Diversicare Of Boaz
Inspection history, citations, penalties and survey trends for this long-term care facility in Boaz, Alabama.
- Location
- 600 Corley Avenue, Boaz, Alabama 35957
- CMS Provider Number
- 015063
- Inspections on file
- 15
- Latest survey
- July 4, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Diversicare Of Boaz during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in food storage, preparation, and sanitation, including expired and improperly stored foods, dishwashing at inadequate temperatures without sanitizer, and cold foods held above safe temperatures on the tray line. These practices had the potential to affect all residents receiving meals, as staff did not consistently follow established policies for food safety and sanitation.
The facility did not ensure residents had ongoing access to their personal funds, as residents and staff reported that funds could only be withdrawn during weekday business office hours. Two residents stated they could not access their money on weekends, and staff interviews confirmed there was no established process for after-hours access. The Business Office Manager and Administrator acknowledged the lack of a system for weekend or after-hours withdrawals, resulting in residents being unable to manage their finances as needed.
A resident with intact cognition reported missing money, and while the facility replaced the funds and documented that a lockbox was offered, the resident never received the lockbox as promised. Multiple staff members were unaware of the lockbox being provided, and the Administrator found no documentation confirming its delivery, indicating the grievance was not fully resolved according to facility policy.
A resident with moderate cognitive impairment and high care needs reported being verbally abused and denied assistance by a CNA, including being told to use a diaper and being refused help with toileting and linen changes. These incidents were overheard by a family member and described by an RN as cruel and bordering on mental abuse. The facility's investigation did not substantiate the abuse, and administration was unaware of the nurse's report of potential mental abuse.
A resident with severe cognitive impairment and a history of Alzheimer's disease was found with a gait belt fastened around their waist and wheelchair, constituting a physical restraint not documented in the care plan or MDS. Staff interviews confirmed that restraints and gait belts were not standard practice in the memory unit, and the device was placed by a hospice CNA.
Staff failed to promptly report allegations of staff-to-resident abuse to administration within the required two-hour window for two residents with moderate cognitive impairment and complex medical needs. In both cases, staff delayed notifying the Administrator and DON about alleged verbal and physical abuse, resulting in late reporting to the state agency and noncompliance with facility policy.
The facility failed to immediately protect a resident after an allegation of staff verbal abuse, allowing the alleged perpetrators to complete their shift before being suspended. Additionally, investigations into abuse allegations for two residents were incomplete, lacking documentation of interviews with all relevant staff and failing to analyze the root cause of unexplained bruising, including whether improper transfer techniques were used.
Deficient Food Storage, Preparation, and Sanitation Practices Identified
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as evidenced by multiple observations and staff interviews. Expired foods, including cucumbers, bell peppers, and buttermilk, were found in the walk-in refrigerator, with visible mold growth and use-by dates that had passed. Staff admitted to not properly rotating stock and sometimes adding new produce to older batches, resulting in expired items not being discarded. Additionally, several items in the walk-in freezer, such as beef hamburger patties, diced chicken, and cookie dough, were stored in open containers, contrary to policy requiring sealed and closed storage to prevent contamination. Dishwashing procedures were also found to be deficient. The dish machine logs showed that wash and rinse temperatures frequently fell below the required minimum of 120 degrees Fahrenheit, and on one occasion, the sanitizer solution was found to be empty during use. Staff responsible for operating the dish machine did not consistently check water temperature or sanitizer levels before washing dishes, and some washed and stored serving trays and dome lids without proper sanitization. The Dietary Manager and Registered Dietitian confirmed that staff were expected to follow manufacturer guidelines for dishwashing, but logs and interviews indicated this was not consistently done. Cold food holding practices on the tray line were inadequate, with temperatures of cold foods such as watermelon and grapes measured well above the required 41 degrees Fahrenheit. Staff reported that cold foods were kept in the refrigerator before service but were then brought out in large quantities, causing them to warm above safe temperatures during meal service. The Dietary Manager acknowledged that staff had not been checking food temperatures during tray line service to ensure compliance with policy. The facility census indicated that all 89 residents, on regular or controlled carbohydrate diets, were potentially affected by these deficiencies.
Failure to Provide Ongoing Access to Resident Personal Funds
Penalty
Summary
The facility failed to provide residents with ongoing access to their personal funds managed by the facility, as required by policy and regulation. Review of the facility's Resident Trust policy revealed it did not specify how or when residents could access their funds. Facility records showed that 62 residents had active trust accounts. Multiple interviews with residents confirmed that they were unable to withdraw funds on weekends or after business office hours, as the business office staff were only available Monday through Friday from 7:00 AM to 4:00 PM. Staff interviews further indicated uncertainty about the process for residents to access funds outside of these hours, with no clear alternative in place. The Business Office Manager (BOM) acknowledged that residents could only access their money during business office hours and that, while there had been discussions about leaving money at the nurse's desk or in the medication cart for after-hours access, this process had not been implemented. The BOM stated that residents were advised to withdraw money on Fridays if they anticipated needing it over the weekend, but there was no established process for those who did not plan ahead. The Administrator was under the impression that money was kept in the nurses' medication carts for distribution after hours, but was unaware that this was not actually occurring. As a result, residents did not have reliable access to their funds outside of regular business hours.
Failure to Resolve Resident Grievance and Provide Promised Safeguards
Penalty
Summary
The facility failed to ensure that a resident's right to voice grievances was fully honored and that prompt efforts were made to resolve the grievance. According to facility policy, when a concern is reported, a plan of action should be developed and implemented, with follow-up to validate resolution and communication with the resident. In this case, a resident with intact cognition and a history of adjustment disorder, neuropathy, spina bifida, and cerebral infarction reported that twenty dollars was missing from their bedside table. The facility documented that the money was replaced and a lockbox was offered to the resident as a resolution. However, interviews and record reviews revealed that the resident did not receive the lockbox as promised, despite being told one would be provided. The resident continued to store money in their overbed table drawer and took extra precautions to safeguard it. Multiple staff members, including the Activity Assistant, CNA, CMA, and DON, were either unaware of the resident receiving a lockbox or could not recall if one was provided. The current Administrator confirmed there was no documentation that the resident received a lockbox and was unaware of the grievance being filed, indicating a lack of follow-through and communication regarding the resolution of the resident's grievance.
Failure to Protect Resident from Verbal and Mental Abuse by Staff
Penalty
Summary
Resident #300, who had chronic peripheral venous insufficiency, a nonthermal blister on the right lower leg, moderate cognitive impairment, and required substantial assistance for toileting and hygiene, was admitted to the facility. The resident was dependent on staff for care and was occasionally incontinent of urine and frequently incontinent of bowel. On the evening in question, the resident reported that after using the call light for toileting assistance, a CNA told them to learn to use the urinal or their diaper, and then refused to help. The resident stated they did not receive help for several hours and, when requesting clean linens, was again refused assistance and told to learn how to change the linens themselves. The resident also reported that when asking for help with a phone charger, the CNA refused and acted aggressively in the room. These incidents were overheard by a family member on the phone, who later reported the behavior to facility staff and administration. A review of the facility's abuse investigation file confirmed that an initial report of verbal abuse was submitted to the State Department of Public Health, naming the CNA as the alleged perpetrator. The investigation included statements from the resident, the family member, and the involved CNA, who denied the allegations. Another CNA present during care also denied hearing any rude or mean comments. However, a registered nurse assigned to the resident that night described the CNAs' behavior as cruel and bordering on mental abuse, noting that the resident became agitated and anxious when the CNAs would not respond to their repeated questions about their identities. The nurse reported this incident to the Director of Nursing, though the timing of the report was unclear. The family member corroborated the resident's account, stating they overheard the CNA telling the resident to toilet themselves and to void in their brief if unable to use the toilet independently. The family member also reported that one CNA sat in a chair while the other changed the resident's clothing in front of them, and that the resident was left without assistance for an extended period. The family member reported the incident to facility staff on the night it occurred and later to the administrator. The administrator and Director of Nursing stated they were unaware of the potential mental abuse reported by the nurse. The facility's investigation ultimately determined there was no evidence to substantiate the alleged abuse.
Failure to Prevent Unauthorized Use of Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints not required for medical treatment. According to facility policy, residents who may require restraints must be evaluated for the least restrictive device, considering physical and medical issues and possible alternatives. In this case, a resident with Alzheimer's disease, severe cognitive impairment, and a high risk for falls was admitted and care planned for various interventions, but there was no documentation or care plan indicating the use of a restraint. The Minimum Data Set (MDS) also did not indicate restraint use. Despite this, the resident was observed by an occupational therapist and the Director of Care Coordination with a gait belt fastened around their waist and buckled behind their back while seated in a wheelchair. Facility documentation and an incident report confirmed this observation, and the gait belt was subsequently removed by the Maintenance Director. Interviews with staff revealed that restraints were not used in the memory unit, and gait belts were typically only used by therapy staff. A hospice CNA was identified as the individual who placed the gait belt on the resident.
Failure to Timely Report Alleged Abuse to Administration and Authorities
Penalty
Summary
The facility failed to ensure that staff reported allegations of staff-to-resident abuse to administration within the required two-hour timeframe for two residents. According to facility policy, all alleged violations involving abuse or resulting in serious bodily injury must be reported immediately, but not later than two hours after the incident. In the first case, a resident with moderate cognitive impairment and multiple chronic conditions reported to a nurse that two CNAs had spoken to them in a threatening and disrespectful manner, delayed their pain medication, treated them roughly, and caused bruising. The nurse who received this report during the night shift did not immediately notify the administration, instead waiting until later in the morning when the Administrator and DON arrived. The incident was not reported to the state agency until several hours after the initial disclosure. In the second case, another resident with moderate cognitive impairment and significant care needs was involved in an allegation of verbal abuse by a CNA. The allegation was initially communicated by a family member to staff, and subsequently relayed through several staff members before reaching the Administrator and DON. Documentation and interviews revealed that the initial report of the incident was delayed, as staff who were made aware of the allegation during or shortly after their shift did not immediately escalate the report to administration. The DON confirmed that the report to the state agency was not made within the required timeframe, and that staff failed to follow the facility's policy for immediate reporting of abuse allegations. Interviews with staff, including nurses and CNAs, confirmed that there was confusion and delay in reporting both incidents. The DON and Administrator both stated that they expect staff to report any allegations or suspicions of abuse immediately, regardless of the perceived severity. However, in both cases, the required immediate notification to administration and timely reporting to the state agency did not occur, resulting in noncompliance with facility policy and regulatory requirements.
Failure to Protect Residents and Incomplete Abuse Investigations
Penalty
Summary
The facility failed to immediately implement protective measures following an allegation of staff-to-resident verbal abuse. In one instance, a resident with moderate cognitive impairment reported to a nurse that two CNAs spoke to them in a derogatory manner and delayed pain medication administration. The nurse did not report the allegation immediately, and the CNAs completed their shift before the incident was reported to the Administrator and DON. The facility's policy required immediate suspension of the alleged perpetrators, but this did not occur until after the shift had ended, leaving the resident potentially unprotected during that time. Additionally, the facility did not thoroughly document or conduct comprehensive investigations into allegations of abuse or neglect for two other residents. In one case, a resident and their family member alleged verbal abuse by a CNA. The facility's investigation file lacked documented interviews with all relevant staff, including another CNA who worked with the alleged perpetrator, the assigned RN, and the family member who made the allegation. The Administrator acknowledged that interviews may have occurred but were not documented, resulting in an incomplete investigation record. In another case, a resident was found with unexplained bruising on their hand and wrist. Although the resident attributed the bruising to staff assisting them, the facility's investigation did not include a root cause analysis or specific questioning of staff about how the resident was transferred or repositioned. The investigation focused on whether abuse occurred but did not address whether improper transfer techniques may have caused the injury. The family member of the resident was not informed of the outcome of the investigation, and the Administrator later admitted that the investigation should have included an assessment of staff transfer practices.
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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