Cumberland Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Bridgeport, Alabama.
- Location
- 47065 Al Highway 277, Bridgeport, Alabama 35740
- CMS Provider Number
- 015420
- Inspections on file
- 16
- Latest survey
- June 6, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cumberland Health And Rehab during CMS and state inspections, most recent first.
The facility failed to ensure the QAPI committee developed interventions to address protective measures following an incident of visitor-to-resident sexual abuse and did not address the issue of a resident keeping vape devices in their room. The facility lacked policies for screening visitors, providing supervision during visits, and managing resident vaping, which had the potential to affect all 86 residents.
The facility failed to protect a resident from sexual abuse by a visitor, another resident from physical abuse, and a resident with a history of substance abuse from neglect. The facility lacked proper policies and training, leading to serious deficiencies.
The facility failed to ensure resident safety while smoking and vaping, as a resident was found with multiple vape devices in their room, including instances where the resident slept with a charging vape device. Despite staff awareness, no actions were taken to address the safety concerns, and the facility's smoking policy was not enforced. Additionally, smoking safety assessments and appropriate interventions were not completed for multiple residents, leading to immediate jeopardy and substandard quality of care.
The facility failed to develop and implement a comprehensive smoking policy that included guidelines for vaping, storage, charging, and noncompliance. This deficiency affected multiple residents, including one who was found with multiple vape devices in their room. Staff were aware of the resident's vaping but did not take appropriate action due to a lack of clear guidelines. Other residents who smoked also had incomplete SSE forms and care plans, posing a significant risk to their safety.
The facility failed to develop and implement policies for residents who vape, leading to multiple incidents where a resident was found with vape devices in their room, charging them unsafely. The DON and FADM acknowledged the need for a vaping policy, but no actions were taken, and staff were not trained on vaping safety.
The Governing Body failed to ensure policies for vaping safety were developed and implemented, leading to multiple instances where a resident was found with vape devices in their room, charging them at bedside. Despite previous findings, no actions were taken, and the facility lacked a specific policy for vaping safety.
The facility failed to develop a behavioral health care plan for a resident with substance abuse issues and noncompliance of care. Staff were not trained to handle such residents, and an incident occurred where a CNA gave the resident Klonopin under pressure. The facility's behavioral policy lacked clarity and did not guide staff in developing care plans for substance abuse residents.
The facility failed to provide substance abuse training to staff, affecting a resident with a history of stimulant dependence. The resident received unauthorized medication from a CNA, and no care plan was developed for their substance abuse issues. The Administrator admitted that the facility assessment was not updated to address substance abuse.
The facility failed to ensure their assessment addressed substance abuse, smoking, and vaping, affecting all 86 residents. A resident with a history of stimulant dependence and smoking was admitted without the necessary care provisions, and the administrator acknowledged the oversight.
The facility failed to accurately code tobacco use in the MDS assessments for two residents. One resident had cigarettes and a vape despite being coded as a non-smoker, and another resident's smoking habits were not reflected in their MDS assessment, despite documentation and staff confirmation of their smoking activities.
A resident's nebulizer mask was found uncovered and not stored in a plastic bag on two occasions, violating the facility's policy and posing an infection control issue. Staff interviews confirmed the mask should have been covered to prevent contamination.
A CNA administered her personal prescription of Klonopin to a resident without authorization, violating the facility's medication administration policy. The resident had no physician order for Klonopin, and the CNA admitted to the action, acknowledging her lack of training and awareness of the risks involved.
Failure to Address Visitor Screening and Resident Vaping Policies
Penalty
Summary
The facility failed to ensure the QAPI committee developed interventions, including training, to systemically address protective measures following an incident of visitor-to-resident sexual abuse. On 12/21/2023, a CNA witnessed a male visitor with his hand down a resident's shirt, fondling the resident's breast. The facility did not have a policy or procedure for screening visitors or providing supervision during visits. The male visitor was later identified as a registered sex offender. The QAPI committee did not identify all causal factors and failed to develop and implement a corrective action plan to address these issues comprehensively. Additionally, the facility failed to address the issue of a resident keeping vape devices in their room. On 03/04/2024, staff found multiple vape devices in the resident's room. It was revealed that the DON had found a vape in the resident's room on two separate occasions weeks prior, and no actions were taken. Multiple staff indicated that the resident would sleep with a vape device on their chest and charge the devices at bedside using a cell phone charger. The facility did not have policies and procedures in place to address resident vaping, including where vaping was prohibited, safe storage of vape devices, and safe charging of the vape devices. The QAPI committee's failure to thoroughly review all factors and implement interventions had the potential to affect all 86 residents. The facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The immediate jeopardy began on 12/21/2023 and continued until 06/02/2024 when the facility implemented corrective action to prevent recurrence.
Removal Plan
- Education was provided to the Nursing Home Administration by the Director of Operations Officer regarding QAPI resources, how to analyze and self-identify potential issues, tools, and programming available to assist in self-identifying issues in the facility that require a root cause analysis, thorough investigation, and process changes with ongoing monitoring.
- All members of QAPI, the Administrator, DON, Medical Director, MDS Coordinators, Infection Control Nurse, Maintenance Director, Social Services Director, Dietary Manager, Environmental Services, Therapy Director, Activities Director, Pharmacy Consultant, Medical Records and Scheduling Coordinator were educated by the Director of Operations Office and Corporate Clinical Consultant on the process of self-identify and report issues within the facility. Once self-identification of an issue occurs, the facility is to immediately identify root causes of such issues and complete a thorough investigation that will ultimately lead to correcting process issues and broken systems, monitoring such issues and continually reviewing to ensure continued compliance.
- A full Quality Assurance and Performance Improvement Committee meeting occurred with the Nursing Home Administrator, Director of Nursing, Facility Medical Director, Director of Operations Officer, and Corporate Clinical Consultant to review the center's processes, policies and the citations at hand to ensure all patients were free from abuse incidents and protective measures were in place to ensure safety.
- The QAPI Committee also implemented policies related to vaping and identified safe storage measures, designated smoking areas, and staff responsible for ensuring vapes are charged.
- E-cigs, vapes and other electronic nicotine distribution systems were reviewed with residents, no residents identified as using these devices. Resident use of these devices will not be permitted at the facility.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse by a visitor. In late November or early December 2023, the resident's daughter informed the facility that a male visitor was upsetting the resident and requested that he not be allowed to visit. The staff member advised the daughter to come to the facility to complete paperwork, but the male visitor returned in early December and visited the resident at the nurses' desk. On December 21, 2023, a CNA witnessed the male visitor fondling the resident's breast. The facility did not have a policy or procedure for screening visitors or providing supervision during visits. The male visitor was later identified as a registered sex offender. The facility's noncompliance was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death to residents, resulting in an Immediate Jeopardy (IJ) situation that continued until June 3, 2024, when corrective actions were verified to have been implemented. The facility also failed to protect another resident's right to be free from physical abuse by another resident. On April 14, 2024, one resident accused another of stealing a TV remote and hit the other resident on the left knee. The incident was reported, and the investigation revealed that physical abuse had occurred. The affected resident did not sustain any injuries, but the incident was classified as physical abuse. Additionally, the facility failed to protect a resident with a history of substance abuse from neglect. A CNA gave the resident a medication, Klonopin, from her personal prescription. The facility had not provided training to staff on how to deescalate situations involving residents with substance abuse. The resident had a history of substance abuse, and the facility did not have a care plan in place to address this issue. The CNA was aware that she was not to administer medication to any resident in the facility, and the incident was reported to the local police department, ombudsman, and state authorities.
Removal Plan
- Visitor was immediately removed from the center and resident's safety ensured.
- Administrator reported incident to AP.
- Residents responsible party was notified of the incident and responded to the center.
- Local Law Enforcement Department was notified and responded to the center.
- The facility County Sheriff Department was notified and responded to the center.
- Facility medical director was notified of the incident.
- RI #27 was assessed by charge nurse and no injuries were noted.
- All patients/residents with a BIMS of 8 and above were interviewed by Activities Director and no patient/right reported ever being abused by a staff member, patient/resident or visitor.
- A full body audit was completed by the charge nurse on all patients/residents with a BIMS of 7 and below and no injuries noted.
- Abuse in-services initiated including sexual, physical, verbal, psychosocial, financial, misappropriation of resident's funds, abandonment, and neglect, as well as practices, including reporting requirements, and notifying the Abuse Coordinator/Administrator immediately regarding any allegation of abuse. This abuse education was provided by the director of nursing to all staff, with 126 out of 132 staff educated.
- HH Health Systems Director of Operations provided education to the facility's administrator and Director of Nursing.
- The Director of Nursing provided education to 126 out of 132. This inservice was provided for nurses, certified nursing assistants, department leaders/management, contract therapy services, housekeeping services and dietary services. All staff will be in-service prior to start of shift.
- All staff that did not receive the in-service will be denied access from clocking into the facility. These staff have been notified either by voice mail or text send to their cellular devices. This notification states that they are not permitted to work until receiving the mandated abuse education per the Director of Nursing.
- The Abuse Coordinator will hold weekly in services on reporting and identifying abuse to the Department Managers for four weeks, then monthly thereafter. The Department Manager will provide in-services on reporting and identifying abuse with their staff weekly for four weeks, then monthly thereafter. An attendance sheet will be maintained on each in-service to ensure full staff compliance. All attendance sheets will be given to the Abuse Coordinator/Administrator.
- A Receptionist/Door Greeter position will allow for closer monitoring of visitors to the facility. This position will be occupied 7 days per week for 12 hours per day. The receptionist will be responsible for ensuring guest sign in/out. A Restricted Visitor List of people not allowed in facility will be located at the Receptionist Desk that includes photos, if available, general identification information of unwanted guest. If anyone on the list tries to enter the building, the receptionist will be trained to not allow them to enter the building. If the visitor refuses to comply, the local police department will be notified.
- After hours the front doors will be locked and the charge nurse or designee will be responsible for monitoring entrance into the facility. They will ensure visitors sign into the Guest Registry and screen visitors to confirm they are not on the Resident Visitor List. If the visitor is restricted, the Charge Nurse or designee will inform them they are not permitted in the facility. If the visitor does not comply with leaving premises, the local police will be notified.
- Residents Council meeting conducted provided education to residents on facility abuse policy and reporting process. All patient/residents reported they feel safe at the center.
Failure to Ensure Resident Smoking and Vaping Safety
Penalty
Summary
The facility failed to ensure a system was in place to ensure residents' safety while smoking and to safely store and charge electronic cigarettes or vape devices. A resident was admitted with a history of daily smoking, but the facility did not assess the resident's smoking safety upon admission. The resident was found with multiple vape devices in their room, including instances where the resident slept with a vape device on their chest while it was charging using a cell phone charger, posing a significant safety risk. Despite staff being aware of the resident's possession and use of vape devices, no actions were taken to address the safety concerns, and the facility's smoking policy was not enforced until much later. The facility's smoking policy required all electronic cigarettes to be stored with other smoking materials and indicated that non-compliance would result in a 30-day discharge after two offenses. However, the facility did not issue a 30-day discharge until several weeks after the resident was found with vape devices. Additionally, the facility failed to complete smoking safety assessments for multiple residents, including the resident in question, and did not develop appropriate interventions for residents assessed as not safe to smoke. This lack of proper assessment and intervention put multiple residents at risk. Interviews with staff revealed that the Director of Nursing (DON) and other staff members were aware of the resident's possession and use of vape devices but did not take appropriate actions to ensure safety. The DON admitted to finding vape devices in the resident's room on two separate occasions but did not follow the facility's smoking policy. Other staff members also observed the resident with vape devices and charging them unsafely but did not report these observations or take corrective actions. The facility's failure to properly assess, monitor, and intervene in residents' smoking and vaping activities led to a determination of immediate jeopardy and substandard quality of care.
Removal Plan
- All smoking material, to include pipes cigars, vapes, snuff, etc. were removed from patient/resident possession and locked on secure cart monitored by nurse.
- All smoking paraphernalia will remain locked on cart and only utilized during designated smoking times.
- E-cigs, vapes and other electronic nicotine distribution systems were reviewed with residents, no residents identified as using these devices. Resident use of these devices will not be permitted at the facility.
- All smoking assessments and care plans updated by the charge nurse for all patients and residents that identify as a smoker. To include patients and residents that utilize electronic smoking devices. Electronic smoking devices identified as any product containing or delivering nicotine or any other substance that can be used by a person for the purpose of inhaling vapor or aerosol from the product.
- All patients and residents that use nicotine products to include electronic smoking devices and smokeless tobacco signed acknowledgement of center revised policy and 30-day discharge issuance should policy be violated.
- All staff in-service regarding the centers revised smoking policy and procedure to include transitioning to a smoke-free campus for all new admissions, daily smoking schedule, safe smoking interventions to be utilized, and facility action plan should the centers revised smoking policy be violated.
- Resident council meeting facilitated by the Activities Director to inform all patients and residents of new smoking policy including smoke-free campus for all new admissions.
- Smoke detectors were installed in all patient and resident rooms that a current smoker reside in.
Failure to Implement Comprehensive Smoking and Vaping Policy
Penalty
Summary
The facility failed to develop and implement a comprehensive smoking policy that included guidelines for vaping, storage, charging, and noncompliance. This deficiency affected multiple residents, including one resident who was found with multiple vape devices in their room. The facility's smoking policy did not address vaping, and staff were not trained on how to handle vaping devices, leading to unsafe conditions. The resident's Smoking Safety Evaluation (SSE) form was incomplete and not properly updated, and the resident was found vaping in their room multiple times, including while asleep with the vape on their chest. Interviews with staff revealed that they were aware of the resident's vaping but did not take appropriate action because the facility's policy did not provide clear guidelines for handling vaping devices. The Director of Nursing (DON) and other staff members admitted that they did not follow the same guidelines for vaping as they did for smoking. The DON had removed vape devices from the resident's room on multiple occasions but did not implement further measures to ensure compliance with safety protocols. Other residents who smoked also had incomplete or improperly filled out SSE forms, and their care plans did not include necessary interventions to ensure their safety while smoking. Staff interviews indicated a lack of training on how to complete the SSE forms and assess smoking safety. The facility's failure to address vaping and smoking safety comprehensively had the potential to affect all residents with a desire to vape or smoke, posing a significant risk to their safety.
Removal Plan
- All smoking assessments and care plans updated by the charge nurse for twelve patients and residents that identify as a smoker. To include patients and residents that utilize electronic smoking devices. Electronic smoking devices identified as any product containing or delivering nicotine or any other substance that can be used by a person for the purpose of inhaling vapor or aerosol from the product.
- The nurses conducted the Smoking Assessments with residents who identified themselves as a smoker. The nurse identified risks and interventions that would be needed due to safety concerns for the resident. These assessments are entered into the facility's Electronic Medical Record (EMR) where the assessment outcomes are available for Social Services to develop Smoking Safety Care Plans. Social Services will print the Smoking Assessment and the Smoking or Smokeless Tobacco Care Plan to forward to the Activities Director.
- The Activities Director will maintain a Smokers and Smokeless Tobacco binder for the smoking area storage cart. This binder includes a list of residents who use tobacco products, smoking and smokeless, the smoking assessment, and the appropriate tobacco-use care plan. The Smoking and Smokeless Tobacco Binder will be stored in the locked storage cabinet at the resident's smoking area. This binder, along with the assessments and care plans provide the Smoke Break Supervisors direction on the care of the resident while participating in the tobacco use scheduled activity. Smoking supervisors are to adhere to the recommended smoking interventions and facility's smoking policy during all smoke breaks.
- All patients and residents that use nicotine products to include electronic smoking devices and smokeless tobacco signed acknowledgement of center policy and 30 day discharge issuance should policy be violated.
- All staff in-serviced regarding the centers revised smoking policy and procedure to include transitioning to a smoke free campus for all new admissions, including smokes tobacco, daily smoking schedule, safe smoking interventions to be utilized and facility action plan should the centers smoking policy be violated.
- E-cigs, vapes and other electronic nicotine distribution systems were reviewed with residents, no residents identified as using these devices. Resident use of these devices will not be permitted at the facility.
- Resident council meeting facilitated by the Activities Director to inform all patients and residents of new smokefree campus for all new admissions.
- Smoke detectors installed in all patient and resident rooms that a current smoker resides in.
- Corporate Clinical Consultant educated the Director of Nursing regarding instructions on how to complete the Safe Smoking Assessment form for all patients and residents. The Director of Nursing was informed that all Licensed Practical Nurses and Registered Nurses can complete and interpret the Safe Smoking Assessment and implement safe smoking interventions. The Director of Nursing implemented education with all Licensed Practical Nurses and Registered Nurses with instructions on how to complete and interpret the Safe Smoking Assessment.
Failure to Implement Vaping Policies and Procedures
Penalty
Summary
The facility failed to develop and implement policies and procedures for residents who vape, specifically addressing safe storage, safe charging, and designated vaping areas. Staff discovered multiple vape devices in a resident's room on several occasions, with the resident often found sleeping with a vape device on their chest and charging the devices at bedside using a cell phone charger. Despite these findings, no actions were taken to address the issue, and the facility lacked a specific policy on vaping, which was confirmed by the Director of Nursing (DON) and the Former Administrator (FADM). The DON admitted to verbally warning the resident but did not document the incidents or take further action. The DON and FADM both acknowledged the need for a policy to address vaping, similar to the existing smoking policy, to ensure staff knew how to handle such situations. The DON was unaware of the proper charging guidelines for vape devices, which posed an electrical safety concern. The FADM confirmed that the facility had never trained staff on vaping or how to charge vape devices safely. Both the DON and FADM emphasized the importance of following the manufacturer's guidelines for charging to prevent potential fire hazards. The current Administrator (ADM) also confirmed the lack of policies and procedures specific to vaping and acknowledged the responsibility to ensure resident safety and policy implementation. The ADM stated that the facility should have reviewed and revised their policies and procedures to address the issues identified with the resident's vaping behavior. The absence of a specific vaping policy left staff without clear guidelines on how to manage residents who vape, potentially compromising resident safety.
Removal Plan
- The new Nursing Home Administrator was educated on role, job description and available tools and resources to effectively administer nursing facility operation by the Chief Operations Officer.
- The Director of Operations Officer will provide oversight of facility administration with weekly 1:1 interaction reviewing the Nursing Home Administrator ability to oversee operations and develop and implement policies and procedures, staffing and the administration of medications by staff to ensure residents are receiving the highest level of care possible.
- Meetings will include a review of any current or ongoing Quality Assurance and Performance Improvement minutes, to validate the Administrator's ability to effectively self-identify new issues and validate available tools are being used to administer the facility in the highest possible manner.
- The Chief Operations Officer and Administrator will have these encounters to ensure education is understood.
- The plan of correction will be reviewed weekly to ensure all the audits are completed and issues are identified for four weeks and/or until substantial compliance is achieved.
- Monthly QAPI meeting will be conducted and attended by the Chief Operations Officer and Clinical QA RN for a period of three months to ensure compliance is sustained.
- E-cigs, vapes and other electronic nicotine distribution systems were reviewed with residents, no residents identified as using these devices.
- Resident use of these devices will not be permitted in the facility.
Failure to Implement Vaping Safety Policies
Penalty
Summary
The Governing Body failed to provide oversight to ensure policies and procedures were developed and implemented for residents who vape, specifically addressing safe storage and charging. On multiple occasions, staff found vape devices in a resident's room, with the resident often sleeping with a vape device on their chest and charging the devices at bedside using a cell phone charger. Despite these findings, no actions were taken to address the issue, and the facility did not have a specific policy for vaping, only a general policy for smoking and tobacco use. The Director of Nursing (DON) had previously found a vape in the resident's room on two separate occasions weeks prior, but no measures were taken to mitigate the risk. The Director of Operations (Care Center) confirmed that he was responsible for the overall safety of the residents and ensuring policy and procedures were implemented. However, he was not made aware of the incidents with the vapes until recently and acknowledged that the facility lacked a specific policy for vaping safety. The facility's noncompliance with the requirements of participation was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) began when the vape devices were first found and continued until corrective actions were implemented. The deficiency was cited as a result of a Facility Reported Incident and was related to the State Operations Manual, Appendix PP, 483.70 Administration, at a scope and severity of J.
Removal Plan
- All patients and residents that use nicotine products to include electronic smoking devices and smokeless tobacco signed acknowledgment of update center policy and 30-day discharge issuance should policy be violated
- All staff in-serviced regarding the centers smoking policy and procedure to include transitioning to a smoke free campus for all new admissions, daily smoking schedule, safe smoking interventions to be utilized, and facility action plan should the centers smoking policy be violated
- E-cigs, vapes and other electronic nicotine distribution systems were reviewed with residents, no resident identified as using these devices. Resident use of these devices will not be permitted at the facility
- Resident council meeting facilitated by the Activities Director informed all patients and residents of new smoke free campus for all new admissions
- Smoke detectors were installed in all patient and resident rooms that a current smokers resides in
Failure to Develop Behavioral Health Care Plan for Resident with Substance Abuse
Penalty
Summary
The facility failed to ensure a behavioral health care plan was developed with person-centered interventions for a resident with documented substance abuse and noncompliance of care. The resident, identified as having stimulant dependence, tested positive for cannabinoids and had a history of non-compliance with the facility's smoking policy. Despite these issues, the facility did not develop a behavioral health care plan to address the resident's needs, nor did they train staff on how to handle residents with substance abuse disorders. Interviews with facility staff revealed significant gaps in the implementation of behavioral health policies. The Social Services Director admitted to not utilizing prior diagnoses or behaviors to develop care plans and stated that she had not been trained to handle substance abuse residents. Similarly, the Minimum Data Set Coordinator and the Director of Nursing acknowledged that the facility's behavioral policy lacked clarity and did not provide guidance for developing care plans for residents with substance abuse disorders. Additionally, staff had not received specific training on how to care for such residents. The deficiency was further highlighted by an incident where a Certified Nursing Assistant (CNA) gave a resident Klonopin after being pressured and physically pinched by the resident. This incident, along with the lack of a comprehensive care plan and staff training, underscores the facility's failure to meet the behavioral health needs of its residents, particularly those with substance abuse issues.
Failure to Provide Substance Abuse Training to Staff
Penalty
Summary
The facility failed to ensure that staff received substance abuse training, which affected a resident with a history of stimulant dependence. The resident, who was cognitively intact, had tested positive for methamphetamines and had a history of visitors bringing illegal drugs. The Social Services Director (SSD) admitted to not being trained in care approaches for residents with substance abuse issues and confirmed that no care plan was developed for the resident's non-compliance. Additionally, a Certified Nursing Assistant (CNA) admitted to giving the resident Klonopin without proper authorization or training, further indicating a lack of staff preparedness to handle substance abuse cases. The Minimum Data Set Coordinator (MDSC) recalled the resident's substance abuse history but did not ensure that the facility assessment was updated to address this issue. The Administrator acknowledged that the facility assessment should have been revised to include substance abuse, and appropriate care, resources, and education should have been provided. This deficiency highlights a significant gap in staff training and facility preparedness to manage residents with substance abuse histories, leading to inadequate care planning and potential safety risks.
Facility Assessment Deficiency
Penalty
Summary
The facility failed to ensure that their facility-wide assessment addressed substance abuse, smoking, and vaping. This deficiency was identified during the investigation of a Facility Reported Incident. The facility's most current assessment did not identify the need for staff competencies regarding substance abuse, which had the potential to affect all 86 residents. Specifically, the assessment did not include provisions for the care, resources, and education necessary for residents with a history of substance abuse or those who smoke or vape. A resident admitted to the facility had diagnoses including Paraplegia, Muscle weakness, and Stimulant Dependence. The resident's medical records indicated a high level of dependence and a history of smoking ten cigarettes per day. Additionally, the resident had tested positive for methamphetamines, amphetamines, and meth at the transferring hospital, which also reported that visitors had brought illegal drugs to the hospital. The facility administrator acknowledged that the facility assessment should have been revised to address substance abuse and smoking to ensure proper care and safety provisions.
Inaccurate Coding of Tobacco Use in MDS Assessments
Penalty
Summary
The facility failed to ensure that Section J of the Minimum Data Set (MDS) assessments for two residents, identified as RI #80 and RI #286, were accurately coded to reflect tobacco use during the assessment period. RI #80 was admitted with diagnoses including Difficulty in Walking, Muscle Weakness, Lack of Coordination, and Chronic Obstructive Pulmonary Disease. Despite a smoking safety evaluation indicating non-smoker status, an observation revealed that RI #80 had cigarettes and a vape labeled with their name. Additionally, an activities staff member confirmed that RI #80 participated in smoking activities, contradicting the MDS assessment coded for no tobacco use. RI #286, admitted with diagnoses including Paraplegia, Muscle Weakness, and Stimulant Dependence, was also inaccurately assessed. The resident's history and physical from a local hospital indicated a social history of smoking ten cigarettes a day. Despite this, the MDS admission assessment coded RI #286 as a non-smoker. The MDS Coordinator admitted to not asking RI #286 about their smoking habits during the assessment. Further, nursing notes and activity logs confirmed that RI #286 participated in smoke breaks, which was not reflected in the MDS assessment. The Director of Nursing acknowledged the inaccuracies in both residents' MDS assessments regarding tobacco use.
Failure to Properly Store Nebulizer Mask
Penalty
Summary
The facility failed to ensure that a resident's nebulizer mask was stored in a covered plastic bag as required by their policy. The resident, who was admitted with a diagnosis of Hypertensive Heart Disease with Heart Failure, had physician orders for Ipratropium-Albuterol to be administered via nebulizer every six hours as needed for shortness of breath or cough. On two separate occasions, the nebulizer mask was observed uncovered and not stored in a plastic bag, which is a violation of the facility's policy on oxygen administration. Interviews with the staff, including a Registered Nurse and the Director of Nursing, confirmed that the nebulizer mask should have been stored in a plastic bag when not in use to prevent contamination and potential infection. The failure to follow this protocol was identified as an infection control issue, as the uncovered mask could harbor bacteria. This deficiency affected the resident who required respiratory care and was sampled for this specific observation.
Unauthorized Medication Administration by CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) did not administer her personal prescription of Klonopin to a resident. The incident was reported to the State Survey Agency, which revealed that CNA #19 had given her personal prescription of Klonopin 0.5 mg to Resident Identifier (RI) #286. This action was not in accordance with the facility's medication administration policy, which mandates that medications are to be administered by licensed nurses or other legally authorized staff as ordered by a physician. The CNA admitted to giving the medication without reviewing the resident's medication orders and acknowledged that she was not trained to administer medications. The resident, RI #286, had diagnoses including paraplegia, muscle weakness, and stimulant dependence. The resident's admission Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 15, suggesting intact cognitive function. There was no physician order for Klonopin for this resident. The incident came to light when another CNA, CNA #18, reported that the resident had disclosed receiving Klonopin from CNA #19. The facility's timeline documented that CNA #19 admitted to giving the medication one time and was aware that she should not have done so. Interviews with the involved CNAs and the Medical Director highlighted the potential harm from such an action, including drug interactions and allergic reactions. The Medical Director emphasized the risks associated with a CNA administering a controlled substance like Klonopin. The facility's policy on medication administration clearly states that only licensed nurses or legally authorized staff should administer medications, and this policy was not followed in this instance.
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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