Birmingham Nursing And Rehabilitation Ctr Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Birmingham, Alabama.
- Location
- 1000 Dugan Avenue, Birmingham, Alabama 35214
- CMS Provider Number
- 015217
- Inspections on file
- 24
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 8 (5 serious)
Citation history
Health deficiencies cited at Birmingham Nursing And Rehabilitation Ctr Llc during CMS and state inspections, most recent first.
A resident with severe mental illness and behavioral disturbances physically struck two other residents on separate occasions in the dining room. Despite a history of unpredictable and aggressive behaviors, the care plans lacked specific supervision interventions, and no assessment was conducted to determine the necessary level of supervision after the first incident. Multiple staff were present but did not witness the abuse until after it occurred, and the facility did not adequately analyze or address the causes to prevent recurrence.
A resident with severe mental illness and dementia, known for unpredictable and aggressive behaviors, was not adequately supervised or provided with individualized behavioral interventions. This lack of supervision led to two incidents where the resident physically struck other residents, with staff and witness interviews confirming the actions were linked to delusional thinking. Facility records and care plans did not reflect ongoing supervision or updated interventions despite the resident's history and repeated incidents.
A resident with severe cognitive impairment was subjected to physical and mental abuse when an LPN placed a hand over the resident's mouth and pinched the nose to force medication administration, despite the resident's right to refuse treatment. The incident was witnessed by a CNA, and subsequent staff interviews confirmed that such actions were improper and could be considered abuse. Facility policies clearly state residents' rights to refuse care, but the LPN admitted to the coercive act, and the facility failed to provide adequate oversight upon the LPN's return to work.
A resident with severe cognitive impairment was physically and mentally abused by an LPN during medication administration, when the LPN covered the resident's mouth and pinched their nose to force medication intake. A CNA witnessed the incident but failed to intervene or report it immediately, and the LPN continued working without supervision. Facility administration did not initially identify the event as abuse, allowing the LPN to return to work and administer medications to other vulnerable residents without monitoring.
A resident with severe cognitive impairment was subjected to physical and mental abuse by an LPN, who attempted to force medication administration by pinching the resident's nose and covering their mouth. A CNA witnessed the incident but did not immediately intervene or report it, leaving the resident alone with the LPN. The facility failed to suspend the LPN as required by policy, allowing the LPN to continue working and placing other residents at risk. The facility's investigation did not initially substantiate the abuse, and staff interviews confirmed that abuse prevention and reporting protocols were not followed.
A CNA failed to immediately report an observed incident where an LPN used physical force to administer medication to a resident with severe cognitive impairment, resulting in a delay in notifying facility administration and the State Agency. The LPN continued working without oversight, and staff interviews confirmed a lack of understanding regarding immediate abuse reporting requirements.
The facility failed to maintain cleanliness in a linen closet and did not handle residents' laundry properly, risking contamination. A staff member also neglected to follow Enhanced Barrier Precautions for a resident with a Stage 4 pressure ulcer, entering the room without a gown despite signage indicating the need for such precautions.
Two residents in a facility engaged in a physical altercation over a misunderstanding involving a bag of chips. Both residents were cognitively intact, and the incident was witnessed by a CNA who intervened. The facility's failure to prevent this altercation indicates a deficiency in protecting residents from physical abuse by others.
A resident with severely impaired cognition wandered into another resident's room, leading to a physical altercation. The facility failed to implement effective interventions to manage the resident's wandering behavior, despite a history of similar incidents. The care plan lacked appropriate measures to prevent such occurrences, resulting in a deficiency citation.
A resident with COPD had their nebulizer mask uncovered and tubing undated, contrary to facility protocols. Staff confirmed that the nebulizer tubing should be changed and dated weekly, and the mask should be covered and dated when not in use. The lack of adherence to these protocols could lead to bacterial growth.
A CNA at a long-term care facility borrowed $250 from a resident, violating facility policy against accepting loans from residents. The resident, who was cognitively intact, reported the incident after the CNA failed to repay the loan as agreed. The CNA admitted to the transaction and was terminated following an investigation.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision and Assessment
Penalty
Summary
The facility failed to protect residents from physical abuse perpetrated by another resident with a known history of severe mental illness and behavioral disturbances. One resident, who had diagnoses including Schizoaffective Disorder, Bipolar Disorder, Dementia with Behavioral Disturbance, and severely impaired cognition, was involved in two separate incidents where they physically struck other residents in the dining room. The first incident involved this resident approaching and hitting another resident on the right upper arm without provocation, and the second incident involved the same resident getting up from their chair and hitting a different resident on the left shoulder during a meal. Despite the resident's documented history of unpredictable and aggressive behaviors, including resistance to care, verbal aggression, and poor impulse control, the care plans did not include specific interventions or guidance for staff regarding the level of supervision required to prevent further abuse. Staff interviews confirmed that the resident's behaviors were unpredictable and that constant supervision would be necessary to prevent such incidents. However, after initial one-to-one supervision was discontinued following the first incident, no assessment was conducted to determine the ongoing level of supervision needed, and the resident was able to commit a second act of physical abuse. The facility's investigative files and staff interviews revealed that during both incidents, multiple staff members were present in the dining room, but most were unaware of the abusive acts until after they occurred. Only one staff member witnessed each event directly. The facility did not analyze or review the incidents in a manner that would determine the underlying causes or implement effective corrective actions to prevent recurrence, resulting in repeated abuse affecting multiple residents.
Failure to Supervise Resident with Psychosis Resulting in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide adequate supervision and appropriate behavioral health interventions for a resident with a known history of chronic delusions, psychosis, restlessness, agitation, and aggressive behaviors. This resident, who had diagnoses including Schizoaffective Disorder, Bipolar Disorder, and Dementia with Behavioral Disturbance, exhibited impaired cognition and was documented as resistant to care, wandering, and receiving antipsychotic medication. Despite these known risk factors and a history of unpredictable and aggressive behaviors, the facility did not consistently implement or document supervision or individualized interventions to prevent harm to other residents. Two separate incidents occurred in which the resident physically struck other residents on the shoulder. In both cases, the actions were linked to the resident's delusional thinking and psychosis, as evidenced by statements made during investigations and interviews with staff and witnesses. Staff interviews confirmed that the resident's behaviors were unpredictable and that effective prevention would require close or one-to-one supervision when the resident was in common areas with others. However, the facility's records and care plans did not reflect ongoing or routine supervision or specific interventions to address the risk of harm to others, despite the resident's established behavioral history and previous incidents. Facility policies on abuse prevention and behavior management required individualized assessment and intervention for residents with behaviors that could harm themselves or others. However, after the initial incident, there was no documented assessment to determine the appropriate level of supervision needed for the resident, and the care plan was not updated to reflect the physical aggression. The lack of consistent supervision and failure to update care plans or implement effective interventions resulted in repeated incidents of resident-to-resident abuse, as observed and reported by staff and documented in investigative files.
Resident Rights Violated During Medication Administration
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) administered medication to a resident with severe cognitive impairment and a history of acute respiratory failure, dementia, and cerebrovascular disease. During the medication administration, the LPN placed his hand over the resident's mouth and pinched the resident's nose to prevent the resident from spitting out the medication. This act was witnessed by a Certified Nursing Assistant (CNA), who observed the resident's face turning red and the resident struggling and moving their head from side to side in response to the force used by the LPN. The CNA considered the LPN's actions to be abusive and left the room to report the incident. Interviews with other staff members, including additional LPNs, the Unit Manager, the Social Worker, and the Director of Nursing (DON), confirmed that the resident had the right to refuse medication and that placing a hand over a resident's mouth to force medication was improper, could be considered abuse, and posed a risk of aspiration. The facility's own policies on medication administration and the Resident Bill of Rights explicitly state that residents have the right to refuse treatment and must not be subjected to coercion or force. Despite this, the LPN admitted to placing his hand over the resident's mouth to prevent the medication from being spit out, acknowledging that this was not appropriate and that the resident should have been allowed to refuse the medication. Following the incident, it was revealed that the LPN was suspended but returned to work without direct monitoring or oversight. There was no evidence that the facility took steps to ensure that the LPN did not repeat this behavior with other residents during medication administration. The lack of immediate and ongoing supervision after the incident, combined with the failure to protect the resident's right to refuse care, led to the citation of Immediate Jeopardy under F578 for violation of resident rights.
Abuse During Medication Administration and Failure to Protect Residents
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of acute respiratory failure, dementia, and cerebrovascular disease was subjected to physical and mental abuse by an LPN during medication administration. The LPN placed his hand and a paper towel over the resident's mouth and pinched the resident's nose to force the resident to swallow medication, while telling the resident to take the medication. This act was witnessed by a CNA, who observed the resident's face turning red and the resident struggling and moving their head from side to side. The CNA left the room, leaving the resident alone with the LPN, and did not immediately report the incident. The LPN continued to work his scheduled shift after the incident, as the facility administration did not immediately identify the event as abuse or take appropriate corrective action to protect residents. The LPN was only suspended after administration was made aware of the incident later in the day. Despite the seriousness of the event, the LPN was allowed to return to work after a brief suspension and was not monitored or supervised while administering medications to other vulnerable residents, including those with dementia, who could be at risk of similar abuse. Interviews with staff familiar with the resident confirmed that the LPN's actions were physically, emotionally, and psychologically abusive, and could have resulted in aspiration. The responsible party for the resident stated that having a hand placed over the resident's mouth would have caused significant fear. The facility's failure to recognize, report, and respond appropriately to the abuse, as well as the lack of monitoring of the LPN after the incident, resulted in a finding of immediate jeopardy due to the likelihood of serious injury, harm, impairment, or death to residents.
Failure to Implement Abuse Prevention Policy and Protect Resident from Staff Abuse
Penalty
Summary
The facility failed to implement its abuse prevention policy and did not take appropriate actions to protect a resident from abuse by an LPN. On the morning of the incident, the LPN was observed by a CNA placing a paper towel over the resident's nose and pinching it, while also covering the resident's mouth, in an attempt to force the resident to swallow medications. The resident, who had a history of severe cognitive impairment and multiple medical diagnoses including acute respiratory failure, dementia, and cerebrovascular disease, was left alone with the LPN after the CNA witnessed the event. The CNA did not immediately intervene or report the abuse, instead leaving the room and only reporting the incident to the DON several hours later. Despite the facility's policy requiring immediate suspension of any employee accused of abuse and immediate reporting, the LPN continued to work and administer medications to residents during the survey period, placing other residents at risk. The facility's investigation did not initially substantiate the abuse, and the LPN was allowed to return to work after a brief suspension. The facility's failure to recognize and act upon the abuse allegation resulted in the LPN maintaining access to residents for over a month after the incident. Interviews with staff revealed a lack of timely reporting and intervention in response to the witnessed abuse. The CNA who observed the incident did not follow the facility's abuse policy for protecting residents, and other staff members did not take immediate action when informed of the situation. The facility's leadership, including the DON and Administrator, acknowledged that the abuse policy was not followed and that the resident was not adequately protected from potential harm.
Failure to Immediately Report and Intervene in Observed Resident Abuse
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) failed to immediately report an observed incident of abuse involving a resident with severe cognitive impairment. The incident involved a Licensed Practical Nurse (LPN) who placed his hands over the resident's mouth and nose, using a paper towel to pinch the nose, in an attempt to force the resident to swallow medication. The resident, who had diagnoses including acute respiratory failure with hypoxia, dementia, cerebrovascular disease, and pain, was observed struggling, turning red in the face, and pushing their head from side to side during the incident. The CNA, after witnessing this, initially attempted to inform another LPN, who declined to get involved, and then delayed reporting the incident to facility administration. The facility's policy required that all alleged violations involving abuse, neglect, or mistreatment be reported immediately, but no later than two hours after the allegation is made, to the administrator or other officials. In this case, the CNA did not report the incident to the Director of Nursing (DON) until several hours after the event, and the abuse was not reported to the State Agency until later that day. During this time, the LPN involved continued to work his shift without direct monitoring or oversight. Interviews with staff confirmed that the CNA did not understand the importance of immediate reporting and that other staff members did not intervene or ensure the report was made promptly. The delay in reporting and failure to protect the resident from further potential harm constituted a violation of the facility's abuse prevention policy. The deficiency was substantiated through interviews, record reviews, and examination of the facility's own investigative documentation. The incident affected one resident who was sampled for abuse, and the failure to report and intervene as required placed the resident at risk.
Infection Control Deficiencies in Linen Handling and Barrier Precautions
Penalty
Summary
The facility failed to maintain cleanliness and prevent contamination in the north hall clean linen closet, as observed by the surveyor. The closet contained used dirty gloves, tissues, hair tracks, and hair on PPE gowns, indicating a lack of proper sanitation. The Infection Preventionist acknowledged the contamination and described the closet's condition as a 'nightmare,' noting that it appeared this way every Monday. This deficiency had the potential to affect one of the two linen closets observed, posing a risk of contamination. Additionally, the facility did not handle residents' laundry in a manner that prevented the spread of infection. A Floor Tech was observed folding residents' personal clothing items in a way that allowed them to contact his body and clothing, contrary to the facility's policy. Both the Floor Tech and the Housekeeping Supervisor recognized the risk of cross-contamination from this practice. Furthermore, a staff member failed to implement Enhanced Barrier Precautions for a resident with a Stage 4 pressure ulcer, as required by the facility's policy. The CNA entered the resident's room without wearing a gown, despite the presence of a sign indicating Enhanced Barrier Precautions. The Infection Preventionist Nurse confirmed that the staff should have worn gloves and a gown to prevent cross-contamination.
Resident Altercation Due to Misunderstanding Over Personal Belongings
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in a physical altercation between them. The incident occurred when a Certified Nursing Assistant (CNA) was transferring one resident back to their room, and the other resident hit them, leading to a fight. The facility's policy on abuse prevention, which includes protection from resident-to-resident abuse, was not effectively implemented in this case. The residents involved were both cognitively intact, with one having a Brief Interview for Mental Status (BIMS) score of 14 out of 15 and the other 11 out of 15. The altercation began when one resident noticed a bag of chips in the other's possession and attempted to take it, leading to a physical confrontation. The CNA witnessed the incident and intervened by separating the residents and calling for the charge nurse. Interviews with the residents and staff revealed that the altercation was triggered by a misunderstanding over personal belongings, specifically a bag of chips. The facility's investigation confirmed that the residents hit each other on the arms during the incident. The facility's failure to prevent this altercation highlights a deficiency in ensuring residents are free from physical abuse by other residents.
Failure to Manage Resident Wandering Behaviors
Penalty
Summary
The facility failed to ensure appropriate interventions were developed to manage a resident's wandering behaviors, which compromised the safety of other residents. The resident in question, identified as having severely impaired cognition, was admitted with diagnoses including Dementia without Behaviors, Alzheimer's Disease with late onset, Adjustment Disorder with Anxiety, and Mood Disorder due to Physiological Condition with Depressive Features. Despite these conditions, the resident's care plan only included monitoring and documenting behavior without effective interventions to prevent wandering into other residents' rooms. An incident occurred where the resident wandered into another resident's room through a shared bathroom, leading to a confrontation. The resident was found standing near the head of another resident's bed, which resulted in a physical altercation where the wandering resident inadvertently slapped the other resident. Interviews with staff revealed that the wandering resident had a history of entering other residents' rooms, and the interventions in place were not sufficient to prevent such incidents. The facility's policy on behavior management required the development of a behavior program for residents with behaviors that could harm themselves or others. However, the facility did not effectively update the care plan with appropriate interventions after the resident's wandering behavior was identified. The staff's response to the incident involved separating the residents and assessing them for injuries, but the lack of proactive measures to address the wandering behavior led to the deficiency being cited.
Failure to Maintain Proper Respiratory Care Protocols
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident diagnosed with Chronic Obstructive Pulmonary Disease. The resident's nebulizer mask was observed uncovered and without a date on the tubing on multiple occasions. Specifically, on two separate days, the nebulizer was found at the resident's bedside without a cover, and the tubing lacked a date, which is necessary to verify when it was last changed. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the nebulizer tubing should be changed and dated weekly, and the mask should be covered and dated when not in use. The staff acknowledged that the absence of a date on the tubing and the lack of a cover on the mask could lead to bacterial growth, posing a risk to the resident's health. The facility's protocol for verifying tubing changes involves the QA nurse checking the dates, which was not adhered to in this instance.
Misappropriation of Resident Funds by CNA
Penalty
Summary
The facility failed to protect a resident from the misappropriation of funds by a staff member. The incident involved a Certified Nursing Assistant (CNA) who borrowed $250 from a resident, identified as Resident Identifier (RI) #1, without repaying it as initially agreed. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, reported the incident to the Business Office Manager (BOM) after the repayment was delayed. The facility's policies, including the Abuse Prevention and Human Resources Management Policy, explicitly prohibit staff from accepting loans from residents. Despite being aware of this policy, the CNA borrowed money from the resident, which constitutes misappropriation of resident property. The incident was reported to the Alabama Department of Public Health (ADPH) and was part of a complaint investigation. The resident had been discharged from the facility prior to reporting the incident. During interviews, both the resident and the CNA confirmed the loan transaction. The CNA admitted to borrowing the money and acknowledged that it was against the facility's policy. The facility administrator was informed of the incident, and an investigation was initiated, leading to the CNA's termination.
Latest citations in Alabama
A cognitively impaired resident with multiple neurologic and psychiatric diagnoses was sent to a hospital for evaluation of coughing up blood, where a urinalysis initially showed sperm in the urine and the hospital documented concern for possible sexual abuse and requested a rape kit. The ADM reported being notified by hospital staff that semen had been detected and that a rape kit was being performed, and that law enforcement and a DHR representative were involved, but there was no documentation of these calls and no evidence the allegation of abuse was reported to the State Agency within the required 2-hour timeframe per the facility’s Abuse Policy. This failure to report and lack of documentation resulted in a cited deficiency related to abuse reporting requirements.
A resident’s family reported that the resident had fallen and developed a new bruise on the left side of the face. An LPN, an RN/unit manager, the DON, the ADON, and the Administrator all became aware of the alleged unwitnessed fall and observed or were informed of the facial bruise, with nursing staff documenting findings such as a raised bruised knot and a light purple bruise extending from the cheek to the eyebrow. Despite a facility policy requiring prompt investigation and completion of an incident/accident report for all resident accidents or incidents, no incident report was completed by any of the involved staff, even though several acknowledged that one should have been done and that they were responsible for doing so.
A hospice resident with multiple serious diagnoses received PRN Lorazepam and Morphine that were signed out by an LPN on the controlled substance inventory record, but the corresponding doses were not documented on the MAR as required by facility policy. During interviews, the LPN reported administering the medications and admitted she only documented on the MAR most of the time, while the ADON confirmed that PRN controlled substances must be recorded on both the MAR and the narcotic sign-out sheet and verified the missing MAR entries. This resulted in incomplete documentation of controlled medication administration and record keeping.
A resident with dementia and an adjustment disorder, care planned as at risk for falls with an intervention to keep the call light within reach, was repeatedly observed lying in bed with the call light on the floor and out of reach over three consecutive survey days. The facility’s call light policy stated the system is to be used to respond to residents’ requests and needs. The assigned CNA and the DON both stated that call lights should be within residents’ reach so they can call for help or tell staff if they need anything, while acknowledging that this resident’s call light had been on the floor.
A resident admitted with a left foot fracture and care planned as needing substantial/maximal assistance with ADLs did not receive documented bathing as scheduled. Facility policy required provision of hygiene services, including showers or complete bed baths, and honoring resident preferences for type and frequency of baths. The resident’s MDS showed dependence for showering/bathing, and the care plan directed staff to assist with baths per schedule and PRN. However, review of documentation for two consecutive months showed no record of showers or self-bathing, despite the DON stating the resident was scheduled for showers three evenings per week and that such care should be recorded on ADL sheets. The DON confirmed there was no documented evidence that the scheduled showers were provided during the resident’s stay.
A resident with multiple medical conditions, including protein-calorie malnutrition and chronic systolic CHF, was observed with a Foley catheter drainage bag placed on a floor mat and left uncovered, contrary to facility policy requiring catheter bags to be covered and properly positioned. An LPN confirmed the bag was not covered and stated it should have been hooked to the bed frame, and the ADON/Infection Control Nurse reported that staff should use a clamp to attach Foley bags to the bed frame. This failure placed the drainage system at risk for contamination and the resident at risk of UTI and did not maintain the resident’s dignity.
The facility failed to prevent multiple forms of abuse and exploitation. A cognitively impaired, wandering resident was not adequately supervised and entered the room of another cognitively impaired resident with a documented history of sexually inappropriate behavior; a CNA later observed that resident fondling the wandering resident’s genitalia, despite prior documentation of repeated sexualized behaviors and no clear supervision directions in the care plan. In a separate event, a staff member posted a photo on social media of a cognitively intact but physically disabled resident soiled with feces, with a derogatory caption, contrary to written policies prohibiting unauthorized resident images and protecting privacy and confidentiality; the resident reported feeling angry and embarrassed. Additionally, a resident with a known history of verbal and physical aggression struck another resident on the arm in the dining room, causing pain, demonstrating inadequate supervision and interventions to prevent resident-to-resident physical abuse.
The facility failed to implement its abuse, neglect, and exploitation policy to prevent and investigate resident‑on‑resident sexual abuse involving two cognitively impaired residents, one with Alzheimer’s disease who wandered into others’ rooms and one with intellectual disability and a documented history of sexually inappropriate behavior. Over several months, staff documented repeated sexually inappropriate acts and aggressive behaviors by the latter resident, yet the resident remained on a memory care unit populated by wandering residents. One evening, a CNA observed this resident with a hand inside another resident’s brief, fondling the genital area. The CNA removed the resident and notified an LPN, but no body audit was performed, and staff reported they had not been instructed on specific supervision of wandering residents. The facility’s investigation was limited to two staff statements, did not include comprehensive interviews or assessments, and concluded the allegation was not substantiated despite acknowledgment that both residents lacked capacity to consent. Leadership, including the abuse coordinator and administrator, could not identify the cause of the incident or effective preventive measures, and surveyors cited Immediate Jeopardy under F607 for failure to establish a safe environment, implement effective protocols, and conduct a thorough abuse investigation.
The facility failed to implement an effective QAPI process after a resident-to-resident sexual abuse incident involving a resident with a known history of sexually inappropriate behavior and another cognitively impaired, wandering resident. Although policies required QAA review of sexual abuse cases to ensure thorough investigation, resident protection, analysis of why the event occurred, and identification of systemic actions, the QAPI Committee did not verify a complete investigation, did not classify the event as abuse, and did not analyze risk factors such as unsupervised wandering and access to other residents’ rooms. The ADM acknowledged that not all aspects of the investigation were documented, did not recall reviewing the investigation before submission to the State Agency, and reported that QAPI did not identify a need for systemic changes, relying instead on separating the residents. The lack of documented QAPI review and failure to identify and address causal and contributing factors resulted in unsafe conditions persisting and led to an Immediate Jeopardy citation at F867.
The facility failed to follow its abuse policy requiring notification of law enforcement for alleged abuse when a staff member observed two residents in a situation documented as sexual abuse, with one resident’s hand inside another resident’s brief. The incident was entered into the state’s online reporting system as sexual abuse, but the report indicated that law enforcement was not notified. In a later interview, the SSD/Abuse Coordinator confirmed that law enforcement should have been contacted for such an allegation and acknowledged that the policy was not followed, affecting two residents reviewed in the abuse sample.
Failure to Timely Report Allegation of Sexual Abuse to State Agency
Penalty
Summary
Failure to timely report an allegation of sexual abuse occurred when the Administrator did not notify the State Agency after being informed by a local hospital that semen had been detected in the urine of a vulnerable, cognitively impaired resident and that a rape kit was requested. The facility’s Abuse Policy, updated 8/2022, required all alleged violations of abuse or neglect to be reported immediately, but not later than two hours, when the alleged violation involves abuse. The resident had diagnoses including Parkinson’s disease, Huntington’s disease, dementia, and schizoaffective disorder, and an MDS BIMS score of 0 indicating severely impaired cognition. The resident was transferred to the hospital for coughing up blood, and the hospital history and physical documented that sperm was noted in the urine and that case management was consulted for possible sexual abuse. A urinalysis on the same date initially showed sperm present in the urine. The Administrator stated he received a phone call from the hospital on or about 10/06/2025 or 10/07/2025 informing him that semen had been detected in the resident’s urine and that a rape kit was needed, and that a detective was referring the matter to the Department of Human Resources. Despite this information, there was no evidence the facility reported the allegation of sexual abuse to the State Agency as required. The Administrator acknowledged there was no documented evidence of the calls from the hospital, including the date and time he was made aware of the rape kit request or the semen finding. Although the urinalysis was later amended to show no sperm present after retesting, the local police department still requested a rape kit, and the Administrator confirmed that abuse allegations were supposed to be reported within a two-hour timeframe. The lack of reporting and documentation constituted the cited deficiency related to the complaint.
Failure to Complete Incident Report After Alleged Fall and Facial Bruise
Penalty
Summary
The deficiency involves the facility’s failure to follow its own "Accidents and Incidents – Investigating and Reporting" policy by not completing an incident/accident report after a family-reported fall and observed facial bruise for Resident #44. The policy requires that all accidents or incidents involving residents on the premises be promptly investigated and documented on a Report of Incident/Accident form, including details such as date and time, nature of injury, circumstances, witnesses, notifications, condition of the resident, and corrective actions. Despite this requirement, no such report was completed for Resident #44 following an allegation of a fall and the discovery of a bruise on the left side of the resident’s face. Resident #44 was admitted on an unspecified date and discharged on 02/10/2026. On that date, the resident’s daughter reported that the resident had fallen and had a new bruise on the left side of the face. LPN #10 stated she was informed that the daughter reported a fall, assessed the resident, and observed a small raised, bruised knot near the left eyebrow, but did not complete an incident report, acknowledging that one should have been done. RN/Unit Manager #7 reported hearing the daughter screaming that the resident had fallen at approximately 7:40 AM, assessed the resident, and noted an unraised bruise on the left side of the face; she confirmed that she did not prepare an incident report and did not find one in the medical record, despite stating that an incident report should have been completed. The DON stated that the daughter had informed her of an unwitnessed fall involving the resident and that the resident had a bruise on the left cheek that could have resulted from hitting the side rail. The DON reported that interviews with RN #4 and CNA #15, supported by signed witness statements dated 02/10/2026, indicated that neither staff member witnessed the resident on the floor or assisted the resident back to bed, and she was unsure whether an incident report had been completed. The ADON stated she was informed of an unwitnessed fall, assessed the resident as confused and lethargic with a light purple bruise from the left cheek to the eyebrow, contacted the NP for an order to send the resident to the hospital, and acknowledged that she should have completed an incident report but did not. The Administrator confirmed he was informed of the bruise and the reported fall, personally observed a light blue bruise from the cheekbone to the midpoint of the eye, and stated that, per policy, an incident report should have been completed, but it was not.
Failure to Document PRN Controlled Medications on MAR
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling and documentation of controlled medications for one hospice resident. The resident, originally admitted on an unspecified date and later admitted to hospice on 02/13/2025, had diagnoses including senile degeneration of the brain, acute respiratory failure with hypoxia, acute ischemic heart disease, and sepsis. Facility policies on Controlled Substances and Administering Medications required that controlled substances be handled and documented in compliance with laws and regulations, including the nurse’s signature on controlled substance records and the initialing of the Medication Administration Record (MAR) after each medication is given. Review of the resident’s Controlled Substance Inventory Record (CSIR) showed that an LPN signed out Lorazepam and Morphine—two doses of each on 01/29/2026 and three doses of each on 01/30/2026. However, review of the resident’s January 2026 MAR revealed no documentation that Lorazepam and Morphine were administered for two doses each day on 01/29/2026 and 01/30/2026, despite the CSIR indicating they had been signed out. During interview, the LPN stated she had administered Morphine and Lorazepam to the resident but could not recall the exact frequency and estimated she documented these administrations on the MAR approximately 85% of the time, acknowledging that documentation only on the controlled substance sheet without corresponding MAR entries would be incomplete. The Assistant Director of Nursing confirmed that facility process required PRN controlled substances to be documented on both the MAR and the narcotic sign-out sheet and verified that there were no MAR entries corresponding to the doses signed out on the CSIR for the specified dates and times. This failure had the potential to affect the resident by limiting the facility’s ability to ensure accurate controlled medication administration, record keeping, and monitoring.
Failure to Keep Resident Call Light Within Reach as Care Planned
Penalty
Summary
The facility failed to ensure a resident’s call light was kept within reach as required by the facility’s “CALL LIGHT” policy and the resident’s care plan. The policy stated the purpose of the call light system was to respond to residents’ requests and needs. The resident, who had dementia and an adjustment disorder with mixed anxiety and depressed mood, had a fall risk care plan initiated on 06/26/2024 that included an intervention to keep the call light within reach and encourage the resident to use it for assistance. On three consecutive survey days, the resident was observed lying in bed with the call light not within reach. On 02/18/2026 at 8:00 AM, the call light was on the floor beneath the bed. On 02/19/2026 at 7:56 AM, the call light was again on the floor beneath the bed while the resident was in bed. On 02/20/2026 at 9:03 AM, the call light was observed on the floor at the head of the bed while the resident was lying in bed. During an interview, the resident’s assigned CNA for the 7–3 shift acknowledged the call light was on the floor and stated that call lights should be within residents’ reach so they can call for help. The DON also stated that call lights should be within residents’ reach so they can tell staff if they need anything.
Failure to Provide and Document Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide scheduled bathing assistance to a resident who was dependent on staff for activities of daily living (ADLs), specifically bathing. Facility policy titled "ADL CARE POLICY AND PROCEDURE" stated that good hygiene and grooming help prevent the spread of infection and promote residents' feelings of self-worth and dignity, and that resident preferences for time of day, type of bath, and frequency of bath should be honored. The policy identified showers, tub baths, and complete bed baths as part of hygiene and grooming services. The resident, admitted with a displaced fracture of the fifth metatarsal bone of the left foot and care planned as requiring limited to total assistance with all ADLs, had an intervention to assist with baths per schedule and as needed. An anonymous complainant reported that the resident had been in the facility for two weeks and had only received two baths. The resident’s MDS with an ARD of 01/19/2026 documented that the resident required substantial/maximal assistance with showering/bathing self. A review of the resident’s Documentation Survey Report for January and February 2026 showed no documentation that the resident received a shower or bathed independently during the admission period. During an interview, the DON stated the resident’s scheduled shower days were Tuesdays, Thursdays, and Saturdays on the 3 PM to 11 PM shift and that staff were to document showers on the ADL sheet. Upon reviewing the ADL sheet, the DON confirmed there was no documented evidence that the resident received scheduled showers from 01/13/2026 to 02/04/2026.
Improper Foley Catheter Drainage Bag Positioning and Lack of Cover
Penalty
Summary
The facility failed to maintain a resident’s urinary drainage bag in accordance with its catheter care policy and professional standards of practice. The facility’s undated Catheter Care policy stated that catheter drainage bags would be covered at all times and that drainage would be located below the level of the bladder to discourage backflow of urine. Resident Identifier (RI) #77, admitted on an unspecified date, had diagnoses including protein-calorie malnutrition, chronic systolic congestive heart failure, and generalized muscle weakness. During an observation on 02/18/2026 at 9:26 AM, RI #77’s urinary drainage bag was seen placed on a blue mat on the floor and uncovered, contrary to the facility’s policy and accepted infection control practices. In a subsequent interview on 02/20/2026 at 11:01 AM, an LPN acknowledged that the catheter bag was not covered and stated that the facility’s protocol was for the Foley catheter drainage bag to be hooked to the bed frame, further acknowledging that placing the catheter bag on the floor could cause infection. Later that day at 12:25 PM, the ADON, who also served as the Infection Control Nurse, stated that staff should use a clamp to hook Foley catheter bags to the resident’s bed frame. The surveyors concluded that the observed practice of leaving the drainage bag uncovered and on the floor placed the drainage system at risk for contamination and the resident at risk of urinary tract infection, and failed to maintain the resident’s dignity as required by the facility’s policy.
Failure to Prevent Resident-to-Resident Abuse and Staff Social Media Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, neglect, and exploitation, including sexual abuse between residents, physical abuse between residents, and mental abuse/exploitation by staff through social media. One resident with Alzheimer’s disease and severe cognitive impairment, who wandered frequently and intruded into other residents’ rooms, was not adequately supervised despite documented wandering episodes and a care plan noting exit-seeking and room entry behaviors. Another resident with myocardial infarction, intellectual disabilities, mood disorder, mild cognitive impairment, and a documented history of sexually inappropriate behavior toward staff and possible other residents was also not care planned with specific directions for supervision. Progress notes over several months documented repeated sexually inappropriate touching and comments toward staff, combative behavior, and the need for two staff for care, yet the care plan did not specify how or when this resident should be supervised. On one evening, a CNA observed the cognitively impaired, wandering resident sitting on the bed of the resident with sexually inappropriate behaviors, and saw the latter with a hand inside the other resident’s brief, fondling the resident’s genitalia. Staff interviews confirmed that both residents lacked the ability to consent to sexual activity and that the contact was non-consensual sexual contact. The CNA who witnessed the event reported having no specific instruction on how to supervise wandering residents beyond photos at the nurses’ station. The unit manager and DON acknowledged that the wandering resident entered other residents’ rooms frequently, that staff were expected to round every two hours or more often, and that more frequent monitoring could have prevented the incident. The administrator stated that the resident with sexually inappropriate behaviors could remain on the memory care unit after allegations of sexual touching because he did not feel the resident posed a threat to others. The facility also failed to protect another resident from mental abuse and exploitation when a former CNA posted a photograph of the resident in a vulnerable, soiled condition on Snapchat with a derogatory caption. The resident, who had anoxic brain damage and spastic quadriplegic cerebral palsy but intact cognition, later reported feeling angry and embarrassed after being informed of the incident. Facility policies on social media use, cell phones, and confidentiality explicitly prohibited taking, keeping, or distributing unauthorized photographs of residents and described such actions as violations of privacy and confidentiality that could degrade or embarrass residents. A nurse aide witness reported seeing the image on social media, recognized the resident by the room items, and described the picture as showing the resident’s body from armpit to ankle covered in feces, with no face or genitalia visible. Staff interviews confirmed that posting such an image would be considered abuse and a violation of policy and resident privacy. In a separate incident, the facility failed to protect a resident from physical abuse by another resident with a known history of aggressive behaviors, including verbal and physical aggression. A CNA witnessed the aggressive resident hitting another resident on the arm in the dining room. The victim reported that his/her arm hurt after being hit. The aggressive resident’s history of physical aggression was known, but the facility did not provide adequate supervision and interventions to prevent this resident from abusing others. These failures occurred despite facility policies that required screening of residents for behavioral risks, assessment and care planning for behaviors that might lead to conflict or neglect, training staff on behavioral symptoms that increase risk of abuse, and implementing policies and procedures to prevent all types of abuse, including sexual, physical, and mental abuse facilitated by technology.
Failure to Implement Abuse Policy and Prevent Resident‑on‑Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy to prevent, identify, and investigate an allegation of sexual abuse involving two cognitively impaired residents. One resident with Alzheimer’s disease had a care plan for wandering, exit seeking, and entering other residents’ rooms, with interventions focused on redirection and a secure care monitor to prevent elopement. Another resident with hemiplegia, unspecified intellectual disabilities, and mild cognitive impairment had a comprehensive care plan identifying a history of attention‑seeking behaviors, combative behavior, verbal abuse, and sexually inappropriate behavior toward staff and possibly other residents, with interventions including administration of medications per MD order and use of two staff for care due to sexually inappropriate episodes. Despite these identified risks and documented behaviors, the facility did not establish or implement effective protocols to prevent sexual abuse between these residents. From December 2024 through February 2025, multiple progress notes documented escalating sexually inappropriate behaviors by the resident with intellectual disability toward staff, including touching female staff inappropriately, grabbing breasts and buttocks, and other aggressive behaviors such as yelling out, throwing items, and being verbally and physically abusive. The Memory Care Unit, where this resident was housed at the time, was described by staff as a unit with wandering residents who had decreased cognition. The wandering resident with Alzheimer’s disease was known to enter other residents’ rooms. On the evening of 02/11/2025, a CNA making rounds observed the wandering resident sitting on the side of the sexually inappropriate resident’s bed, with the latter’s hand inside the wandering resident’s brief, fondling the genital area. The CNA immediately removed the wandering resident from the room and reported the incident to an LPN. The LPN did not perform a body audit on either resident, and the CNA reported she had not been instructed on how to supervise wandering residents beyond recognizing their photos at the nurses’ station. The facility’s investigation did not follow its own written procedures for abuse investigations. The investigative file contained only two staff statements (from the CNA and the LPN) and did not include interviews with all potentially involved or knowledgeable staff, nor did it document a body assessment of either resident. The Abuse Coordinator’s closing report concluded the incident was “not substantiated” sexual abuse, citing insufficient evidence regarding which resident initiated the contact and the absence of observed distress, despite acknowledging that neither resident had the ability to consent. In subsequent interviews, the Abuse Coordinator stated they had no identified cause for the incident because neither resident could explain what happened and acknowledged that staff did not observe the wandering resident entering the room because they were in other residents’ rooms providing care. The Abuse Coordinator also stated that, given both residents lacked capacity to consent, there was nonconsensual sexual contact on 02/11/2025. The Administrator reported he did not recall reviewing the investigation findings before submission to the State Agency and could not identify what could have been done to prevent the abuse. The surveyors determined that the facility failed to establish a safe environment, failed to implement protocols to prevent sexual abuse among residents with known wandering and sexually inappropriate behaviors, and failed to conduct a thorough investigation to accurately determine that abuse occurred and the cause of the incident, resulting in Immediate Jeopardy under F607. Additional documentation after the incident showed that the resident with sexually inappropriate behaviors continued to exhibit similar behaviors toward staff throughout 2025, including inappropriate touching and aggressive actions, with periodic notes indicating that such behaviors had increased in frequency. Interviews with the Memory Care Unit manager confirmed awareness of the resident’s ongoing sexually inappropriate behaviors and refusal of medications, and acknowledged that when the resident was later returned to the Memory Care Unit, that unit continued to house more wandering, confused residents than other units. The manager also confirmed there was no staff specifically assigned to monitor wandering residents, and that the primary intervention was general redirection. Staff interviews, including with an RN who characterized the 02/11/2025 event as abuse, further supported that the facility did not implement targeted supervision or environmental controls to prevent recurrence of sexual abuse between residents with known risk factors, despite the facility’s written policy requiring identification, ongoing assessment, care planning, monitoring, and establishment of a safe environment with protocols for preventing sexual abuse.
Failure of QAPI Oversight After Resident-to-Resident Sexual Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective Quality Assurance and Performance Improvement (QAPI) program in relation to a resident-to-resident sexual abuse incident. The facility’s QAPI plan and abuse policy required that cases of physical or sexual abuse be reviewed by the Quality Assurance and Assessment (QAA) Committee to ensure a thorough investigation, protection of residents, analysis of why the situation occurred, identification of contributing risk factors, and determination of whether systemic actions were needed. Despite these written policies, the QAPI Committee did not review the sexual abuse incident in a manner that verified a thorough investigation, did not classify the incident as abuse, and did not analyze why it occurred. The report states that the incident involved a resident with a documented history of sexually inappropriate behavior toward staff and another resident who wandered without supervision. The facility failed to analyze contributing risk factors, including the presence of wandering, cognitively impaired residents on the same unit as a resident with known sexually inappropriate behaviors. The QAPI Committee did not identify or address the lack of supervision that allowed wandering residents to enter other residents’ rooms without supervision. The Administrator later stated that the incident was discussed in QAPI, including who was involved, what happened, and how the facility would do things differently, but acknowledged that not all aspects of the investigation were in the documentation. The Administrator reported that QAPI did not determine that systemic changes were needed, explaining that the mental capacity of both residents led the team to believe that separation of the residents was sufficient. The Administrator also indicated he did not recall reviewing the investigation before it was submitted to the State Agency and was unsure what could have been done to prevent the abuse. The facility did not provide documentation showing that the allegation of resident-on-resident abuse was reviewed to ensure the investigation identified contributing or causal factors to be corrected and prevent recurrence. These failures in QAPI oversight and follow-through allowed unsafe conditions to persist and placed residents at risk for serious harm, leading surveyors to cite Immediate Jeopardy at F867 for QAPI/QAA improvement activities.
Failure to Report Alleged Sexual Abuse to Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse to local law enforcement as required by its own abuse policy. According to the facility’s written policy on Abuse, Neglect and Exploitation, revised 01/01/2024, sexual abuse is defined as non-consensual sexual contact of any type with a resident, and the policy requires reporting all alleged violations to the administrator, state agency, adult protective services, and other required agencies, including law enforcement when applicable, within specified timeframes. On 02/11/2025 at approximately 7:30 PM, a staff member observed one resident standing over another resident’s bed with the second resident’s hand down the first resident’s brief, and this was documented in the Online Incident Reporting System as an incident of sexual abuse. The Online Incident Reporting System entry for this event indicated that the incident type was “Abuse – Sexual” and that the incident was not reported to any law enforcement agency. During an interview on 01/18/2026 at 4:47 PM, the Social Service Director, who also served as the Abuse Coordinator, stated that law enforcement should be notified when abuse is alleged and acknowledged that law enforcement was not notified of the 02/11/2025 incident. The Social Service Director further stated that the facility’s abuse policy was not followed and expressed that the concern with not reporting the allegation to law enforcement was that vulnerable residents were at risk. This failure to report affected two of six residents sampled for abuse and was cited as a result of complaint investigation #471525.
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