Greenway Health And Rehabilitation Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Bay, Alabama.
- Location
- 13750 Highway 90 West, Grand Bay, Alabama 36541
- CMS Provider Number
- 015406
- Inspections on file
- 19
- Latest survey
- June 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Greenway Health And Rehabilitation Center, Llc during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and behavioral issues engaged in a physical altercation after one began yelling and struck the other, who then retaliated. Staff present did not intervene promptly or follow the care plan for behavior management, resulting in both residents hitting each other before being separated. The incident was identified as physical abuse due to lack of adequate supervision and timely intervention.
An Administrator failed to promptly identify, investigate, and report a sexual abuse incident involving a resident with severely impaired cognition who could not consent, after an LPN observed another resident engaging in inappropriate contact. The Administrator did not follow the facility's abuse policy, did not collect all necessary witness statements, and admitted to lacking training on abuse procedures, resulting in a deficiency under F835-Administration.
The QAPI committee failed to review and ensure thorough investigation of multiple abuse allegations and injuries of unknown origin, including a sexual abuse incident and two cases of unexplained fractures. Investigations lacked comprehensive staff and resident interviews, timely reporting, and follow-up on concerns, with leadership interviews revealing gaps in investigative processes and documentation.
Multiple residents experienced or were at risk for abuse due to the facility's failure to communicate behavioral risks, implement adequate supervision, and ensure staff were aware of residents' histories of inappropriate or aggressive behaviors. Incidents included a resident with impaired cognition being found with another resident who was nude and making inappropriate contact, as well as physical altercations between residents with behavioral issues. Staff were not consistently informed of risks, and care plans lacked specific interventions to prevent such incidents.
Multiple incidents of alleged abuse, neglect, and injury of unknown origin were not reported to the State Agency or Administrator within the required two-hour timeframe. In one case, an LPN witnessed a resident nude and touching another resident, but the Administrator delayed reporting the incident as sexual abuse. Other cases included delayed reporting of verbal abuse, physical altercations, and injuries, affecting several residents, including those with severe cognitive impairment.
The facility failed to thoroughly investigate multiple incidents involving potential abuse and injuries of unknown origin. In one case, an LPN found a resident in another resident's room, partially undressed and making inappropriate contact, but the investigation lacked key details, staff interviews, and preservation of evidence. In two other cases, residents were found with unexplained fractures and bruising, but the facility did not interview all relevant staff or document post-incident assessments, resulting in incomplete investigations and failure to identify root causes.
The facility failed to manage and supervise residents with behavioral health needs, resulting in incidents where a resident with severe cognitive impairment and a history of sexually inappropriate and wandering behaviors entered another resident's room and engaged in inappropriate contact, while other residents with dementia and behavioral disturbances physically assaulted or initiated altercations with peers. Staff and care plans did not consistently address or communicate the necessary interventions to prevent these incidents.
Surveyors found that food items in the freezer were not labeled with opened or use-by dates, the ice machine contained a black substance due to inadequate cleaning, and the stove hood and bulbs were covered in grease. The Dietary Director and Registered Dietitian confirmed that these practices did not follow facility policy and that staff responsible for labeling and cleaning had not completed required tasks, potentially affecting all residents receiving meals.
Surveyors observed that the doors on two dumpsters were left open, contrary to facility policy requiring them to be closed to prevent the spread of infection and deter pests. The Dietary Director and Registered Dietitian both confirmed the importance of keeping the dumpster doors closed, and it was acknowledged that staff did not ensure this was done. This lapse had the potential to impact all residents in the facility.
The facility failed to submit accurate direct care staffing data to CMS for one quarter, as the timekeeping system incorrectly recorded salaried staff hours, resulting in excessively low reported weekend staffing. This issue was attributed to a system error and affected all residents.
Two residents were affected when an LPN signed out controlled medications that were not administered or documented, resulting in missing doses. Another resident experienced financial loss after a CNA used the resident's check card for unauthorized purchases, as confirmed by bank records and interviews. These incidents demonstrate a failure to safeguard residents' property and medications.
An LPN failed to properly document and administer controlled medications according to facility policy, resulting in missing signatures, unaccounted-for doses, and discrepancies between the EMAR and controlled drug records. This affected multiple residents who required medications for pain, seizures, and anxiety, and was discovered after the LPN exhibited erratic behavior and was removed from the facility. The deficiency was identified through medication counts, record reviews, and staff interviews.
A resident with a diagnosis of schizophrenia and a PASRR Level II determination for serious mental illness was not accurately coded as such on the MDS assessment. Staff confirmed the resident's Level II status and acknowledged the MDS should have reflected this, emphasizing the importance of accurate coding for tracking and mental health service provision.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect two residents from physical abuse when staff did not provide adequate supervision or timely intervention during an altercation. On the morning of the incident, one resident, who had a history of behavioral issues and severe cognitive impairment, was reported to be agitated and was seated in a gerichair outside their room near the nursing station. Another resident, also with severe cognitive impairment and a history of agitation, was being escorted by staff in a wheelchair to the same area. As the second resident passed by, the first resident began yelling obscenities and then struck the second resident on the arm. The second resident retaliated by hitting back, resulting in both residents striking each other multiple times before staff intervened and separated them. The care plan for the first resident specifically indicated that staff should promptly intervene when acute behaviors are noted to reduce the risk of escalation. Despite this, staff did not act quickly enough to prevent the physical altercation. Witness statements from both a CNA and an RN confirmed that the first resident was agitated and verbally aggressive prior to the incident, and that staff were present in the area but did not remove or redirect the residents before the situation escalated to physical abuse. The RN acknowledged that the incident could have been prevented by not positioning the residents near each other or by removing the agitated resident from the area as soon as the behavior began. Both residents were assessed after the incident, and one was noted to have purplish bruising. The facility's policy defines abuse to include resident-to-resident altercations, and both the DON and the administrator identified the incident as physical abuse. The deficiency was cited as a result of the facility's failure to follow the care plan and to provide adequate supervision and intervention to prevent abuse between residents with known behavioral risks.
Failure to Identify, Investigate, and Report Sexual Abuse Incident
Penalty
Summary
The facility's Administrator failed to identify and report an incident of sexual abuse in a timely manner to the State Agency, as required by federal and state regulations. According to the report, an LPN observed a resident with severely impaired cognition, who lacked the capacity to consent, being approached inappropriately by another resident who was nude from the waist down and caressing the resident's hip and thigh. The Administrator did not promptly recognize this as sexual abuse, nor did he initiate a thorough investigation as outlined in the facility's abuse policy. Interviews and record reviews revealed that the Administrator, who also served as the Abuse Coordinator, did not follow the established procedures for investigating allegations of abuse. The Administrator admitted that not all witness statements were collected and that the facility had not thoroughly investigated all incidents reviewed by the survey team. He also acknowledged that he had not received training on the abuse policy upon assuming his role, despite being responsible for reporting, investigating, and following up on all abuse allegations. The deficiency was cited under F835-Administration, as the Administrator's actions and inactions resulted in non-compliance with requirements of participation, causing or likely to cause serious harm or psychosocial harm to residents. The failure to properly investigate and report the incident had the potential to affect all residents in the facility, as it demonstrated a breakdown in the facility's system for protecting residents from abuse.
Failure of QAPI Committee to Review and Investigate Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to review all allegations of abuse and injuries of unknown origin to ensure thorough investigations were conducted, investigations were conducted per facility policy, residents were protected, and reporting was timely. The QAPI committee did not review incidents of abuse to ensure the Abuse Policy was fully implemented for all allegations, including staff identifying, stopping, and reporting abuse. The committee also did not ensure that allegations were thoroughly investigated or that appropriate corrective actions were taken to prevent further abuse. Specific incidents were not thoroughly reviewed or investigated by the QAPI committee. These included a case where a resident was sexually abused by another resident, and two separate cases where residents sustained fractures due to injuries of unknown origin. In the case of the sexual abuse allegation, the QAPI documentation did not recognize failures in timely reporting, thorough investigation, or resident protection measures. For the injuries of unknown origin, investigative files lacked comprehensive staff and resident interviews, did not include body assessments after the injuries were identified, and failed to follow up on concerns raised by residents or their representatives. In one instance, a handwritten note suggesting possible mishandling was not investigated or traced to its source. Interviews with facility leadership, including the Administrator and DON, revealed gaps in the investigative process, such as not interviewing all potentially involved staff or residents, not documenting discussions with families, and not ensuring that all relevant information was considered. The QAPI committee meetings did not consistently identify these investigative shortcomings or develop action plans to address them, resulting in a failure to ensure that all contributing factors were identified and that appropriate corrective actions were implemented.
Failure to Protect Residents from Abuse and Inadequate Supervision
Penalty
Summary
The facility failed to protect residents from abuse, including sexual, physical, and verbal abuse, as evidenced by multiple incidents involving both staff and residents. In one incident, a resident with severely impaired cognition and no capacity to consent was found in their room with another resident who was nude from the waist down and caressing the first resident's hip and thigh. The staff assigned to these residents were unaware of the history of sexually inappropriate behaviors by the perpetrating resident, and the facility had not communicated these behaviors or implemented adequate interventions to ensure supervision and prevent such incidents. The incident was not reported to the State Agency until several days later, after the LPN who discovered the situation resigned and cited the unreported sexual assault as a reason for resignation. The facility's investigation did not include thorough documentation or interviews to clarify the nature of the incident, and staff were unclear on the required level of supervision for the resident with a history of inappropriate behaviors. Additional incidents included physical abuse between residents. In one case, a resident with severe cognitive impairment and a history of aggressive behaviors struck another resident in the back of the head multiple times. Staff who witnessed the event intervened to separate the residents, but the incident was still classified as physical abuse. In another case, a resident with a history of behavioral issues physically assaulted their roommate, resulting in both residents sustaining injuries. The facility's records indicated that both residents were evaluated and monitored following the incident, but the underlying behavioral risks had not been adequately addressed to prevent the altercation. The facility's policies required ongoing oversight, supervision, and individualized care planning for residents with behavioral symptoms that might lead to conflict or abuse. However, the survey found that these policies were not effectively implemented. Staff were not consistently informed of residents' behavioral risks, care plans did not include specific interventions to prevent residents from entering others' rooms, and there was a lack of clear documentation and communication regarding supervision requirements. These failures resulted in multiple residents experiencing or being at risk for abuse, and the facility was cited for noncompliance with federal regulations regarding freedom from abuse, neglect, and exploitation.
Failure to Timely Report Alleged Abuse and Injuries
Penalty
Summary
The facility failed to ensure timely reporting of multiple allegations of abuse, neglect, and injury of unknown origin to the State Agency and the Administrator/Abuse Coordinator, as required by federal regulations and the facility's own policy. In one incident, an LPN witnessed a resident nude from the waist down in another resident's room, sitting on the bed and caressing the other resident's hip and thigh. The LPN immediately reported the incident to the Administrator/Abuse Coordinator, but the Administrator did not report the allegation of sexual abuse to the State Agency until three days later. The Administrator stated that he did not initially perceive the incident as sexual abuse and therefore did not report it within the mandated two-hour timeframe, despite the facility's policy requiring immediate reporting of all abuse allegations. Additional deficiencies were identified in other cases where staff failed to report allegations of abuse or injury within the required timeframe. In one case, an allegation of verbal abuse involving a housekeeper and a resident with severe cognitive impairment was not reported to the Administrator or State Agency until more than 24 hours after the incident occurred. In another case, bruising and a subsequent fracture of a resident's finger, discovered in the morning, was not reported to the State Agency until after X-ray results were obtained later that day, rather than within two hours of discovery. There was also a physical altercation between two residents that resulted in injuries, but the incident was not reported to the Administrator or State Agency within the required timeframe. These failures affected at least four residents sampled for abuse, as determined by the investigation of multiple facility reported incidents and complaints. The survey found that the facility's noncompliance with reporting requirements caused, or was likely to cause, serious injury, harm, impairment, or death to residents, resulting in the citation of Immediate Jeopardy and substandard quality of care under F609 - Reporting of Alleged Violations.
Failure to Conduct Thorough Investigations of Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to conduct thorough investigations into multiple allegations and incidents involving potential abuse and injuries of unknown origin among residents. In one incident, a resident was found by an LPN in another resident's room, naked from the waist down and caressing the other resident's hip and thigh. The investigation did not determine when the resident entered the room, the duration of the encounter, or provide detailed accounts of what was witnessed. The facility also failed to collect comprehensive statements from all staff present, did not clarify the sequence of events regarding the separation and monitoring of the residents, and did not preserve or document video footage from the night of the incident. The investigative file lacked sufficient detail and failed to address the resident's known behavioral history, and the conclusion was made without substantiating the allegation or fully exploring the extent and cause of the incident. In two additional cases, the facility did not thoroughly investigate injuries of unknown origin. One resident was found with a bruised and fractured finger, and another with a bruised, swollen, and fractured foot/ankle. In both cases, the facility's investigations did not include interviews with all staff who may have had knowledge of the incidents or who worked with the residents in the days prior to the injuries. There was also a lack of documentation regarding body assessments after the injuries were identified. In one case, the administrator was unaware of a note containing potentially important information, and there was no evidence that the results of the investigation were discussed with the resident's family. These failures affected three residents who were sampled for abuse. The facility's actions did not comply with its own policy, which required immediate and thorough investigations, identification and interviewing of all involved persons, and complete documentation. The lack of comprehensive investigations and documentation prevented the facility from determining the root causes of the incidents and from developing appropriate action plans to prevent recurrence.
Failure to Manage and Supervise Residents with Behavioral Health Needs
Penalty
Summary
The facility failed to ensure that residents with behavioral health needs, including those exhibiting aggressive, wandering, and sexually inappropriate behaviors, were properly managed and supervised to protect other residents from abuse and to maintain their safety and privacy. One resident with severe cognitive impairment and a history of inappropriate sexual behaviors, including masturbation and wandering, was found by an LPN in another resident's room, undressed from the waist down and caressing the other resident's hip and thigh. Staff and family members had previously observed and reported this resident's sexually inappropriate behaviors, but these were not effectively communicated or care planned to prevent such incidents. Interviews with staff revealed a lack of awareness and inconsistent knowledge about the resident's behaviors, and the care plan did not include specific interventions to address the risk of the resident entering other residents' rooms. Additional deficiencies were identified involving other residents with behavioral disturbances. One resident with Alzheimer's disease and severe cognitive impairment became agitated and physically assaulted another resident, hitting them multiple times in the back and head. Staff had noted the resident's increasing agitation and combative behavior, but the care plan did not specify the level of supervision or interventions required to prevent such incidents. Staff interviews indicated that the resident's behaviors were known, but supervision was limited to periodic checks and monitoring in common areas, which proved insufficient to prevent the physical altercation. Another incident involved a resident with dementia and behavioral disturbance who entered another resident's room, initiated an altercation, and took a personal item. This resident had a documented history of aggressive and combative behavior toward staff and other residents, including cursing, slapping, and spitting. Despite these behaviors, the care plan did not include interventions or supervision levels to prevent the resident from affecting others. Staff and administrative interviews confirmed the presence of behavioral issues but did not recall or implement specific measures to address the risks posed by these behaviors.
Deficiencies in Food Labeling, Ice Machine Sanitation, and Kitchen Hood Cleanliness
Penalty
Summary
Surveyors identified several deficiencies in the facility's food service operations. During a kitchen tour, multiple food items stored in the freezer, including diced potatoes, hamburger patties, chicken thighs, and potato tarts, were found without opened or use-by dates, contrary to facility policy. Interviews with the Dietary Director (DD) and Registered Dietitian (RD) confirmed that labeling was required to ensure proper food rotation and prevent the use of expired items. The DD acknowledged that cooks were responsible for labeling and that staff had been trained on this process, but could not explain why the items were not labeled at the time of inspection. Additionally, the ice machine was observed to have a black substance in the upper corner next to the ice guard, indicating inadequate cleaning. The DD stated that all staff were responsible for weekly cleaning, with maintenance scheduled to clean the machine quarterly, but admitted that cleaning had not been performed as required. The stove hood and bulbs were also found to be dirty, with a grease-like substance dripping from the hood and covering the bulbs. The DD attributed this to missed monthly cleaning and identified the nighttime dishwasher as responsible for this task. These failures in food storage, equipment cleaning, and kitchen sanitation had the potential to affect all residents receiving meals from the kitchen.
Failure to Keep Dumpster Doors Closed for Infection Control
Penalty
Summary
The facility failed to ensure that the doors on two dumpsters were kept closed, as required by their policy to prevent the spread of infection and deter pests and rodents. During a tour of the dumpster area with the Dietary Director, it was observed that the side doors of both dumpsters were open and facing each other. The Dietary Director confirmed that she had seen the dumpsters with the doors open and acknowledged that staff did not close them. She stated that all staff were responsible for keeping the dumpster doors closed for infection control and to keep out rodents, pests, and wildlife. The Registered Dietitian also confirmed that the dumpster doors should be closed to keep pests away. This deficiency had the potential to affect all 65 residents residing in the facility.
Inaccurate PBJ Staffing Data Submission Due to Timekeeping Error
Penalty
Summary
The facility failed to report accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for Fiscal Year Quarter 1, affecting all 65 residents. Review of the Payroll Based Journal (PBJ) report for the quarter revealed excessively low weekend staffing data, which was triggered as an area of concern. The Director of Informatics, responsible for PBJ submission, explained that the previous ownership submitted data for the first part of the quarter, while she submitted data for the latter part. She further stated that the facility's time and attendance system incorrectly clocked salaried employees at 7.5 hours per workday instead of 8.5 hours, due to not accounting for a 30-minute lunch period, and attributed the error to a system malfunction.
Failure to Protect Residents from Misappropriation of Medications and Personal Funds
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property, specifically controlled medications and personal funds. During a shift, an LPN signed out a controlled substance (Lorazepam) for one resident and Gabapentin for another, but neither medication was documented as administered on the residents' Medication Administration Records (MARs). A subsequent medication count revealed discrepancies, with missing doses not accounted for. The LPN in question was reported to have exhibited erratic behavior and was removed from the facility by authorities after the discrepancies were discovered. The facility's investigation substantiated that misappropriation of resident property had occurred. Additionally, a CNA was found to have misappropriated a resident's personal funds by using the resident's check card to make unauthorized purchases. The resident became aware of the missing funds when attempting to withdraw money and found the account overdrawn. A review of bank statements revealed multiple unauthorized Cash App debits totaling $1,172, which the resident did not recognize or authorize. The CNA was identified as the individual responsible for the transactions, and the incident was reported to the police. These incidents affected three residents: two who were deprived of their controlled medications and one who suffered financial loss due to unauthorized use of personal funds. The deficiencies were identified through interviews, record reviews, and facility investigative files, confirming that the facility did not ensure residents were free from misappropriation of their property as required by policy.
Failure to Document and Administer Controlled Medications per Policy
Penalty
Summary
A Licensed Practical Nurse (LPN) failed to adhere to professional standards and facility policy regarding the administration and documentation of controlled substances during a specific overnight shift. The LPN did not document the removal of controlled medications on the Controlled Drug Records, despite recording their administration on the Electronic Medication Administration Record (EMAR). This discrepancy was identified for multiple residents, with missing signatures and unaccounted-for doses of medications such as Gabapentin, Phenobarbital, Tramadol, Percocet, Norco, and Lorazepam. In some cases, the LPN documented administration on the EMAR but did not sign the controlled drug record, while in other instances, medications were not administered or documented at all. The issue came to light after reports of the LPN's erratic behavior during the shift, which led to her removal from the facility by law enforcement. Subsequent medication counts and record reviews revealed multiple discrepancies, including missing doses and lack of proper documentation. Interviews with staff confirmed that the LPN was responsible for both administering and documenting the medications, and that the discrepancies were not identified until after the shift ended. The facility's policies required that all controlled substances be documented on both the MAR and the narcotic control record, with complete signatures and times, which was not followed in these instances. The affected residents had various medical conditions requiring controlled medications for pain, seizures, anxiety, and other diagnoses. The failure to properly document and administer these medications impacted at least nine residents and involved one of two medication carts on a specific hall. The investigation was initiated following a complaint and incident report, and the findings were corroborated by record reviews, staff interviews, and policy examination.
Inaccurate MDS Coding for PASRR Level II Status
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment was accurately coded to reflect the presence of a Preadmission Screening and Resident Review (PASRR) Level II. According to the CMS Long-Term Care Resident Instrument 3.0 Manual, residents with a PASRR Level II determination for serious mental illness or intellectual disability must be coded accordingly on the MDS. The resident in question was admitted with diagnoses including depression, adjustment disorder, and psychotic disorder, and was later diagnosed with schizophrenia. A PASRR Level II Service Determination completed for the resident indicated a diagnosis of serious mental illness, specifically schizophrenia. Despite this, the resident's annual MDS assessment was marked as 'No' for the question regarding current PASRR Level II status. During an interview, a social services staff member confirmed that the resident was indeed a Level II as of the PASRR determination date and acknowledged that the MDS should have been coded to reflect this status. The staff member also noted the importance of accurate coding for tracking and ensuring appropriate mental health services for residents with such diagnoses.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
