Decatur Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Decatur, Alabama.
- Location
- 2326 Morgan Avenue Southwest, Decatur, Alabama 35603
- CMS Provider Number
- 015206
- Inspections on file
- 16
- Latest survey
- February 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Decatur Health & Rehab Center during CMS and state inspections, most recent first.
A resident with a history of COPD and Atrial Fibrillation experienced elevated heart rates, but the facility failed to notify the physician, resulting in delayed treatment. The resident was eventually transferred to the ICU for Atrial Fibrillation with Rapid Ventricular Response. Staff interviews revealed non-compliance with the facility's notification policy.
A facility failed to ensure licensed staff followed professional standards, leading to a deficiency. An LPN did not accurately transcribe an order for a resident with an elevated heart rate, failing to send the resident to the ER as instructed. The resident, with conditions like COPD and atrial fibrillation, had a heart rate of 142 bpm. The LPN did not reassess the heart rate or communicate the order to the oncoming nurse. Additionally, the facility lacked a system to ensure heart rate assessment before administering Digoxin, a high-risk medication.
A facility failed to monitor vital signs of a newly admitted resident with Atrial Fibrillation as expected by the physician, leading to an Immediate Jeopardy citation. The resident's heart rate was significantly elevated without timely intervention, and no parameters were established for notifying the physician of abnormal values. This oversight resulted in a delay in addressing the resident's condition until they experienced chest pain and shortness of breath.
The facility failed to properly thaw frozen chicken and did not date mark boiled eggs, violating FDA guidelines and facility policies. The chicken was left in a sink without running water, and the eggs lacked a use-by date, posing potential foodborne illness risks. Staff acknowledged these oversights during interviews.
The facility failed to properly dispose of garbage and refuse, as observed with two dumpsters that were not closed and food-related trash scattered around the area. This non-compliance with the U.S. FDA 2022 Food Code and facility policy could attract rodents, potentially affecting all residents receiving meals from the facility's kitchen.
The facility failed to maintain essential kitchen equipment, including a Tilt Skillet and Double Steamer, which had been inoperable for extended periods. The Stove Ovens also had operational issues with pilot lights extinguishing. The Dietary Manager and Registered Dietitian expressed concerns about the impact on food preparation, while the Maintenance Director noted financial considerations and management changes as factors in the delay of repairs.
A resident with severe cognitive impairment due to dementia was verbally abused by an LPN who used profanity during a care incident. The resident was being combative, and multiple CNAs witnessed the LPN telling the resident to "shut the fuck up." The incident was reported, and the facility's investigation confirmed the LPN's inappropriate behavior, leading to their termination.
A resident with COPD was admitted to a facility without a transcribed order for oxygen use, despite having a hospital order to maintain oxygen saturation above 88%. The admitting nurse failed to verify and transcribe the order, resulting in the absence of an oxygen order in the facility's system until several days later. Interviews with staff confirmed the oversight, and the Medical Director acknowledged the need for an oxygen order upon admission.
A resident's MDS assessment was not submitted to CMS within the required 14-day period following its completion. The MDS, with an Assessment Reference Date in October, was only submitted in January due to an oversight. The resident had Type 2 diabetes mellitus without complications and was discharged from the facility.
A resident with Diabetes Mellitus was affected by inaccurate documentation of insulin administration by an LPN, who mistakenly recorded the administration of Lantus Insulin on the MAR when it was not given. The LPN admitted to the error, citing a documentation mistake, and the DON confirmed the facility's policy requires accurate documentation of medication administration.
An LPN in a facility breached infection control protocols by handling medications with bare hands and failing to disinfect medical equipment between resident uses. This affected two residents, as the equipment was used on multiple residents without proper cleaning, posing a risk of infection transmission.
A resident with cognitive deficits eloped from the facility and was found by local law enforcement at a grocery store 1.9 miles away. Staff failed to monitor the resident adequately, and lapses in communication and supervision contributed to the incident.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident identified as RI #497. On January 4, 2025, the resident experienced an elevated heart rate of 142 beats per minute at 1:24 PM, which was not communicated to the physician. Later that day, at 9:22 PM, the resident's heart rate remained elevated at 120 beats per minute, yet again, the physician was not informed. This lack of communication resulted in no additional treatment or interventions being implemented, leading to a delay in necessary medical care. The resident, who had a history of Chronic Obstructive Pulmonary Disease and Atrial Fibrillation, continued to experience elevated heart rates and eventually complained of chest pain and difficulty breathing. Despite these symptoms, the resident was not transferred to the hospital until the early hours of January 5, 2025. Upon arrival at the hospital, the resident was admitted to the Intensive Care Unit for treatment of Atrial Fibrillation with Rapid Ventricular Response. Interviews with facility staff revealed that there was a failure to follow the facility's policy on notifying physicians of changes in a resident's condition. The Registered Nurse and Licensed Practical Nurse involved did not notify the physician or follow up on instructions given by the Certified Nurse Practitioner. This oversight was identified as a deficiency under Resident Rights, specifically regarding the notification of changes in a resident's condition.
Removal Plan
- The Director of Nursing (DON) provided 1:1 in-service with the licensed nurse who failed to notify the physician on physician notification when resident experiences change in condition and notification parameters on vital signs.
- All residents in house most recent vital signs were reviewed by the DON, Regional Director of Health Services and Regional Assessment Coordinator for any change of condition as well as vital signs outside parameters that were set forth by the Medical Director.
- Any resident with a change of condition or vital signs outside the parameters, the provider was notified by DON, Unit Manager or Charge nurse for any additional orders or treatment.
- All licensed nurses, which are 31 in total, were educated on notification to the provider for change in condition, to include vital signs outside the parameters given by the DON and Staff Development Coordinator. Any licensed nurse who did not receive the in-service will not be allowed to work until the in-service has been provided. There is 1 LPN pending (on medical leave) and the DON is responsible to ensure they are educated before working.
Failure to Follow Professional Standards in Heart Rate Monitoring and Medication Administration
Penalty
Summary
The facility failed to ensure that licensed staff followed professional standards of practice, resulting in a significant deficiency. Specifically, an LPN did not accurately transcribe a critical order for a resident with an elevated heart rate. The resident, identified as having chronic obstructive pulmonary disease, hypertension, and atrial fibrillation, had a heart rate of 142 bpm. The LPN received an order to manually check the resident's heart rate twice daily and to send the resident to the emergency room if the heart rate did not decrease. However, the LPN failed to transcribe the order to send the resident to the ER and did not reassess the resident's heart rate before the end of her shift. The resident's heart rate was not checked again until several hours later, at which point it was still elevated. No new interventions were implemented, and the resident was not transferred to the ER until the following day when they complained of chest pain and difficulty breathing. Interviews with the LPN and CRNP revealed that the LPN did not communicate the order to the oncoming nurse, and the CRNP confirmed that the resident should have been sent to the hospital if symptomatic. Additionally, the facility failed to have a system in place to ensure the resident's heart rate was assessed before administering Digoxin, a high-risk medication. The standard of practice requires checking the apical pulse before administering Digoxin, but this was not done. Interviews with nursing staff and the DON revealed a lack of understanding and documentation regarding the necessity of heart rate monitoring before administering the medication.
Removal Plan
- The facility failed to ensure licensed staff followed standards of practice and completely and accurately transcribed an order received from a CRNP to send RI#497 to the emergency room if heart rate did not go down. The nurse also did not communicate the order to the oncoming nurse. The nurse further failed to re-assess RI #497's heart rate at the time the order was provided to ensure RI#497 did not need to be transferred to the ER. The facility further failed to ensure process was in place to ensure resident's HR was checked prior to administration of digoxin.
- The Director of Nursing (DON) provided 1:1 education to the licensed nurse that took the verbal order, and did not communicate to the oncoming nurse. Education included completely and accurately transcribing an order received from a physician or CRNP, following up on an order and communicating new orders to the oncoming nurse that require follow up, and assessing residents heart rate prior to administering digoxin.
- The DON reviewed all current in-house residents last recorded vital signs to identify any resident with vital signs outside the parameters set forth by the Medical Director. Any resident identified with vitals signs outside the parameters, the provider was notified, and any new orders as indicated.
- All residents in house on Digoxin (and amiodarone, clonidine) were reviewed by the DON, Regional Director of Health Services (RDHS) and Pharmacist to ensure heart rate/blood pressure documentation was included on the Medication Administration Record with parameters for Digoxin (and amiodarone, clonidine).
- The nurse that transcribes the order will be responsible for ensuring HR/BP as indicated documentation is included for any residents with new digoxin (and amiodarone, clonidine) orders. The clinical meeting by the DON and Nurse Managers will verify HR/BP documentation will be included with any new Digoxin orders.
- The process to ensure the MAR includes vital sign monitoring/parameters for ALL medications which require monitoring of vitals before administration per standards of practice will be: MD and Facility Pharmacist determined the following medications require VS monitoring preadministration: Clonidine-hold if systolic BP <90 or diastolic BP <55 and notify MD/NP; Amiodarone-hold if pulse < 55bpm or systolic BP <100 or diastolic BP <60 and notify MD/NP; Digoxin-hold if pulse <60bpm and notify MD/NP. The DON/ Regional Director of Health Services/ Facility Pharmacist completed an audit of residents' medications to ensure all medications with an established standard of practice to check vitals pre-administration are identified and the monitoring is included on the MAR. During the clinical meeting the DON and Nurse Managers will verify all new orders for medications requiring VS monitoring include the required monitoring and documentation on the MAR. The nurses will know the thresholds for VS, HR monitoring for newly ordered digoxin and HR and blood pressure for Amiodarone and blood pressure monitoring for Clonidine because it was posted at the nurses station by the DON, additionally the specific instructions are included on the MAR to notify the MD/NP if the VS are out of the parameters.
- Vital Sign threshold alerts were updated to the electronic medical record for all residents by the DON and RDHS.
- The RDHS revised the New Admit/Readmit Checklist to include setting the vital sign parameter thresholds set forth by the Medical Director and Pharmacist related to Clonidine, Amiodarone, and digoxin orders have heart rate and or BP parameters for monitoring, holding of medication and notification of MD/NP.
- All licensed nurses were provided with education by the DON and Staff Development Coordinator. Any licensed nurse who did not receive this education will not be allowed to work until the education has been provided. Education included completely and accurately transcribing an order received from a physician or CRNP, following up on an order and communicating new orders to the oncoming nurse that require follow up, and assessing residents' heart rate and or BP prior to administering Clonidine, Amiodarone and Digoxin, the updated procedures including entering the order for assessment and documentation of HR monitoring for newly ordered digoxin and HR and blood pressure for Amiodarone and blood pressure monitoring for Clonidine. The nurses were educated that the thresholds for VS was posted at the nurses station by the DON, additionally the specific instructions are included on the MAR to notify the MD/NP if the VS are out of the parameters.
Failure to Monitor Vital Signs in Newly Admitted Resident
Penalty
Summary
The facility failed to ensure that a system was in place to assess the vital signs of newly admitted residents at a frequency expected by the physician or CRNP. Specifically, a resident admitted after hospitalization for Atrial Fibrillation with Rapid Ventricular Response had orders for vital signs to be checked only once a month, contrary to the physician's expectation of daily assessments for new admissions. This oversight led to a situation where the resident's heart rate was significantly elevated, reaching 142 bpm, without timely intervention. The deficiency was further compounded by the lack of established parameters for when the physician should be notified of abnormal vital sign values. On one occasion, the resident's heart rate was recorded at 120 bpm, but no action was taken until the resident experienced chest pain and shortness of breath, prompting a request for hospital transfer. Interviews with facility staff, including the DON and CRNP, revealed a discrepancy between the expected and actual practices for monitoring vital signs in newly admitted residents. The facility's non-compliance with the requirements of participation was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death, resulting in an Immediate Jeopardy citation. The deficiency was identified during the investigation of a complaint, highlighting the need for a systematic approach to vital sign monitoring and physician notification for newly admitted residents.
Removal Plan
- The facility failed to ensure a system was in place to ensure newly admitted residents' vital signs were assessed at a frequency expected by the physician/CRNP.
- Resident specific vital sign parameters were established including when the physician should be notified of abnormal values.
- The Director of Nursing contacted the Medical Director for guidance on updating vital sign thresholds for notification.
- The Medical Director was contacted by the DON on his expectations on vital sign monitoring.
- An updated New Admit/Readmit Checklist was implemented to ensure vital sign frequency and parameters are established at the time of admission.
- The vital sign monitoring policy was updated by the RDHS to require at least daily vital signs for all newly admitted or readmitted residents for 2 weeks.
- The Director of Nursing contacted the Medical Director for guidance on updating vital sign thresholds for notification.
- The Medical Director was contacted by the DON on his expectations on vital sign frequency.
- Vital sign parameter thresholds and frequency were updated for all newly admitted or readmitted residents over the last 30 days, vital sign orders by the RDHS and DON.
- The Daily Clinical Meeting form was revised by RDHS to include review of vital signs outside physician ordered parameters with follow up documentation.
- The DON and Staff Development Coordinator provided education for licensed staff on the updated VS Monitoring Policy, monitoring residents' vital signs at least daily for 2 weeks following an admission or re-admission and vital signs thresholds that require physician notification, and process to document vitals, notification, and physician recommendations.
Improper Thawing and Date Marking in Facility Kitchen
Penalty
Summary
The facility failed to adhere to proper food safety protocols as outlined by the U.S. FDA 2022 Food Code and the facility's own policies. During an observation, it was noted that frozen chicken was improperly thawed in a preparation sink without running water or submersion, contrary to the FDA guidelines which require thawing under refrigeration or under running water at a specific temperature. The Dietary Manager admitted to placing the chicken in the sink to start the defrosting process before transferring it to the cooler, which is not an approved method. Additionally, two boiled eggs were found in the Reach-in Cooler without a use-by date, violating the facility's policy for date marking. The absence of a use-by date on the eggs meant there was no way to determine how long they had been stored, posing a potential risk for foodborne illness. The Dietary Manager acknowledged the potential danger of not having a date, as it could lead to the consumption of expired food. Interviews with the Dietary Manager and the Registered Dietitian confirmed the improper handling of the chicken and the lack of date marking on the eggs. Both staff members recognized the potential for foodborne illness due to these oversights, as improper thawing and lack of date marking could result in food being stored in the temperature danger zone for too long or being consumed past its safe period.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse as per the U.S. FDA 2022 Food Code and the facility's own policy. During an inspection, it was observed that two dumpsters located outside the facility were not properly closed. One dumpster had a side door left open, and the other had a broken lid. Additionally, food-related trash was found strewn on the ground around the dumpster area, including plastic utensils, a food container, condiment packages, straws, gloves, and cup lids. The Dietary Manager acknowledged that the open dumpsters and scattered trash could attract rodents, which could potentially enter the facility. The Registered Dietitian also expressed concern that the presence of pests and rodents could affect the residents by potentially entering the facility's kitchen. This deficiency had the potential to impact all 100 residents receiving meals from the facility's kitchen.
Inoperable Kitchen Equipment in Facility
Penalty
Summary
The facility failed to maintain essential kitchen equipment in working order, as observed during a survey. The Tilt Skillet had been out of order for approximately four years and was being used as a countertop. The Double Steamer was also inoperable, having stopped working in 2023. Additionally, there were operational issues with the two Stove Ovens, where the pilot lights would extinguish when the doors were closed. These deficiencies were identified during a kitchen tour and interviews with the Dietary Manager and Maintenance Director. The Maintenance Director explained that the previous and current facility owners were informed that replacing the Tilt Skillet and Double Steamer would be more cost-effective than repairing them. The Maintenance Director also noted that the Stove Ovens' pilot lights were affected by fans used to dry the floor, which would blow them out. The Dietary Manager and Registered Dietitian expressed concerns about the impact of having broken equipment, highlighting the risk of cooking delays and inadequate equipment for food preparation. The Maintenance Director acknowledged that major equipment issues were reported to the corporate office for decisions due to financial considerations, and a change in management had led to some issues being overlooked.
Verbal Abuse Incident Involving LPN and Resident with Dementia
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse. On the night of the incident, a newly admitted resident with severe cognitive impairment due to dementia was involved. The resident was reportedly being combative and yelling, which prompted the intervention of several CNAs. During this time, an LPN entered the room and was witnessed using profanity towards the resident, telling them to "shut the fuck up." This incident was witnessed by multiple CNAs who considered the language used by the LPN to be verbal abuse. The resident, identified as having severe cognitive impairment, was unable to recall the incident. However, the staff present during the incident reported the LPN's behavior to their supervisor. The LPN's actions were described as inappropriate and unprofessional, and the language used was considered abusive by the staff who witnessed it. The facility's policy on abuse defines verbal abuse as the use of disparaging and derogatory terms, which aligns with the behavior exhibited by the LPN. The incident was reported to the state agency, and the facility conducted an investigation. The investigation confirmed that the LPN used foul language in the presence of the resident. Despite the resident's inability to recall the incident, the staff's testimonies and the facility's policy on abuse led to the conclusion that the resident's rights were violated. The LPN was subsequently terminated for violating the resident's rights.
Failure to Transcribe Oxygen Order for Resident with COPD
Penalty
Summary
The facility failed to ensure an order for the use of oxygen was obtained for a resident upon admission. The resident, identified as having Unspecified Atrial Fibrillation, Respiratory Disorders, and Chronic Obstructive Pulmonary Disease (COPD), was admitted with a hospital order for oxygen to maintain saturation levels above 88%. However, the facility did not have an order for oxygen use upon the resident's admission. The order for oxygen at 2 liters per minute via nasal cannula was not entered into the facility's system until several days later. Interviews with facility staff revealed that the admitting nurse was responsible for verifying and transcribing the hospital orders into the facility's system. However, this was not done, leading to the absence of an oxygen order in the Medication Administration Record (MAR). The CRNP who assessed the resident noted the need for supplemental oxygen but confirmed there was no order at the time. The Director of Nursing and the Medical Director both acknowledged that the resident should have had an oxygen order upon admission, highlighting a lapse in the facility's admission process.
Delayed MDS Submission for Resident
Penalty
Summary
The facility failed to ensure the timely transmission of a completed Minimum Data Set (MDS) assessment for a resident, identified as RI #38, to the Centers for Medicare & Medicaid Services (CMS) system. According to the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. However, the MDS for RI #38, with an Assessment Reference Date of October 15, 2024, was not submitted within the required timeframe. The oversight was identified during an interview with the Minimum Data Set Coordinator (MDS-C), who acknowledged the delay in submission. RI #38 was admitted to the facility with a diagnosis of Type 2 diabetes mellitus without complications and was later discharged. The MDS-C indicated that the MDS should have been submitted within fourteen days after the Assessment Reference Date to ensure proper reporting to CMS. The MDS was eventually submitted on January 29, 2025, by the Regional Assessment Compliance Coordinator, highlighting a lapse in the facility's compliance with federal and state transmission requirements.
Inaccurate Insulin Administration Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for a resident identified as RI #447. The resident, who was admitted with a diagnosis of Diabetes Mellitus with Hyperglycemia, had an incident where LPN #27 documented the administration of Lantus Insulin on the Medication Administration Record (MAR) when it was not actually given. This discrepancy was noted in a nursing note dated 11/02/2024, where LPN #27 acknowledged mistakenly charting the insulin as administered. During an interview, LPN #27 explained that the insulin was not administered because the resident was not eating or drinking, and she accidentally documented it as given by hitting the wrong key. The Director of Nursing confirmed that the facility's policy requires staff to document medications as not administered if they are not given, along with the reason. This failure to follow the facility's documentation policy resulted in an inaccurate record of treatment for the resident.
Infection Control Breach by LPN
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by an LPN during medication administration and vital sign assessment. The LPN was observed handling medications with bare hands while preparing them for a resident, which is against the facility's infection control policy. The LPN admitted to normally wearing gloves but failed to do so in this instance, acknowledging the infection control concern associated with touching medications with bare hands. Additionally, the LPN did not follow proper protocol for handling medical equipment used for obtaining vital signs, as the equipment was placed on a resident's bed and later on a medication cart without being cleaned or disinfected. The Director of Nursing and the Infection Preventionist confirmed that the actions of the LPN were not in compliance with the facility's infection control policies. They emphasized that medications should not be touched with bare hands and that medical equipment should be placed on a barrier and sanitized after use. The failure to adhere to these protocols had the potential to affect two residents, as the equipment was used on multiple residents without proper disinfection, posing a risk of infection transmission.
Failure to Supervise Resident Leads to Elopement
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with cognitive deficits, leading to an elopement incident. On the specified date, the resident eloped from the facility around 5:35 PM. A CNA noticed the resident was not in their room around 6:00 PM but did not take action to locate them, assuming the resident had been discharged. It wasn't until 8:47 PM that an LPN realized the resident's whereabouts were unknown and initiated a search. The resident was eventually found by local law enforcement at a grocery store 1.9 miles away from the facility at 8:57 PM. The resident had been admitted for rehabilitation services and had diagnoses including dementia, encephalopathy, and alcohol abuse. The resident's care plan indicated a desire to return home, and staff interviews revealed that the resident had expressed confusion and a desire to go home. Despite these indicators, the resident was not identified as being at risk for wandering or elopement. The facility's policies on elopement and missing residents were not adequately followed, as staff failed to monitor the resident and did not conduct timely checks. Interviews with staff revealed lapses in communication and supervision. The CNA who first noticed the resident missing did not report it immediately, and the LPN on duty did not receive a proper handover from the previous nurse. The facility's previous Director of Nursing confirmed that residents should be checked every two hours, but the resident was not monitored for over three hours. This lack of supervision and failure to follow established protocols led to the resident's elopement and the subsequent finding by law enforcement.
Removal Plan
- The resident was located nearby by local law enforcement and taken to the emergency room for an evaluation upon family request. No injuries noted. The resident discharged home with the RP after the ER visit.
- A one-time head count to verify all current residents were inside the facility was completed by the charge nurse on duty. All residents were accounted for.
- All facility exits were verified by the Administrator and DON to be locked and alarms functional.
- DON/Social Worker completed a new elopement risk User Defined Assessment for all current residents to identify any resident who may have had a change in condition deeming them at risk for elopement. Any residents found to be newly at risk will have their care plan reviewed and revised as indicated.
- The front door will be monitored until all reassessments have been completed.
- All staff will be interviewed to ascertain if there are any residents with wandering behavior that may not be documented. If residents are identified with wandering behavior not previously identified, their assessment and care plan will be updated to reflect the wandering.
- A discharge communication form will be instituted to reflect scheduled discharges each day indicating discharge date/time to effectively communicate between discharge planner and direct care staff. The discharging nurse will sign acknowledging when discharge occurs.
- Facility front door was locked and/or supervised. Facility changed the door system to remain locked at all times with keypad code required for entry/exit. Residents and family members notified and educated of change in entry/exit process by resident council meeting and family notifications by phone and written notification.
- Staff re-educated by DON/Designee regarding reporting of new behaviors such as wandering and elopement policy. Staff also reeducated on steps to take if a resident displays wandering behavior. Charge nurses reeducated regarding documentation of behaviors, specifically wandering with the need to obtain an order for a Wander guard Bracelet if indicated.
- 24-hour report/Nurse-to-nurse communication process updated to a more efficient method of communicating changes from shift to shift. A 24-hour notebook will be utilized rather than 24-hour report form. Staff education was initiated. Staff education on the new process for 24-hour report was completed.
- The facility will utilize elopement risk assessment in Electronic Medical Record that scores residents on a scale of 0-10 according to elopement risk level.
- Staff educated regarding discharge communication form initiated by discharge planner to communicate with direct care staff the scheduled discharges each day. The discharging nurse will sign acknowledging the discharge is complete and return to the DON.
- Facility doors will be checked daily x 1 week and then weekly x 4 weeks to verify that all doors are secured and functioning properly.
- The facility Interdisciplinary Team (IDT) will review nurse's 24-hour report information and discuss new or worsening behaviors in daily clinical meetings 5 x weekly. If a new behavior is reported or documented, IDT will verify that care plan and orders reflect interventions as indicated. DON/Designee will also interview 5 staff members to verify reporting and documentation of any new wandering behaviors. The interviews will be weekly x 4 weeks, then monthly x 2 months.
- 24-hour report/Nurse-to-nurse communication process monitored daily in clinical meeting 5 x weekly X 4 weeks to verify the 24-hour notebook is being utilized and report is thorough.
- Elopement risk assessments (that score residents on a scale of 0-10 according to elopement risk level) will be reviewed on all new admissions X 3 months to verify that assessment is complete, interventions in place and care planned if appropriate.
- The facility IDT will review the discharge communication forms from the previous day to verify each discharge occurred as scheduled and will initiate a new discharge communication form listing the discharges scheduled for the day and will provide the form to direct care nurses on each unit.
- An emergency Quality Assessment Program Improvement (QAPI) meeting was conducted, attendance included the Medical Director.
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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