Cordova Health And Rehabilitation, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Cordova, Alabama.
- Location
- 70 Highland Street West, Cordova, Alabama 35550
- CMS Provider Number
- 015115
- Inspections on file
- 13
- Latest survey
- November 21, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cordova Health And Rehabilitation, Llc during CMS and state inspections, most recent first.
A resident with a history of manipulative romantic behaviors and entering other residents' rooms was not adequately supervised, leading to a serious incident of sexual abuse by another resident. Despite being aware of the behaviors, the facility failed to implement effective interventions, resulting in immediate jeopardy for the resident.
A facility failed to thoroughly investigate an incident of abuse involving two residents, leading to a citation for non-compliance. Staff witnessed a compromising situation between the residents, but the investigation did not include interviews or identify the facility's failure to supervise a resident with a history of inappropriate behaviors. The lack of a comprehensive investigation and protective measures resulted in Immediate Jeopardy due to the risk of serious harm.
The facility failed to prevent potential cross-contamination in its food service areas. Staff were observed chewing gum while assisting residents with meals, posing a contamination risk. Additionally, clean pots and pans were stored on rusty shelves, and the storeroom for supplements had a dirty floor and uncleanable wooden shelving. The food preparation sink lacked proper backflow prevention, further risking contamination.
The facility failed to maintain the Three-compartment Pot and Pan Sink in good repair, as two of its drain levers were not functioning, preventing proper use. This issue persisted since the kitchen floor renovation, leading to deviations from standard procedures for washing and sanitizing pans. The deficiency had the potential to affect all 108 residents receiving meals from the kitchen.
The facility failed to maintain a clean and homelike environment, with deficiencies including a corroded and dusty vent in the Dining Room, dusty ceiling vents in hallways, a non-functional clock, and torn vinyl chairs. These issues were confirmed by staff and could lead to cross-contamination and respiratory issues.
The facility failed to report abuse allegations within the required two-hour timeframe on multiple occasions. One incident involved a resident reporting verbal abuse by another resident, and another involved a CNA allegedly cursing at a resident. Delays in reporting were attributed to administrative oversights and lack of access to necessary resources.
A facility failed to transmit a completed MDS assessment for a resident to CMS within the required timeframe. The assessment, completed by the MDS Coordinator, was not sent after its completion, as confirmed during an interview. This oversight was discovered during a record review, highlighting non-compliance with federal transmission requirements.
The facility failed to accurately code the MDS assessments for two residents, affecting their PASRR Level II status. One resident with PTSD and a Developmental Disorder and another with Depression were incorrectly marked as not having a PASRR Level II status, despite documentation indicating otherwise. The MDS Coordinator confirmed these errors during interviews.
The facility did not adhere to its Enhanced Dining policy, serving meals on transport trays in the dining room, affecting 40 residents. Staff interviews revealed a lack of awareness about the policy's intent to eliminate trays for a more homelike dining experience. The Resident Council President confirmed the issue was never discussed with residents.
Inadequate Supervision Leads to Resident Abuse
Penalty
Summary
The facility failed to provide adequate supervision and appropriate interventions to prevent sexual abuse perpetrated by one resident against another. The incident involved a resident with known manipulative romantic behaviors and a history of entering male residents' rooms. Despite being aware of these behaviors, the facility did not develop or implement interventions to address the resident's repeated behaviors and ensure their protection. On the day of the incident, staff heard a resident yelling for help and found the resident on the floor beside another resident's bed, with the latter attempting to force the former into a non-consensual sexual act. The resident who was victimized had a history of hemiplegia, aphasia, and depression, and was unable to complete a mental status interview due to memory problems. The facility's social services department had documented the resident's behaviors over time, including entering other residents' rooms and engaging in manipulative romantic behaviors. However, the facility's care plan did not include the necessary level of supervision to ensure the resident's safety or specify when and how the resident should be monitored. Interviews with staff revealed that the facility's approach to managing the resident's behaviors was limited to redirection and monitoring, without any formal documentation or specific interventions. Staff members were aware of the resident's behaviors but did not have clear guidance on how to manage them effectively. The lack of adequate supervision and intervention led to a situation where the resident was placed in immediate jeopardy, resulting in a serious incident of abuse.
Removal Plan
- RI #82 was placed back on 1:1 observation. RI #82 will not be left unsupervised until deemed safe by facility medical director. The facility will communicate to the medical director after there is no behaviors that increase her vulnerability for sexual abuse.
- RI #82 care plans were reviewed and revised by MDS coordinator to include 1:1 supervision.
- RI #325 was placed on 1:1 supervision until discharged to hospital then discharged home to family. Resident has not returned to the facility.
- RI #82 was assessed by RN Unit Manager and noted to have right ankle pain.
- Management nursing staff completed a facility audit to identify any other residents with known manipulative romantic behaviors, history of consenting to sexual relationships with other residents and history of entering male residents' rooms without supervision. None were identified.
- The Regional Administrator provided 1:1 in-service education to Administrator and DON regarding the abuse policy, distressed behavior management program and identification and notification of new or worsening behaviors that increase residents' vulnerability to sexual abuse.
- Education was initiated by Staff Development Nurse with facility staff regarding abuse policy to include protecting residents from sexual abuse and identifying behaviors that increase residents vulnerability to sexual abuse, by use of notification of new or worsening behaviors from NM.II-24B (exhibit 2) the form will be reviewed in the morning to reduce the risk of abuse. No staff will be allowed to work unless they have been in serviced. CNA's will communicate behaviors to the nurse, the nurse will implement immediate appropriate intervention will document on the electronic medication administration (EMAR) record under resident task. The Director of Nursing or the assistant director of nursing will review resident task history each business day during morning meeting to ensure the appropriate intervention to maintain the safety of the resident. MDS coordinator will then update resident care plans to reflect the new behavior of the resident with the appropriate care plan.
- Emergency QAPI meeting was held with all key personnel (Administrator, Director of Nursing, Department Heads, Regional Administrator and Regional Nurse Consultant). QAPI meeting discussed residents are kept safe from all types of abuse/sexual abuse and neglect. This was done by educating staff on who to report abuse to, when to report abuse and what to report.
- There are no residents known to the facility to be demonstrating with known manipulative romantic behaviors, history of consenting to sexual relationships with other resident, and history of entering male residents' rooms without supervision besides resident RI #82. Any sexually inappropriate behavior will be reported immediately to the Administrator or DON. The facility will immediately initiate the abuse protocol to include immediate protection of residents, notification of local police, MD/CRNP, ADPH and responsible parties followed by complete investigation.
Failure to Investigate and Prevent Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an incident of abuse involving two residents, which led to a citation for non-compliance with federal regulations. On the date of the incident, staff members witnessed a situation in which one resident was found in a compromising position with another resident. Despite the severity of the situation, the facility's investigation did not include interviews with the residents involved, nor did it identify the facility's failure to provide adequate supervision to one of the residents, who had a known history of inappropriate behaviors. The investigation was incomplete as it did not explore potential contributing factors, such as the resident's history of entering other residents' rooms without supervision. The facility's policies required a thorough investigation to determine the cause of the incident and to implement measures to prevent recurrence. However, the investigation lacked critical elements, such as obtaining witness statements and identifying causal factors, which hindered the development of effective interventions. The deficiency was cited as Immediate Jeopardy due to the facility's non-compliance with the requirement to protect residents from abuse, neglect, and exploitation. The failure to conduct a comprehensive investigation and implement corrective actions put residents at risk of serious harm. The facility's inability to address the repeated behaviors of one resident and the lack of protective measures contributed to the deficiency.
Removal Plan
- Regional Administrator and Regional Nurse Consultant provided 1:1 in-service education to Administrator, DON and ADON regarding Abuse/Sexual Abuse policies implemented, including conducting a thorough investigation, to include contributing factors to the occurrence and take appropriate corrective action based on investigation results and contributing factors, completion of Abuse Questionnaire NM.II-20exh.A and collecting and retaining resident statements to determine a clear time of occurrence of events and that all staff responding appropriately per the abuse policy; identification of prospective residents who may pose a risk of sexual abuse to other residents due to their behaviors and planning for management of those behaviors.
- Director of Nursing re-interviewed RI #82.
- Regional nurse consultant and Regional Administrator reviewed for all previous investigations. None were identified that the Regional Administrator or Regional Nurse Consultant disagreed with the investigation outcome.
- QAPI completed with administrator for understanding the administrator's responsibility regarding facility policies being implemented and followed. Regional Administrator will sign off on facility reportable investigations to include sexual abuse investigations for compliance to the facilities abuse/sexual abuse policy, QAPI policy, behavior monitoring policy and notification policy are implemented/conducted according to the policy.
- The Administrator was educated by the regional nurse consultant to utilize the Verification of Investigation (VOI) form to conduct a consistent and thorough investigation of alleged abuse. The VOI includes detained description of events/allegation, BIMS score, Resident interview summary, immediate resident protection initiated, and the related.
Sanitation and Cross-Contamination Issues in Food Service
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation standards, leading to potential cross-contamination risks. During dining observations, several staff members, including CNAs and a Restorative Nurse, were seen chewing gum while assisting residents with their meals. This behavior was noted to occur directly over residents' food, which could lead to contamination. Interviews with the staff revealed a lack of awareness regarding the prohibition of gum chewing during meal assistance, highlighting a gap in training or policy enforcement. Additionally, the facility's kitchen had several sanitation issues. Clean pots and pans were stored on rusty wire shelving, which could lead to contamination from rust and dirt. The storeroom for thickened liquids and nutritional supplements had a dirty floor, with a delivery of supplements placed directly on it. The wooden shelving in the storeroom had gaps along the floor line, making it difficult to clean and potentially attracting pests. These conditions were acknowledged by the Dietary Manager and Registered Dietitian, who recognized the contamination risks posed by these deficiencies. Furthermore, the food preparation area had a double sink with a direct connection to the sewer, lacking an air gap or backflow prevention device. This setup could allow for contamination of food preparation areas. The Director of Maintenance was unaware of any backflow prevention measures in place and indicated the need to consult with a plumber. These findings indicate significant lapses in maintaining a sanitary environment in the facility's food service areas, as required by the U.S. FDA 2022 Food Code.
Failure to Maintain Kitchen Equipment in Good Repair
Penalty
Summary
The facility failed to maintain the Three-compartment Pot and Pan Sink in good repair, as required by their Sanitation Principles policy and the U.S. FDA 2022 Food Code. During an initial kitchen tour, it was observed that the sink was not set up for use because two of the three drain levers were not functioning, preventing the rinse and sanitizing sinks from holding water. The Dietary Manager confirmed that the sink had been out of order since March or April 2024, following the kitchen floor renovation. As a result, the facility had been using the dishroom to wash and sanitize pans, which deviated from the standard procedure. Interviews with the Dietary Manager and the Registered Dietitian revealed that the sink is considered a basic piece of kitchen equipment and should not have been out of service for such an extended period. The facility uses a maintenance system called TELS, which should have addressed the issue. The Director of Maintenance was unaware of why the sink had not been repaired, despite being informed about the problem when the sink was reinstalled after the floor renovation. This deficiency had the potential to affect all 108 residents receiving meals from the kitchen.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment, as evidenced by several deficiencies observed during the survey. In the Dining Room, a large return vent was found to be heavily corroded with rust and covered in dust, which could be easily removed by touch. This vent was located near the emergency exit door and was observed to be in this condition over multiple days while residents were present for meals. Interviews with the Director of Maintenance, Dietary Manager, and Registered Dietitian confirmed the presence of rust, dirt, and dust, and acknowledged that this did not contribute to a homelike environment and could potentially lead to cross-contamination. In the hallways, several ceiling vents on C and D Halls were observed to have a build-up of a dark black substance, identified as dust by the Director of Maintenance. This accumulation of dust was noted to potentially affect residents by exacerbating allergies and respiratory issues. Additionally, a clock in the front hallway on C Hall was found to be non-functional, displaying an incorrect time, which could mislead residents relying on it to attend activities on time. The facility also failed to maintain the condition of vinyl upholstered chairs in the front lobby and hallway. Several chairs were observed with torn or cracked upholstery, making them difficult to clean and potentially leading to injury or cross-contamination. The Director of Maintenance acknowledged that the condition of these chairs was not homelike and could pose a risk of fluid transfer and contamination. These deficiencies were identified as part of a complaint investigation.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse within the required two-hour timeframe to the state agency on three separate occasions, affecting three residents. On April 9, 2024, a resident reported verbal abuse involving another resident, but the incident was not reported to the state agency until the following day. The facility's administrator acknowledged the delay, stating that the incident should have been reported on the day it occurred. This incident was part of a complaint investigation. Another incident occurred on October 27, 2024, when a resident reported verbal abuse by a CNA. The assistant director of nursing (ADON) was informed of the incident shortly after it occurred but did not report it to the state agency until the next day, citing a lack of access to necessary resources as the reason for the delay. The ADON admitted that the report was late and should have been made within the required timeframe. The administrator confirmed the late reporting, which was also part of a separate complaint investigation.
Failure to Transmit MDS Assessment
Penalty
Summary
The facility failed to ensure the timely transmission of a completed Minimum Data Set (MDS) assessment for a resident, identified as RI #2, to the Centers for Medicare & Medicaid Services (CMS) system. According to the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. In this case, RI #2's annual MDS assessment was completed on October 7, 2024, but was not transmitted to CMS as required. The MDS Coordinator confirmed during an interview that the assessment for RI #2 was started on September 23, 2024, and completed on October 7, 2024. However, the coordinator acknowledged that the assessment was not transmitted to CMS after its completion. The failure to transmit the MDS assessment was identified during a record review on November 14, 2024, indicating a lapse in the facility's compliance with federal transmission requirements.
Inaccurate MDS Coding for PASRR Level II Status
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for two residents, which affected the accuracy of their Preadmission Screening and Resident Review (PASRR) Level II status. Resident Identified (RI) #60 was admitted with diagnoses including Generalized Anxiety Disorder, Post-Traumatic Stress Disorder (PTSD), and a Developmental Disorder. Despite having a PASRR Level II Service Determination indicating serious mental illness and a related condition, the MDS assessment incorrectly marked the PASRR status as 'No'. This discrepancy was confirmed during an interview with the MDS Coordinator, who acknowledged the error and emphasized the importance of accurate MDS data. Similarly, RI #82, who was admitted with a diagnosis of Depression, also had an incorrect MDS assessment. The PASRR Level II Service Determination for this resident indicated a serious mental illness, yet the MDS was marked as 'No' for PASRR Level II status. The MDS Coordinator confirmed this was an error during a follow-up interview, acknowledging that the MDS should have been marked to reflect the resident's Level II status. These inaccuracies in the MDS assessments were identified during a review of 22 sampled residents.
Deficiency in Dining Experience Due to Use of Meal Trays
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents during lunch meals on two consecutive days. Observations revealed that meals were served on transport trays directly placed on tables in the dining room, contrary to the facility's Enhanced Dining policy, which aims to eliminate food trays for a more homelike environment. This practice affected all 40 residents present in the dining room. The dining room was set with green linen tablecloths and seasonal decorations, yet the meal service did not align with the policy's standard of providing a non-institutional dining experience. Interviews with staff, including the Registered Dietitian, Dietary Manager, and Restorative Nurse, indicated a lack of awareness and discussion regarding the appropriateness of serving meals on trays in the dining room. The Resident Council President confirmed that the topic had never been discussed with residents. Staff acknowledged that serving meals on trays could detract from the homelike atmosphere intended by the facility's dining policy. The deficiency highlights a disconnect between the facility's policy and its implementation, impacting the residents' right to a dignified dining experience.
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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