Falkville Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Falkville, Alabama.
- Location
- 10 West 3rd Street, Falkville, Alabama 35622
- CMS Provider Number
- 015136
- Inspections on file
- 15
- Latest survey
- September 2, 2025
- Citations (last 12 mo.)
- 40 (7 serious)
Citation history
Health deficiencies cited at Falkville Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility's Administrator failed to ensure abuse policies were implemented, including reporting and investigating suspected abuse and implementing protective measures. The Administrator made a decision on two cognitively impaired residents' capacity to consent to sexual contact without proper policy and procedure, leading to unreported and uninvestigated incidents.
The facility failed to protect residents from sexual and verbal abuse by another resident on the Memory Care Secured Unit (MCSU). A resident with dementia exhibited sexually inappropriate behaviors towards other residents, including entering rooms, disrobing in public, and making sexual comments. Despite these behaviors being documented, the facility did not report or investigate the incidents, nor did they implement protective measures. The facility also failed to assess the capacity of residents to consent to sexual activity.
The facility failed to establish and implement policies to prevent sexual abuse, leading to multiple incidents of inappropriate sexual behavior by a cognitively impaired resident. The administrator used an unsanctioned questionnaire to assess consent without proper guidelines, and no protective measures were implemented.
A resident exhibited inappropriate sexual behavior towards other residents on multiple occasions, but these incidents were not reported to the Administrator or the State Agency as required by the facility's abuse policy. This failure to report prevented timely investigation and intervention, leaving other residents at risk.
A resident exhibited repeated inappropriate sexual behavior towards other residents, which was reported by staff but not investigated by the Administrator or Director of Nursing. This failure to investigate allowed the behavior to continue, putting other residents at risk.
A resident exhibited pain over two days, but the physician was not notified until the second day, and the family was not informed about ordered X-rays. Staff interviews and Progress Notes confirmed the lack of timely notifications, violating facility policies.
A facility failed to assess and manage a resident's pain daily, especially after a fall. Despite exhibiting facial grimacing and complaining of pain, the resident was not medicated, and no pain assessments were documented. X-rays later revealed fractures, leading to a hospital transfer.
The facility failed to meet the nutritional needs of residents on Pureed, Regular, and Mechanical Soft diets by serving incorrect portion sizes of meals on two consecutive days. This discrepancy was observed during supper service, where the cooks used smaller scoops than required, resulting in residents not receiving the necessary calories and nutrients as per the menu guidelines.
A resident with Vitamin B and D deficiencies did not receive whole milk at meals as ordered by the physician. Despite having whole milk available in gallon containers, the dietary staff failed to pour it into cups, leading to non-compliance with physician orders.
Failure to Implement Abuse Policies and Investigate Allegations
Penalty
Summary
The facility's Administrator failed to provide oversight to ensure the facility's abuse policies were implemented. This included not reporting suspected abuse, not investigating documented allegations of abuse, and not implementing protective measures for residents. Facility staff documented occurrences of potential abuse in a resident's medical record over a period of time, but there was no evidence that these occurrences were reported, investigated, or that protective measures were implemented. When the Administrator became aware that two cognitively impaired residents needed to be assessed for their capacity to consent to sexual contact, the Administrator made a decision on the residents' capacity to consent without a policy and procedure in place. This decision was made without ensuring the assessment was completed accurately and interpreted ethically and without conflict of interest. Based on the Administrator's determination that the residents were in a consensual relationship, the incident was not reported or investigated, and no protective measures were implemented. Interviews with the Director of Nursing, Social Service Director, and other staff revealed that the incident involving inappropriate touching between the two residents should have been reported and investigated as potential sexual abuse. The Administrator admitted that an investigation should have been conducted but did not think immediate safety measures were needed because she believed the residents were consenting. The failure to report and investigate the incident, as well as to implement protective measures, was a significant oversight that had the potential to affect all residents in the facility.
Removal Plan
- The facility's Administrator failed to ensure the facility's Abuse policies were implemented, including reporting, protection, and investigation of abuse allegations or suspected abuse. The facility Administrator conducted an assessment without a policy supporting the ability to conduct a consent assessment and made the decision of RI #13 and RI#19 capacity to consent.
- VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding reporting abuse and investigating.
- The Administrator was in-serviced on revised Abuse Policy to include when any resident expresses the desire to engage in sexual activity. Refer to the supplemental questions for determination of capacity related to sexual decisions. This will be completed by the Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. This final determination will be documented in the medical record.
- Progress notes on all residents were reviewed by the Regional Nurse Consultant, Clinical Nurse educator, and Case Manager to ensure that no sexual abuse allegations have gone unreported. No incidents or issues noted in these notes.
- No other incidents regarding not reporting timely or investigating allegations of abuse were noted through the staff and resident interviews.
- Corporate QAPI completed to ensure that 1 member of the corporate team, either the Executive VP, VP of operations, or Nurse Consultant will be in the facility to ensure operational and clinical meetings are being held and to provide oversight of Administrator's management practices (to include abuse reporting, investigating allegations of abuse).
Failure to Protect Residents from Sexual and Verbal Abuse
Penalty
Summary
The facility failed to protect residents from sexual and verbal abuse by another resident on the Memory Care Secured Unit (MCSU). Resident Identifier (RI) #13, who had dementia, exhibited sexually inappropriate behaviors towards other residents, including entering residents' rooms, disrobing in public, and making sexual comments. Despite these behaviors being documented in RI #13's medical record, the facility did not report or investigate the incidents, nor did they implement protective measures to safeguard other residents. The facility also failed to assess the capacity of residents on the MCSU to consent to sexual activity. RI #13's behaviors were noted to have worsened over time, with multiple incidents of inappropriate sexual conduct documented. These included touching another resident's upper thigh, making sexual comments, and attempting to engage in sexual activity with other residents. Staff members, including Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs), reported these incidents to their supervisors, but no investigations were conducted, and no protective measures were put in place. The Director of Nursing (DON) and other administrative staff were not notified of these incidents, which were considered abusive given the residents' cognitive impairments. Interviews with staff and review of progress notes revealed that the facility's failure to act on these incidents put residents at risk. The facility's policy on abuse did not provide clear guidelines on determining residents' capacity to consent to sexual activity. The facility's inaction and lack of supervision allowed RI #13's behaviors to continue, causing potential harm to other residents. The Immediate Jeopardy (IJ) was identified, and the facility was found to be non-compliant with the requirement to protect residents from abuse, neglect, and exploitation.
Removal Plan
- The facility failed to implement protective measures and provide supervision to residents on the Memory Care Secured Unit (MCSU) after identifying RI #13, a male resident with dementia, was exhibiting sexual inappropriate behaviors towards staff and other residents. No residents on the MCSU were properly assessed for the capacity to consent to sexual activity.
- VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding ensuring residents are kept safe from all types of abuse and neglect. This in-service was completed, and no concerns were noted.
- Abuse policy was updated to include (When any resident expresses the desire to engage in sexual activity. Refer to the supplemental questions for determination of capacity related to sexual decisions. This will be completed by Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. This final determination will be documented in the medical record)
- Progress notes all residents were reviewed by the Regional Nurse Consultant, Clinical Nurse educator, and case manager to ensure that no abuse allegations have gone unreported. No incidents or issues noted in these notes. This review of note was completed.
- All residents on the Memory Care unit were interviewed and/or assessed by the Memory Care Unit Manager to verify that no resident was exhibiting any sexually inappropriate behavior, nor had any complaints or verbalized any allegations of abuse. No residents were engaging in sexual behaviors. However, if residents desire to engage in sexual activity refer to the supplemental questionnaire for determination of capacity related to sexual decisions. This will be completed by the Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. The final determination will be documented in the medical record.
- VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding updated abuse policy. The facilities abuse policy has always included that all residents have the right to be free from abuse, identification of abuse, and immediately protecting residents when abuse is suspected. The administrator and don were in-serviced on (When any resident expresses the desire to engage in sexual activity. Refer to the supplemental questions for determination of capacity related to sexual decisions. This will be completed by Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. This final determination will be documented in the medical record)
- Education was completed with all staff regarding the abuse policy. The facilities abuse policy has always included that all residents have the right free from abuse, identification of abuse, and immediately protecting residents when abuse is suspected. New hires will be educated on the new revision of the abuse policy.
- DON/Designee completed an audit to ensure they were not aware of any other allegations of abuse; this was completed by questionnaire. No issues were identified.
- Emergency QAPI meeting was held with all key personnel (Administrator, Director of Nursing, Regional Director of Health services, President of Operations, RN Infection Control and medical director). Facility discussed ensuring residents are kept safe from all types of abuse and neglect. This was done by educating staff on who to report abuse to, when to report abuse and what to report.
- There are no residents known to the facility to be consented and engaging in current sexual activity. Any sexual activity will be reported immediately. In the event that the Administrator and DON are unavailable, the activity will be reported immediately to a member of the Ethics Committee to complete the assessment for the capacity to consent.
Failure to Implement Policies to Prevent Sexual Abuse
Penalty
Summary
The facility failed to establish and implement policies and protocols to prevent sexual abuse, including a protocol to identify when, how, and by whom determinations of capacity to consent to sexual contact would be made. This failure was highlighted by the case of a resident in the Memory Care Secured Unit (MCSU) who had a history of escalating sexual behaviors. Despite multiple documented incidents of inappropriate sexual behavior, the facility did not report, investigate, or implement protective measures to safeguard other residents from potential abuse. The resident in question, identified as having moderate to severe cognitive impairment, exhibited inappropriate sexual behaviors towards other residents on several occasions. These behaviors included rubbing, grabbing, and making verbal sexual remarks. On one occasion, the resident was found touching another resident's upper thigh in a private room. The facility's administrator used an unsanctioned questionnaire to assess the capacity of both residents to consent to sexual contact, without any supporting policy or guidelines to ensure the accuracy of this determination. Interviews with facility staff revealed that the administrator was not notified of several incidents of inappropriate behavior, and no investigation or safety measures were put in place. The facility's policy on abuse was found to be inadequate, lacking specific guidelines on how to handle situations involving residents' capacity to consent to sexual activity. This deficiency had the potential to affect all residents in the MCSU, as the facility failed to protect them from potential sexual abuse.
Removal Plan
- The facility failed to implement an abuse policy and procedure to protect residents on the Memory Care Secured Unit from abuse including affectionate physical touching, and verbal sexual statements made to female residents about their body parts. Abuse policy was instituted.
- The facility further failed to develop and implement a policy and to ensure resident's capacity to consent to sexual contact prior to the Administrator deciding RI #19 and RI #13, residents residing on the MCSU, could consent to sexual contact.
- Abuse policy was updated to include (When any resident expresses the desire to engage in sexual activity. Refer to the supplemental questions for determination of capacity related to sexual decisions. This will be completed by Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. This final determination will be documented in the medical record).
- This had the potential to affect all residents on the memory care secured unit. No residents are engaging in sexual conduct currently. All residents on the Memory Care unit were interviewed and/or assessed by the Memory Care Unit Manager to verify that no resident was exhibiting any sexually inappropriate behavior, nor had any complaints or verbalized any allegations of abuse. No residents were engaging in sexual behaviors. However, if residents desire to engage in sexual activity refer to the supplemental questionnaire for determination of capacity related to sexual decisions. This will be completed by the Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. The final determination will be documented in the medical record.
- VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding updated abuse policy. The facilities abuse policy has always included that all residents have the right free from abuse, identification of abuse, and immediately protecting residents when abuse is suspected and the seven components of abuse: screening, training, prevention, identification, reporting, protection and investigation. Residents will be assessed when they desire or display to engage in sexual activity.
- Education was completed with all staff regarding the abuse policy. The facilities abuse policy has always included that all residents have the right free from abuse, identification of abuse, an immediately protecting residents when abuse is suspected and the seven components of abuse: screening, training, prevention, identification, reporting, protection and investigation. Residents will be assessed when they desire or display to engage in sexual activity. New hires will be educated on the new revision of the abuse policy.
- Emergency QAPI meeting was held with all key personnel (Administrator, Director of Nursing, Regional Director of Health services, [NAME] President of Operations, RN Infection Control and medical director). Facility discussed ensuring residents are kept safe from all types of abuse and neglect. This was done by educating staff on who to report abuse to, when to report abuse and what to report.
- There are no residents known to the facility to be consented and engaging in current sexual activity. Any sexual activity will be reported immediately. In the event that the Administrator and DON are unavailable, the activity will be reported immediately to a member of the Ethics Committee to complete the assessment for the capacity to consent.
Failure to Report Suspected Abuse by Resident
Penalty
Summary
The facility failed to immediately report incidents of suspected abuse by a resident identified as RI #13 to the Administrator, resulting in a failure to investigate and protect other residents on the Memory Care Secured Unit (MCSU). RI #13 exhibited inappropriate sexual behavior towards other residents on multiple occasions, including making sexual comments, touching female residents inappropriately, and entering female residents' rooms with inappropriate intentions. These incidents occurred on several dates, including 01/03/2024, 01/04/2024, 01/08/2024, 01/11/2024, and 01/12/2024, but were not reported to the Administrator or the State Agency as required by the facility's abuse policy. The facility's policy mandates that any incident or allegation of abuse must be reported immediately to the Administrator, who is then responsible for reporting to the State Agency within two hours. However, interviews with staff members, including LPNs and the DON, revealed that the incidents involving RI #13 were either not reported at all or were reported to supervisors who did not escalate the reports to the Administrator. This lack of reporting prevented timely investigation and intervention, leaving other residents at risk. The failure to report these incidents was confirmed through interviews with the DON and the Administrator, who both stated that they were not informed of the incidents involving RI #13. The DON acknowledged that the inappropriate touching of a female resident by RI #13 should have been considered sexual abuse and reported to the State Agency. The Administrator also confirmed that the incidents were not reported to her, which was a violation of the facility's abuse policy. This deficiency was identified during the investigation of a complaint and was determined to have the potential to affect all residents on the MCSU.
Removal Plan
- Immediate action(s) taken for the resident(s) found to have been potentially affected include: The facility failed to immediately report incidents of suspected abuse by RI #13 to the Administrator which resulted in failure of the Administrator to investigate and protect female residents residing on the Memory Care Secured Unit (MCSU).
- According to the facility's abuse policy facility staff must immediately report to the Administrator any incident or allegation that could constitute an instance of abuse. The staff is to immediately protect or safeguard the resident in question and any other residents at potential risk of the alleged abuse. The administrator is to report to ADPH the allegation of suspected abuse or neglect within 2 hours of being notified and complete the investigation within 5 business days.
- VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding reporting abuse and investigating according to F-609. This includes safeguarding the identified residents at risk for abuse or potential for abuse and reporting to ADPH according to the reporting guidelines from ADPH.
- Identification of other residents having the potential to be affected: This had the potential to affect all residents. Progress notes on all residents were reviewed by the Regional Nurse Consultant, Clinical Nurse educator, and case manager to ensure that no sexual abuse allegations have gone unreported. No incidents or issues noted in these notes.
- Actions taken/systems to be put into place to reduce the risk of future occurrences include: Education was completed with staff members in person and staff members via telephone; Education was completed when to report, who to report and what to report.
- According to the facilities abuse policy it has always been for facility staff to report immediately any suspected allegation of abuse to the administrator. New hires will be educated on the new revision of the abuse policy.
- DON/Designee completed an audit with staff members in person and staff members via telephone; Education was completed on abuse policy, when to report, who to report and what to report. According to the facilities abuse policy it has always been for facility staff to report immediately any suspected allegation of abuse to the administrator. Also, to ensure they were not aware of any other allegations of abuse; this was completed by questionnaire. No issues were identified.
- Emergency QAPI meeting was held with all key personnel (Administrator, Director of Nursing, Regional Director of Health services, [NAME] President of Operations, RN Infection Control and medical director). Facility discussed ensuring residents are kept safe from all types of abuse and neglect. This was done by educating staff on who to report abuse to, when to report abuse and what to report.
- There are no residents known to the facility to be consented and engaging in current sexual activity. Any sexual activity will be reported immediately. In the event that the Administrator and DON are unavailable, the activity will be reported immediately to a member of the Ethics Committee to complete the assessment for the capacity to consent.
- Facility requests for IJ removal plan to be effective.
Failure to Investigate Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate incidents of abuse by a resident identified as RI #13, which led to repeated inappropriate sexual behavior towards other residents. The incidents began on 01/03/2024, when RI #13 exhibited inappropriate sexual behavior, and continued on multiple occasions, including making sexual comments and touching a female resident's thigh. Despite these behaviors being reported by an LPN to the Administrator (ADM) and Director of Nursing (DON), there was no evidence that these incidents were investigated as required by the facility's abuse policy. Interviews with the ADM and DON revealed that they were either not made aware of the incidents or did not have specific details about them. Both acknowledged that the incidents should have prompted an investigation. The ADM admitted that any type of allegation of abuse would necessitate an investigation, while the DON confirmed that she should have been notified to make a judgment call on how to proceed. The lack of investigation allowed RI #13's inappropriate behavior to continue, putting other residents at risk. Further review of RI #13's progress notes and additional interviews with staff, including another LPN and the Social Service Director (SSD), confirmed that the incidents were not properly communicated or investigated. The SSD was unaware of specific incidents and emphasized the importance of reporting such behaviors to the Administrator for investigation. The Regional Director of Health Services (RDHS) also highlighted the need for administrative staff to be aware of incidents to ensure proper follow-up. The failure to investigate these incidents resulted in a finding of immediate jeopardy and substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation.
Removal Plan
- VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding investigating abuse allegations. Administrator and DON were instructed on when to initiate an abuse investigation and how the investigation will be conducted and reviewed.
- Progress notes on all residents were reviewed by the Regional Nurse Consultant, Clinical Nurse educator, and case manager to ensure that no sexual abuse allegations have gone unreported. No incidents or issues noted in these notes.
- All residents on the Memory Care unit were interviewed and/or assessed by the Memory Care Unit Manager to verify that no resident was exhibiting any sexually inappropriate behavior, nor had any complaints or verbalized any allegations of abuse. No residents were engaging in sexual behaviors. However, if residents desire to engage in sexual activity refer to the supplemental questionnaire for determination of capacity related to sexual decisions. This will be completed by the Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. The final determination will be documented in the medical record.
- VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding investigating abuse allegations.
- DON/Designee completed an audit with staff to ensure staff were made aware of what to report, when to report and who to report to. This is to ensure the administrator could complete a thorough investigation. This was completed by questionnaire. No issues were identified.
- Emergency QAPI meeting was held with all key personnel (Administrator, Director of Nursing, Regional Director of Health services, [NAME] President of Operations, RN Infection Control and medical director). QAPI Discussed RI#13 and the incident surrounding this incident Discussed in QAPI, Administrator would investigate thoroughly all allegations of abuse timely, investigate immediately by way of staff interviews, resident medical records, and will be reviewed by Director of Health Services and/or VP of Operations before submitting.
- Facility requests for IJ removal plan to be effective. This plan was written by VP of Operations, Director of Health Services, Clinical Nurse Educator, Executive VP of Operations.
Failure to Notify Physician and Family of Resident's Pain and Medical Orders
Penalty
Summary
The facility failed to notify the physician and family of a resident's pain and subsequent medical orders. The resident exhibited facial grimaces indicating pain on two consecutive days, 11/26/2023 and 11/27/2023, but the physician was not notified until the second day. Additionally, the resident's family was not informed about the order for X-rays on 11/27/2023, despite the facility's policies requiring such notifications. The resident, identified as RI #14, had a care plan in place for pain management, which included notifying the physician of any changes in pain symptoms. Despite this, the resident's facial grimaces and complaints of pain were not communicated to the physician promptly. The resident's Progress Notes confirmed the presence of pain and bruising, but there was no documentation of physician notification until the second day of pain complaints. Interviews with staff, including LPNs and the Director of Nursing, corroborated the failure to notify the physician and family as required. The physician also confirmed that he expected to be notified about any pain issues and that such notifications should be documented in the Progress Notes. The deficiency was identified during an investigation of a complaint/report and affected one of five residents sampled for falls.
Failure to Assess and Manage Resident's Pain
Penalty
Summary
The facility failed to ensure that a resident's pain was assessed on a daily basis, especially after the resident fell. According to the facility's policy, an ongoing assessment of pain utilizing either a numerical scale of 0-10 or a verbal descriptor scale should be conducted daily and documented on the Medication Administration Record (MAR). However, upon review of the resident's MAR, there was no evidence that the resident's pain was being assessed daily, nor was there a physician's order for pain management. This deficiency was particularly concerning given that the resident exhibited facial grimacing, a symptom of pain, on multiple occasions following the fall, yet was never medicated for the pain. The resident, who had a history of falls, was originally admitted to the facility on a previous date and readmitted on another date. The resident's care plan included interventions to observe for worsening pain symptoms and notify the physician of changes, as well as to assess pain daily using a 1-10 scale. Despite these interventions, the resident's pain was not assessed daily, and there was no documentation of pain assessments on the MAR. The resident exhibited facial grimacing when his/her leg was moved and complained of pain when turned to the left side, yet no pain medication was administered. X-rays later revealed that the resident had a fracture of the right hip and left and right femurs, necessitating a transfer to the hospital for treatment. Interviews with multiple Licensed Practical Nurses (LPNs) and the Director of Nursing (DON) confirmed that pain assessments were supposed to be completed every shift and documented on the MAR. However, there was no evidence that these assessments were conducted for the resident on several dates. The DON acknowledged that the resident's pain was not managed appropriately and that the physician should have been notified when symptoms of pain were observed. The facility's failure to assess and manage the resident's pain appropriately led to the resident suffering from untreated pain and subsequent fractures that were only identified days after the initial fall.
Failure to Meet Nutritional Needs of Residents
Penalty
Summary
The facility failed to ensure that the nutritional needs of residents on Pureed, Regular, and Mechanical Soft diets were met according to the established menus. On 04/24/2024, residents receiving Pureed diets were served a 3-ounce portion of pureed Lasagna instead of the required 6-ounce portion. This discrepancy was observed during the resident tray line for supper, where the AM Cook used a smaller, green-handled scoop instead of the appropriate #6 scoop. The AM Cook acknowledged the error, attributing it to a routine practice of using the green-handled scoop for pureed meats. The Dietary Manager confirmed that residents on Pureed diets did not receive a full serving of Lasagna, thus not meeting their nutritional needs as per the menu guidelines. The Registered Dietitian (RD) also confirmed that the residents were not given all the calories or nutrients required by the menu due to the incorrect portion size served. On 04/25/2024, a similar issue was observed with the serving of hot dogs for supper. Residents on Regular, Mechanical Soft, and Pureed diets were served portions that did not meet the menu requirements. The PM Cook used a #12 scoop, which is smaller than the required #10 scoop, resulting in portions less than the 3 ounces specified by the menu. The PM Cook and the Dietary Manager both acknowledged the error, with the Dietary Manager noting that the residents were not getting enough protein. The RD confirmed that the residents on Regular, Mechanical Soft, and Pureed diets were not receiving the necessary calories and nutrients due to the incorrect portion sizes served. The facility's policies for Menus and Adequate Nutrition and Nourishment, dated 02/20/2024, were not followed, leading to these deficiencies. The policies state that menus should meet the nutritional needs of residents and be reviewed by a dietitian for nutritional adequacy. However, the observed practices on 04/24/2024 and 04/25/2024 did not align with these policies, resulting in residents not receiving the appropriate portions of their meals. This failure had the potential to affect all 84 residents receiving meals from the facility's kitchen.
Failure to Provide Whole Milk as Ordered
Penalty
Summary
The facility failed to ensure that a resident received whole milk at each meal as ordered by the physician. This deficiency was observed during the dinner meal on 04/24/2024 and the lunch meal on 04/25/2024. The resident, who had Vitamin B and Vitamin D deficiencies, was supposed to receive whole milk with all meals according to the April 2024 Medication Review Report and the resident's tray cards. However, during these meals, the resident was not served whole milk as required by the physician's orders. The issue arose because the facility's food vendor could not provide individual cartons of whole milk due to a packaging problem. Despite having whole milk available in gallon containers, the dietary staff did not pour the milk into cups for the resident. Both the Administrator and the Dietary Manager confirmed that whole milk was available in the facility and could have been served in cups. The Dietary Manager admitted that the dietary staff probably did not think of pouring the milk into cups and had to be instructed to do so. The Registered Dietitian confirmed that not serving whole milk as ordered meant the physician's orders were not being followed, and the resident was not receiving the prescribed intervention.
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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