatric evaluations, behavioral notes, and Behavior Review Committee documentation through November 2025. The Unit Manager later confirmed that the resident did not have a behavioral care plan prior to the January 5, 2026 incident and stated that both she and the DON should have been updating the care plan but did not. The Unit Manager reported that the DON had asked her not to document resident behaviors and that when she did document them, the documentation was changed, which contributed to the absence of a behavioral care plan. The DON acknowledged that behavioral care plans were expected to be reviewed and revised when incidents were reported, that it was important to have a behavioral care plan in place so staff would be aware of behavioral risks, and that the resident’s behaviors were not documented in the Kardex. The DON stated she assumed the Unit Manager was updating the care plan and Kardex but did not review them and did not know how the resident lacked a behavioral care plan until four days after the incident and two days after the state survey agency began its investigation. On January 5, 2026, an LPN entered the room of a severely cognitively impaired female resident and observed the male resident positioned over her, with one leg on the bed, holding her hands down with one hand and pushing her back into the bed with the other while attempting to get on top of her. The LPN reported this to the SSD/Assistant ED and the DON and was told the situation was speculation and not to make a mountain out of a molehill. Subsequent documentation for the female resident, including behavior notes, a psychiatric evaluation, and social services notes, showed that after the incident she was very upset and crying, fearful, uncomfortable, did not want to remain at the facility, and exhibited increased anxiety and worsening emotional symptoms. The SSD/Assistant ED stated that she, the ED, and the DON decided the witnessed incident did not meet the definition of abuse and believed that the severely cognitively impaired resident could consent to being touched. The ED, who served as the abuse coordinator, similarly stated that she, the DON, and SSD/Assistant ED had not determined that abuse had occurred and believed the cognitively impaired resident could consent to the male resident coming into her room and touching her, but could provide no evidence to support this belief. The DON also stated she did not identify the incident as abuse because she believed the severely cognitively impaired resident could consent to being touched. The facility also failed to immediately report this allegation of abuse and other allegations or injuries of unknown origin as required. The LPN’s report of the January 5, 2026 incident to the DON and SSD/Assistant ED was not reported to outside agencies, including law enforcement or the state survey agency. The SSD/Assistant ED stated that facility practice was to gather information, discuss as a team, and then decide whether to report to the Office of Inspector General, and that the leadership team decided the incident did not need to be reported because they did not feel it met the definition of abuse, again citing the belief that the cognitively impaired resident could consent. The ED acknowledged that policy required suspected abuse to be reported within two hours but stated they decided the incident was not reportable for the same reason. The DON initially expressed uncertainty about whether the incident should have been reported and, after reviewing the Abuse and Reporting Policy, stated that a leadership member should have reported it and confirmed that incidents involving alleged sexual misconduct between residents should be reported. Further review of facility investigations showed additional failures to immediately report allegations of abuse or injuries of unknown origin that did not rise to the level of immediate jeopardy. These included resident‑to‑resident abuse on December 26, 2025, and injuries of unknown origin for several residents on dates in 2025 and early 2026. The DON stated she was not aware she was supposed to report allegations or suspicions of alleged abuse immediately to state agencies. The ED stated there had not been any recent incidents requiring reporting and that she, the SSD/Assistant ED, and the DON made decisions not to report incidents, and that she often reached out to corporate for direction. A corporate Director of Clinical Reimbursement confirmed that allegations of abuse should be reported within two hours but was aware the facility would investigate first before reporting, and indicated that in the case of the incident between the two residents, corporate determined it was not a reportable allegation and characterized it as “just touching.” These combined failures in care planning, abuse prevention, and mandatory reporting led surveyors to identify immediate jeopardy under 42 CFR §483.70 (F835).
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.
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