Knollwood Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Mobile, Alabama.
- Location
- 3151-a Knollwood Drive, Mobile, Alabama 36693
- CMS Provider Number
- 015463
- Inspections on file
- 23
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Knollwood Healthcare during CMS and state inspections, most recent first.
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 severe cognitive impairment and a history of aggressive behaviors struck another resident after being left unsupervised at their room doorway by a CNA. Despite existing care plans and facility policies addressing behavioral risks, staff did not provide the necessary supervision or interventions to prevent the incident, resulting in a physical altercation witnessed by staff.
During an internet outage, the facility failed to notify the physician and relevant parties when residents on the second and third floors did not receive their medications and treatments as ordered. The outage prevented access to the EHR system, and staff did not have pre-printed documentation forms to administer medications. The DON and ADM were not informed of the issue until much later, and the Physician/Medical Director was not notified at all, leading to an Immediate Jeopardy citation.
During a forecasted winter storm, a facility experienced an internet outage that prevented access to the EHR system, leading to neglect as residents did not receive medications as ordered. The nursing staff failed to implement a backup plan or notify management of the issue. Additionally, a CNA verbally abused a resident, which was substantiated by the facility's investigation, resulting in the CNA's termination.
The facility failed to ensure that nurses adhered to professional standards of practice and facility policies regarding medication administration and CBG monitoring. Several nurses did not administer medications or perform CBG checks as ordered, nor did they notify the appropriate personnel about the missed medications and checks. This affected a significant number of residents, with many not receiving their medications as ordered during the specified period. The facility's policy on Computer or Internet Downtime and EHR Access was not followed, contributing to the deficiency.
During a snowstorm, a facility lost internet access, preventing staff from accessing the eMAR and leading to significant medication errors. Residents with conditions such as diabetes and epilepsy missed critical medications, including insulin and anticonvulsants. Interviews revealed that staff were unable to administer medications or monitor blood glucose due to the lack of access to records.
The facility failed to follow its food safety and sanitation policies, affecting all residents receiving meals. Observations revealed unlabeled and undated food items in storage, a dirty ice machine, and improper hand hygiene practices in the dish room. The Food Service Director acknowledged these lapses, which could lead to foodborne illnesses and cross-contamination.
A CNA verbally abused a resident due to frustration from working a double shift, highlighting the facility's failure to provide adequate abuse prevention training. The Social Services Director also lacked proper training on the abuse policy, contributing to insufficient monitoring of the resident post-incident. The facility did not have a plan to address staff burnout, affecting one of 18 sampled residents.
A resident with Vascular Dementia was unable to reach their call light, which was repeatedly found on the floor behind their bed over two days. The facility's policy requires call lights to be within reach, and the RN Unit Manager confirmed the oversight, acknowledging the importance of accessibility for timely assistance.
A privacy breach occurred when a resident's medication was mistakenly sent home with another resident during discharge. The error involved Cyclobenzaprine prescribed for muscle spasms, and the facility's policy on confidentiality was not followed. Interviews with involved parties confirmed the mistake, highlighting a lapse in maintaining resident privacy.
A facility failed to report an allegation of verbal abuse within the required two-hour timeframe. A resident reported being verbally abused by a CNA, and the incident was reported to the Administrator at 11:20 AM. However, the Facility Reported Incident was not submitted to the State Agency until after 3:00 PM, exceeding the two-hour reporting requirement.
A facility failed to thoroughly investigate and address a verbal abuse incident involving a resident and a CNA. The CNA, frustrated from working double shifts, verbally abused the resident. The investigation lacked clarity, did not identify contributing factors, and failed to involve other residents or staff. Additionally, the Social Services Director and Mental Health Nurse were not notified, leaving the resident without necessary support.
A facility failed to implement a care-planned preventive measure for a resident with potential for impaired skin integrity. The resident's oxygen tubing was observed without padding behind the ears on multiple occasions, despite the care plan's directive. An LPN confirmed the absence of padding and its importance in preventing skin breakdown.
A resident was verbally abused by a CNA, but the facility failed to provide necessary social services and mental health evaluation as per policy. The SSD was unaware of the incident and did not assess the resident, while the DON failed to ensure communication and documentation. The Administrator was aware but the mental health evaluation was not conducted.
A medication error occurred when a resident's prescribed Cyclobenzaprine was mistakenly sent home with another resident upon discharge. The error was confirmed by the family of the discharged resident and a nurse who admitted to the mistake. The facility's DON and pharmacist were involved in addressing the issue, emphasizing the need to retrieve the medication.
The facility's QAPI committee failed to adequately review and analyze an abuse allegation involving a resident who was verbally abused by a CNA. The incident was not reported to the State Agency within the required timeframe, and the committee did not conduct a thorough investigation or root cause analysis. Contributing factors, such as the CNA's fatigue after a double shift, were not identified, and no action plan was developed to address these issues.
The facility failed to properly dispose of garbage and refuse, as 20-25 discarded pallets were observed outside the kitchen backdoor near dumpsters. These pallets, left for at least two weeks following deliveries, posed a potential risk of attracting pests or rodents. The Dietary Manager and Registered Dietician acknowledged the issue, noting that pallets should be placed in a dumpster to prevent such risks.
The facility failed to maintain essential kitchen equipment, including a steamer and a plate warmer, in working order. The steamer had been non-functional for at least two weeks, and one side of the plate warmer was also broken. The Dietary Manager and Registered Dietitian highlighted the importance of these appliances in meal preparation and maintaining food temperature, potentially affecting all residents receiving meals.
The facility did not adhere to the planned menu for residents on a pureed diet, serving yogurt instead of the specified pureed chocolate cream pie. This affected four residents, and both the RD and DM acknowledged the importance of following the menu to meet nutritional needs.
The facility's admission agreement failed to inform residents and their representatives that signing the binding arbitration agreement was not a condition for admission or care, nor did it inform them of their right to rescind the agreement within thirty days. This affected multiple residents, and both the Admissions Director and Administrator confirmed the omission.
The facility's admission agreements failed to include clear provisions for selecting a neutral arbitrator and a convenient venue, affecting several residents. The Admissions Director and Administrator confirmed the absence of these provisions, with no updates made since 2019.
Two residents with cognitive impairments were involved in a physical altercation in the dining room, initiated by one resident who slapped the other. The incident was classified as physical abuse, with one resident sustaining minor injuries. Staff intervened to separate the residents, but the facility's failure to prevent the altercation was identified as a deficiency.
The facility's Administrator did not ensure the QAPI committee convened to conduct a root cause analysis after a resident eloped from the facility. This oversight placed all residents at risk for immediate jeopardy due to potential elopement. Interviews with the Former Administrator and the DON revealed no evidence of a QAPI meeting or documentation of the incident. The Former Administrator indicated that no formal action plan was implemented, and all QAPI records were stored on the medical records computer. The DON confirmed the absence of documentation and QAPI meetings following the elopement.
A deficiency in oversight by the Governing Body resulted in a resident eloping from the facility after being administered psychotropic medication. The resident exited through an unsecured door and was found on a busy road by an off-duty staff member who did not provide adequate supervision. The resident was returned to the facility after a significant delay. The Governing Body did not guide the QAPI committee in conducting a root cause analysis to prevent future incidents. Additionally, the facility lacked an acting Administrator for a period, revealing gaps in oversight, communication, and adherence to protocols, leading to an Immediate Jeopardy situation affecting all residents.
A facility's QAPI committee did not thoroughly review all factors related to a resident's elopement through an unsecured side door, resulting in the resident being unsupervised in an unsafe area 2,640 feet from the facility. The committee failed to develop and implement effective plans and interventions to prevent recurrence, potentially impacting all 53 residents. Interviews with the DON and Former Administrator revealed a lack of documentation and evidence of actions taken post-incident, including proper notification, investigation, in-services, monitoring, root cause identification, and safety measures. The QAPI committee included key personnel such as the Administrator, DON, Social Services, MDS, Activities, and the Medical Director.
A resident with a history of agitation and cognitive impairment expressed a desire to leave the facility and was given Ativan for agitation. Despite this, the resident was not adequately supervised and exited through an unsecured door. An off-duty staff member encountered the resident on a busy road but did not provide adequate supervision. The resident was later returned by another off-duty staff member. The investigation highlighted issues with door security and staff practices, as well as non-compliance with policies on wandering and elopements.
A resident with Hemiplegia, Acute Respiratory Failure, and Vascular Dementia experienced verbal and potential physical abuse by two CNAs during a care interaction. The abuse was discovered through a recording made by the resident's daughter, capturing derogatory statements, threats, and sounds of physical harm. The facility's investigation confirmed the abusive behavior, with multiple staff and administrators corroborating the incident.
The facility did not maintain minutes of all Quality Assurance and Performance Improvement (QAPI) meetings according to their policy. An interview with the Administrator revealed that the QAPI minutes were not being signed by members in attendance, raising concerns about the validation of meetings and attendance tracking.
Multiple deficiencies were observed, including missing baseboards, ceiling tiles, and handrail pieces, as well as scuffs and holes on walls. Issues such as an electrical box hanging from the ceiling and exposed ceiling tiles with stains were noted. The Maintenance Director cited reasons like running out of materials, ceiling tiles falling back, and scuff marks from food carts. Additionally, cable wires were found hanging loosely, and some areas were overlooked for repairs, indicating lapses in maintenance and repair tasks.
The facility failed to ensure that call lights were accessible for four residents, making it impossible for them to call for assistance. Observations and interviews confirmed that the call lights were out of reach, posing a risk to the residents in case of an emergency.
The facility failed to report an allegation of verbal abuse to ADPH within the required two-hour timeframe. A family member provided a recording of two CNAs verbally abusing a resident, which was reported internally but delayed in being reported to ADPH.
A resident with moderate cognitive impairment and diagnoses of Alcohol Abuse and Anxiety Disorder was not properly monitored after receiving a one-time dose of Ativan for agitation. The resident was later found outside the facility, and there was no documentation of monitoring for effectiveness or adverse effects.
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 Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of severe intellectual disabilities, anxiety disorder, and documented verbal and physical behaviors struck another resident. The incident took place as staff attempted to take the resident to their bed, during which the resident became irritable, cursed, and was left at the doorway of their room by a CNA. Another CNA witnessed the resident hit a fellow resident on the arm as the second resident was trying to leave the room. The resident who was struck did not sustain any injuries but reported feeling shocked by the event. The resident who initiated the altercation had a BIMS score of 0, indicating severely impaired cognition, and had care plans addressing verbal and physical aggression. However, these care plans did not include specific directions for staff regarding the level of supervision required to ensure the safety of other residents until after the incident occurred. Staff interviews confirmed that the resident was known to be easily agitated and had a history of combative behaviors, but the necessary supervision and interventions to prevent such incidents were not in place at the time. The facility's abuse policy outlined the need for staff training in managing aggressive behaviors and for care planning and monitoring residents with behavioral issues. Despite these policies, the staff failed to adequately supervise the resident with known behavioral risks, resulting in the physical altercation. The deficiency was identified through interviews, record reviews, and the facility's own investigative documentation.
Failure to Notify Physician of Medication Administration Issues During Internet Outage
Penalty
Summary
The facility failed to ensure that the physician was notified when residents on the second and third floors did not receive their medications and treatments as ordered due to an internet outage. This outage occurred on January 21 and 22, 2025, and prevented access to the Electronic Health Record (EHR) system. As a result, nurses did not have access to pre-printed paper documentation forms such as physician orders and Medication Administration Records (MARs) to administer medications during this period. The facility staff did not notify the Director of Nursing (DON), residents, or resident representatives about the residents not receiving their ordered medications and treatments. Interviews revealed that the Licensed Practical Nurse (LPN) who was a supervisor during the snowstorm was unsure if the residents received their medications and did not inform the DON or Administrator (ADM) about the system being down. The DON was not at the facility during the outage and was not informed about the issue until March 20, 2025. Similarly, the ADM was unaware that residents did not receive their medications until informed by the survey team. The Physician/Medical Director was also not informed about the facility's computer system being down and the residents not receiving their medications. The physician expressed that he would have liked to have been informed of this situation, as missing medications could lead to various health issues for the residents. The facility's non-compliance with the requirement to notify the physician and other relevant parties was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death, leading to an Immediate Jeopardy citation.
Removal Plan
- The medication administration Record (MAR) will be printed monthly by the Director of Nursing, Assistant Director of Nursing, or Unit Manager.
- The paper MAR will be updated at the time the order is received or confirmed for all current residents and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes.
- The updated MAR will be located by the nursing stations.
- All LPNs and RNs were in-serviced to ensure they know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR.
- In-services were conducted to educate all nurses, physical therapy staff, and administrative staff on the policy titled Policy on Computer or Internet Downtime and EHR, standard practices for administering medication, monitoring blood glucose, implementing physician orders, and documenting medication administration.
- In-service included calling the physician and notifying the Director of Nursing or Designee if staff are unable to carry out a physician's order.
- In-service included how the situation led to neglect and the facility's Abuse Policy.
- The Administrator educated the Director of Nursing and the Assistant Director of Nursing that they are responsible for printing the paper MAR and placing it by each nurse's station.
- A monthly MAR printout schedule was created for clarity.
- The DON and ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm or other reason to expect downtime.
- A mock drill was conducted for the nursing personnel on shift.
- The facility replaced the router through its internet provider.
- The entire Medical Record Administration was reprinted in the event of an outage, and nurses were educated that any medication changes or new admissions will need to be updated in the paper medical administration records.
- All residents that had the potential of being affected by this deficient practice were assessed by the medical director, and no adverse effects were identified.
- An ad-hoc Quality Assurance meeting was conducted to discuss the deficient practice and plan of correction.
- The nurses responsible were immediately educated about the improper practice and on the Policy on Computer or Internet Downtime and EHR access.
Neglect and Verbal Abuse During Internet Outage
Penalty
Summary
The facility failed to protect residents from neglect during a forecasted winter storm that caused an internet outage, preventing access to the Electronic Health Record (EHR) system. This outage occurred on January 21 and 22, 2025, and the facility did not have systems in place to ensure continuity of care. As a result, pre-printed paper documentation forms such as physician orders and Medication Administration Records (MARs) were not available for the licensed nursing staff to use for resident care, treatment, and medication administration. Consequently, residents on the second and third floors did not receive their medications as ordered by the physician during this period. The nursing staff, including the nurse supervisor on duty, failed to ensure that residents received their medications and treatments as ordered. They also did not notify management staff or the residents' physicians of their inability to safely administer medications. This lack of communication and failure to implement a backup plan for medication administration during the internet outage led to a situation where residents did not receive necessary medications, including insulin and other significant medications, for more than 24 hours. Additionally, the facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA). The CNA, who was reportedly tired and frustrated from working a double shift, verbally abused the resident by using derogatory language. The resident reported feeling shocked and stunned by the CNA's behavior. The facility's investigation substantiated the allegation of verbal abuse, and the CNA was subsequently terminated.
Removal Plan
- The medication administration Record (MAR) will be printed monthly by the Director of Nursing Assistant Director of Nursing or Unit Manager.
- The paper MAR will be updated at the time the order is received or confirmed for all current resident and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes including all new orders for new admits.
- The updated MAR will be located by the nursing stations.
- All LPNs and RNs were in-serviced to ensure nurses know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR.
- The Director of Nursing and Assistant Director of Nursing began to educate all nurses, all physical therapy staff and administrative staff and provided the education with 1:1 in-service to specific staff.
- The in-services included the policy titled Policy on Computer or Internet Downtime and EHR, the standard of practice to administer medication, monitor blood glucose, the implementation of the prescribing physicians' orders, the importance of documenting medication administration at the time of administration.
- Inservice included calling the physician as well as notify the Director of Nursing or Designee if staff including nurses are unable to carry out a physician's order.
- Inservice included how it led to neglect and the facility's Abuse Policy titled Abuse Policy.
- The in-service was completed for all nurses, PT staff, and administrative staff.
- The nursing staff were all educated by the Director of Nursing or Assistant Director of Nursing and 1:1 in-service to specific staff.
- The in-service included that a printed MAR will be ready for each month.
- A copy of the paper MAR will be kept at each nurses' station for use during downtime.
- Education included that RNs and LPNs who receive an order or confirm a new order for any medication changes including all new orders for new admits will update the paper medication administration records at the time the order is received or confirmed for all current resident and new admits.
- The Administrator educated the Director of Nursing and the Assistant Director of Nursing that both of them are responsible to print the paper MAR to be ready for each month and will be placed by each of the nurse's station.
- A monthly MAR print out schedule was created for clarity.
- The education included that the DON and the ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm or other reason to expect downtime.
- A mock drill was conducted for the nursing personnel on shift.
- The facility replaced the router through its internet provider.
- The entire Medical Record Administration was reprinted in the event of outage and nurses were all educated that any medication changes or new admissions will need to be updated in the paper medical administration records.
- A report was generated from the electronic medical records to see which residents could have been affected.
- All residents that had the potential of being affected by this deficient practice were assessed by the medical director.
- An ad-hoc Quality Assurance meeting which included the entire IDT team was conducted to discuss the deficient practice and plan of correction.
- The nurses that were responsible were immediately educated about the improper practice and on the Policy on Computer or Internet Downtime and EHR access.
- The QA team discussed the needed in services/education for specific staff.
Failure to Administer Medications and Perform CBG Monitoring
Penalty
Summary
The facility failed to ensure that several nurses adhered to professional standards of practice and facility policies regarding medication administration and capillary blood glucose (CBG) monitoring. Specifically, LPN #14 and RN #15 did not administer medications or perform CBG checks as ordered by the physician during their shift. They also failed to notify the residents' physician, Director of Nursing (DON), or the Administrator about the missed medications and CBG checks. This non-compliance was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death, leading to an Immediate Jeopardy citation. Additionally, RN #20 and RN #16 administered medications using pre-packaged medications without verifying the physician's order and did not document the administration of medications at the time of administration or when the Electronic Health Record (EHR) system was restored. LPN #18 also failed to administer and document medication administration per standards of practice and facility policy. This affected a significant number of residents on the Second and Third Floors, with a total of 48 out of 52 residents not receiving their medications as ordered during the specified period. The facility's policy on Computer or Internet Downtime and EHR Access was not followed, as staff did not initiate downtime procedures or use paper documentation for resident care activities during the internet outage. The failure to administer medications and perform CBG checks as ordered, along with the lack of proper documentation and notification, contributed to the deficiency. The facility's non-compliance with these requirements was identified during the investigation of a complaint, leading to the citation of Immediate Jeopardy.
Removal Plan
- The medication administration Record (MAR) will be printed monthly by the Director of Nursing, Assistant Director of Nursing, or Unit Manager.
- The paper MAR will be updated at the time the order is received or confirmed for all current residents and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes.
- The updated MAR will be located by the nursing stations.
- All LPNs and RNs were in-serviced to ensure they know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR.
- In-services were conducted to educate all nurses, physical therapy staff, and administrative staff on the policy titled Policy on Computer or Internet Downtime and EHR.
- In-services included the standard of practice to administer medication, monitor blood glucose, implement the prescribing physicians' orders, and the importance of documenting medication administration at the time of administration.
- In-service included calling the physician as well as notifying the Director of Nursing or Designee if staff are unable to carry out a physician's order.
- In-service included how the failure led to neglect and the facility's Abuse Policy.
- The Administrator educated the Director of Nursing and the Assistant Director of Nursing that both are responsible for printing the paper MAR to be ready and will be placed by each nurse's station.
- A monthly MAR printout schedule was created for clarity.
- The education included that the DON and the ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm or other reason to expect downtime.
- A mock drill was conducted for the nursing personnel on shift.
- The facility replaced the router through its internet provider.
- The entire Medical Record Administration was reprinted in the event of an outage and nurses were educated that any medication changes or new admissions will need to be updated in the paper medical administration records.
- All residents that had the potential of being affected by this deficient practice were assessed by the medical director.
- An ad-hoc Quality Assurance meeting was conducted to discuss the deficient practice and plan of correction.
- The nurses responsible were immediately educated about the improper practice and on the Policy on Computer or Internet Downtime and EHR access.
Medication Administration Failure During Internet Outage
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors during a forecasted snowstorm when the internet connection was lost, preventing access to the Electronic Health Record (EHR) and Electronic Medication Administration Record (eMAR). This resulted in the failure to administer critical medications, including insulin and other significant medications, to residents from the evening of one day until the following evening. The deficiency was identified as Immediate Jeopardy, indicating that the non-compliance was likely to cause serious harm or death. Resident Identifier #12, who had Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Hyperglycemia, did not receive their prescribed insulin doses and blood glucose monitoring during this period. Similarly, Resident Identifier #15, with diagnoses including Type 2 Diabetes Mellitus and Hypertension, missed doses of insulin, blood pressure, and seizure medications. Resident Identifier #30, with conditions such as Type 2 Diabetes Mellitus and Chronic Heart Failure, also missed critical medications, including insulin and anticoagulants, and did not have their blood glucose monitored. Resident Identifier #308, who had epilepsy, did not receive their anticonvulsant medications, increasing the risk of seizure recurrence. Interviews with nursing staff revealed that the lack of access to the eMAR due to the internet outage was a significant barrier to medication administration. Some staff were unable to administer medications or monitor blood glucose levels because they did not have access to the necessary records. The facility's policy required medications to be administered in a timely manner and in accordance with prescriber orders, but the outage led to a failure in adhering to these protocols, affecting the care of the residents involved.
Removal Plan
- The medication administration Record (MAR) will be printed monthly by the Director of Nursing Assistant Director of Nursing or Unit Manager.
- The paper MAR will be updated at the time the order is received or confirmed for all current resident and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes including all new orders for new admits.
- The updated MAR will be located by the nursing stations.
- All LPNs and RNs were in-serviced to ensure they know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR.
- The Director of Nursing and Assistant Director of Nursing educated all nurses, physical therapy staff, and administrative staff on the policy titled Policy on Computer or Internet Downtime and EHR.
- In-service included the standard of practice to administer medication, monitor blood glucose, implement the prescribing physicians' orders, and the importance of documenting medication administration at the time of administration.
- In-service included calling the physician as well as notifying the Director of Nursing or Designee if staff are unable to carry out a physician's order.
- In-service included how it led to neglect and the facility's Abuse Policy.
- A printed MAR will be ready and a copy will be kept at each nurses' station for use during downtime.
- RNs and LPNs who receive an order or confirm a new order for any medication changes including all new orders for new admits will update the paper medication administration records at the time the order is received or confirmed.
- The Administrator educated the Director of Nursing and the Assistant Director of Nursing that both are responsible to print the paper MAR to be ready and will be placed by each of the nurse's station.
- A monthly MAR print out schedule was created for clarity.
- The DON and the ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm or other reason to expect downtime.
- A mock drill was conducted for the nursing personnel on shift.
- The facility replaced the router through its internet provider.
- The entire Medical Record Administration was reprinted in the event of outage and nurses were all educated that any medication changes or new admissions will need to be updated in the paper medical administration records.
- All residents that had the potential of being affected by this deficient practice were assessed by the medical director.
- An ad-hoc Quality Assurance meeting was conducted to discuss the deficient practice and plan of correction.
- The nurses responsible were immediately educated about the improper practice and on the Policy on Computer or Internet Downtime and EHR access.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to its own policies regarding food safety and sanitation, which had the potential to affect all 53 residents receiving meals from the kitchen. During an inspection, it was observed that food items in the freezer and cooler, such as a large bag of okra, chicken fingers, and corned beef, were not labeled or dated as required by the facility's DATING AND LABELING POLICY. The Food Service Director (FSD) confirmed that these items should have been labeled with the date opened, use-by date, and the initials of the person who stored them. The lack of proper labeling and dating could lead to foodborne illnesses, as stated by the FSD. Additionally, the facility's ICE MACHINE SANITATION POLICY was not followed, as a black substance was found on the ice guard and lid inside the ice machine. The FSD acknowledged that the ice machine was dirty and had not been serviced, which could result in bacteria or infectious diseases contaminating the ice served to residents. The FSD admitted responsibility for ensuring the cleanliness of the ice machine, which was supposed to be cleaned monthly. The HAND WASHING POLICY was also violated, as observed in the dishware washing area. Dietary Aide (DA) #23 was seen working on both the dirty and clean sides of the dish room without changing gloves or apron, leading to potential cross-contamination. DA #24 also failed to change his apron when moving from the dirty to the clean side. Both aides admitted to not following proper procedures, with DA #23 citing inexperience and DA #24 mentioning being too busy. The FSD confirmed that such practices could lead to cross-contamination, posing a risk to resident health.
Inadequate Abuse Prevention Training Leads to Verbal Abuse Incident
Penalty
Summary
The facility failed to provide adequate abuse prevention training to its staff, which resulted in a Certified Nursing Assistant (CNA) verbally abusing a resident. The incident occurred when the CNA, who was tired from working a double shift, expressed frustration while providing care to the resident. The facility's investigation revealed that the CNA had not received sufficient training to identify and address factors that could lead to abuse, such as staff burnout and stress. Additionally, the facility lacked a plan to monitor staff working extended hours to prevent burnout and frustration. The Social Services Director (SSD) also did not receive proper training on the facility's abuse policy, which contributed to the failure to monitor the resident after the incident. The SSD, who had been in the position since early January, was instructed to backdate her signature on the abuse policy training document, indicating that she had not completed the required training at the time of the incident. The Human Resources Director confirmed that the SSD had not signed off on her abuse training until after the incident, despite being assigned the task earlier. This lack of training and oversight affected one of the 18 sampled residents.
Resident's Call Light Inaccessible
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a violation of their policy titled 'Answering the Call Light.' The policy, revised in October 2010, mandates that call lights should be within easy reach of residents when they are in bed to respond to their requests and needs. The resident in question, who was admitted with a diagnosis of Vascular Dementia, had a care plan that specifically required staff to maintain a safe environment by ensuring the call light was accessible. However, on multiple occasions over two days, the call light was observed on the floor behind the head of the resident's bed, making it inaccessible. The surveyor's observations were confirmed through an interview with the RN Unit Manager, who acknowledged that the call light was not in the correct position and that it was the responsibility of all staff to ensure it was within reach. The RN Unit Manager also recognized the importance of having the call light accessible so that the resident could summon assistance as needed. This deficiency affected one of the 18 sampled residents, highlighting a lapse in adherence to the facility's policy and the resident's care plan requirements.
Medication Privacy Breach During Resident Discharge
Penalty
Summary
The facility failed to maintain personal privacy and confidentiality for a resident, identified as RI #52, when licensed staff mistakenly provided medication labeled with RI #52's information to another resident, RI #308, upon discharge. This incident occurred on January 29, 2025, and was identified during an investigation related to complaint/report number AL00050173. The facility's policy on confidentiality and personal privacy, revised in October 2017, mandates the protection of residents' medical treatment information, which was not adhered to in this case. RI #52 was prescribed Cyclobenzaprine for muscle spasms, and this medication was inadvertently sent home with RI #308. Interviews conducted with RI #308's family member, the nurse responsible for the discharge, and the Director of Nursing confirmed the error. The nurse, RN #13, admitted to unintentionally placing RI #52's medication in RI #308's bag. The Director of Nursing acknowledged that sending a resident home with another's medication is a privacy concern. The pharmacist also highlighted the privacy issue and suggested retrieving the medication from the family.
Delayed Reporting of Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the State Agency within the required two-hour timeframe. On January 30, 2025, a Licensed Physical Therapy Assistant (LPTA) became aware of an incident at 10:50 AM where a resident claimed to have been verbally abused by a Certified Nursing Assistant (CNA), who allegedly called the resident a 'stupid mother fucker.' The LPTA reported this allegation to her supervisor and the Administrator (ADM) at approximately 11:20 AM. However, the Facility Reported Incident (FRI) was not submitted to the State Agency until 3:04 PM, exceeding the two-hour reporting requirement outlined in the facility's Abuse Policy. The deficiency affected one resident who was part of a sample of three residents reviewed for abuse. During interviews, both the LPTA and the ADM acknowledged the requirement to report such allegations immediately, but the ADM confirmed that the report was delayed. The facility's policy, updated in August 2022, clearly states that all alleged violations involving abuse must be reported immediately, but no later than two hours after the allegation is made known. This delay in reporting constitutes a failure to adhere to the established protocol for handling allegations of abuse.
Failure to Investigate and Address Verbal Abuse Incident
Penalty
Summary
The facility failed to conduct a thorough investigation and take appropriate corrective actions following an incident of verbal abuse involving a resident identified as RI #15. On the date of the incident, Certified Nursing Assistant (CNA) #10 verbally abused RI #15, expressing frustration and fatigue from working double shifts. The facility's investigation did not identify potential contributing factors to the verbal abuse, such as staff burnout or inadequate training on handling stress, which prevented the development and implementation of measures to prevent recurrence. The investigative file contained handwritten statements that were unclear and lacked proper identification of the individuals who provided them. The facility did not conduct interviews with other residents or staff to determine if there were additional instances of unreported abuse involving CNA #10. Furthermore, there was no evidence of a root cause analysis being conducted to address the incident, and the facility did not have a process in place to monitor or support staff working extended hours to prevent burnout and frustration. Additionally, the facility failed to ensure that the Social Services Director (SSD) and Mental Health Nurse were notified and involved in assessing and supporting RI #15 following the incident. The SSD was unaware of the abuse until the survey, and no mental health evaluation was conducted for RI #15. This lack of communication and follow-up could have resulted in emotional distress for the resident, as noted by the Director of Nursing (DON).
Failure to Implement Preventive Measures for Skin Integrity
Penalty
Summary
The facility failed to implement a care-planned preventive measure to prevent skin breakdown for a resident identified as having a potential for impaired skin integrity. The resident, who was admitted to the facility with a care plan indicating the need for padding around oxygen tubing when in use, was observed on multiple occasions without padding on the tubing behind their ears. This was noted during observations on two consecutive days, where the resident's oxygen was set at two liters per minute via a nasal cannula/concentrator, yet the tubing remained unpadded. An interview with an LPN confirmed the absence of padding and acknowledged the importance of padding to prevent skin breakdown.
Failure to Provide Social Services After Verbal Abuse Incident
Penalty
Summary
The facility failed to provide appropriate social services to a resident, identified as RI #15, following an incident of verbal abuse by a Certified Nurse Assistant (CNA). The incident occurred when the CNA allegedly called the resident a derogatory name. Despite the facility's policy requiring the Social Services Director (SSD) to monitor the resident's reactions and statements following such incidents, the SSD was unaware of the abuse and had not assessed the resident. The SSD, who had been in the position since early January 2025, stated that she was not informed of the incident or the need for a mental health evaluation for the resident. The Director of Nursing (DON) acknowledged that the policy required notifying the SSD to evaluate the resident, but this was not documented or communicated. The Administrator was aware of the incident and had planned for a mental health evaluation, but it had not been conducted. The lack of communication and follow-up resulted in the resident not receiving the necessary monitoring and counseling, potentially causing emotional distress.
Medication Error Involving Two Residents
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for its residents, specifically in the case of a medication error involving two residents. Resident #52 was prescribed Cyclobenzaprine (Flexeril) to be taken orally three times a day for muscle spasms. However, this medication was mistakenly sent home with another resident, Resident #308, upon their discharge from the facility. This error was confirmed through interviews with Resident #308's family member, who reported having the medication at home, and with RN #13, who admitted to the mistake but was unsure if the medication had been retrieved. The Director of Nursing (DON) acknowledged being informed by Resident #308's family that they had another resident's medication, specifically Flexeril. The facility's pharmacist indicated that the proper procedure for disposing of medications involved using a service for non-narcotic drugs, but emphasized that medications should be retrieved if sent home with the wrong resident. The pharmacist advised that the facility should attempt to retrieve the medication from the family. This incident was part of a complaint investigation and affected one of the 18 sampled residents.
Inadequate QAPI Review of Abuse Allegation
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee adequately reviewed and analyzed an allegation of abuse to determine causes and implement corrective actions to prevent recurrence. Specifically, the committee did not identify concerns with the reporting and investigation of an abuse allegation involving a resident who was verbally abused by a CNA. The incident was not reported to the State Agency within the required two-hour timeframe, and the QAPI committee did not conduct a thorough investigation or root cause analysis. The QAPI committee also failed to identify contributing factors to the verbal abuse, such as the CNA's fatigue and frustration after working a double shift. The facility's policies on abuse and QAPI were not effectively followed, as the committee did not develop an action plan to address the late reporting or the lack of a comprehensive investigation. The facility administrator acknowledged that a root cause analysis was not performed and was unaware that a written action plan was necessary.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during an initial tour of the kitchen. On 10/08/2024, a surveyor noted 20-25 discarded pallets outside the kitchen backdoor, near the facility dumpsters. These pallets had been left there for at least two weeks following deliveries to the facility. The Dietary Manager acknowledged that the pallets could serve as a shelter for pests or rodents, potentially allowing them to enter the building. An interview with the Registered Dietician confirmed that pallets should not be stacked outside the kitchen back door and should be placed in a dumpster instead. The presence of these pallets posed a potential risk of attracting rodents and pests, affecting all 49 residents residing in the facility.
Failure to Maintain Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in working order, specifically a steamer and a plate warmer, which were observed to be non-functional. The steamer, used for steaming vegetables and reheating food, had been out of order for at least two weeks, as reported by the Dietary Manager (DM). The DM also noted that one side of the plate warmer was not working, although he was unsure of how long it had been broken. The Registered Dietitian (RD) confirmed that kitchen equipment should be operational, emphasizing the convenience of a working steamer and the importance of the plate warmer in keeping food at an appropriate temperature before serving to residents. This deficiency had the potential to affect all 49 residents receiving meals from the facility's kitchen.
Failure to Follow Pureed Diet Menu
Penalty
Summary
The facility failed to ensure that the menu for residents on a pureed diet was followed as planned. Specifically, the menu indicated that a pureed chocolate cream pie should be served as part of the lunch meal. However, during the lunch service, residents on a pureed diet were instead served yogurt. This discrepancy was observed during the lunch tray line preparation and the meal service in the main dining room, affecting four residents who were supposed to receive the pureed pie. The Registered Dietician (RD) confirmed that the menu should have been followed and expressed uncertainty as to why it was not. The RD emphasized the importance of providing the same quality of food to all residents, including those on pureed diets. The Dietary Manager (DM) explained that the cook did not puree the pie despite having the necessary equipment and access to the menu. The DM acknowledged the importance of adhering to the menu to meet the residents' nutritional needs.
Deficiency in Arbitration Agreement Disclosure
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement within the admission agreement contained a clear and detailed statement explaining that neither the resident nor their representative was required to sign the agreement as a condition of admission or to receive care. Additionally, the agreement did not inform the residents or their representatives of their right to rescind the agreement within thirty days of signing. This deficiency was identified during a review of the facility's Admission Agreement for three residents, all of whom had signed the arbitration agreement without being informed of these rights. The Admissions Director was questioned about the current binding arbitration agreement and was unsure when it had last been updated. The Director confirmed that the agreement did not include provisions allowing parties the right to refuse to sign or to rescind the agreement within thirty days. The Administrator also reviewed the agreement and acknowledged that it lacked the correct wording and language, indicating a systemic issue with the facility's admission process.
Deficiency in Arbitration Agreement Provisions
Penalty
Summary
The facility failed to ensure that the binding arbitration agreements within the admission agreements contained a clear and detailed statement explaining the provision for the selection of a neutral arbitrator agreed upon by both parties and the selection of a venue convenient to both parties. This deficiency was identified during a review of the facility's Admission Agreements for three residents, which revealed that the agreements lacked the necessary documentation to inform the residents or their representatives about these provisions. The residents affected by this deficiency were admitted at various times, with their agreements dated between September 2022 and October 2023. During interviews conducted on October 10, 2024, the Admissions Director was unable to confirm when the arbitration agreement was last updated and acknowledged that the current document did not include the required provisions for selecting a neutral arbitrator and a convenient venue. The Administrator also reviewed the current binding arbitration agreement and confirmed that it lacked the correct wording and language as required. It was noted that no disputes had been resolved through binding arbitration since 2019, indicating a potential oversight in updating the agreement to meet regulatory standards.
Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to protect two residents from a physical altercation that occurred in the dining room. Resident Identifier (RI) #1, who has a history of dementia with behavioral disturbances, approached RI #2 and initiated a physical altercation by slapping them. This led to both residents hitting each other. The incident was witnessed by staff and other residents, and it was reported that RI #1 was the aggressor. Both residents involved in the altercation have severely impaired cognitive skills, as indicated by their assessments. The facility's policy on abuse defines abuse as the willful infliction of injury or harm, and this incident was classified as physical abuse. The altercation resulted in RI #1 sustaining bruising and scratches on their right forearm, while RI #2 did not have any skin issues identified. Witness statements from other residents confirmed that RI #1 initiated the altercation by hitting RI #2 first. The staff present at the time of the incident, including a CNA and an LPN/UM, intervened to separate the residents and ensure their safety. The facility's investigation revealed that both residents were cognitively impaired and could not recall the incident. The root cause analysis suggested that RI #1's behavior might have been influenced by a urinary tract infection (UTI), as they were later treated for this condition. Despite the immediate separation of the residents and the subsequent actions taken, the facility's failure to prevent the altercation and protect the residents from abuse was identified as a deficiency.
QAPI Committee Oversight and Documentation Deficiency
Penalty
Summary
The facility's Administrator failed to ensure the QAPI committee met to identify concerns using root cause analysis after Resident Identifier (RI) #1 eloped from the facility on 02/05/2023. This failure placed all 53 residents at risk for immediate jeopardy due to the ongoing risk of elopement. The deficiency was cited as a result of the investigation of complaint/report numbers AL00043280 and AL00046465. The Immediate Jeopardy (IJ) was related to Administration at a scope and severity of L. During interviews with the Former Administrator #1 and the Director of Nursing (DON), it was revealed that there was no evidence of a QAPI meeting following RI #1's elopement, no documentation of the incident available, and the facility was not in compliance with effective administration. The Former Administrator #1 mentioned that no formal action plan was implemented by QAPI after the elopement incident, and all QAPI records were maintained on the medical records computer. The DON confirmed the lack of documentation and evidence of QAPI meetings post the elopement incident.
Oversight Deficiency Leads to Resident Elopement and Immediate Jeopardy
Penalty
Summary
The report highlights a deficiency in oversight by the Governing Body of a long-term care facility, leading to a serious incident where a resident (RI #1) eloped from the facility on 02/05/2023. Despite being given psychotropic medication at 2:21 PM, RI #1 was not supervised and left through an unsecured door. An off-duty staff member encountered RI #1 on a busy road but did not provide adequate supervision, leaving the resident in an unsafe environment until another staff member returned them to the facility at approximately 4:10 PM. The Governing Body failed to guide the Quality Assurance and Performance Improvement (QAPI) committee in using root cause analysis to determine corrective actions needed to prevent similar occurrences in the future. The deficiency was deemed to have caused or had the potential to cause serious harm to all 53 residents in the facility, resulting in an Immediate Jeopardy situation. The Governing Body also neglected to ensure the facility had an acting Administrator for a period from 03/29/2024 to 04/08/2024. Interviews with Facility Owners and the Regional Nurse Consultant revealed gaps in oversight and accountability, with the Governing Body failing to provide adequate guidance and supervision to prevent elopement incidents and ensure proper staffing and security measures were in place. The facility's policies outlined the responsibilities of the Governing Body in establishing and implementing policies for facility management, including appointing a licensed Administrator accountable to the Governing Body. However, the investigation revealed shortcomings in oversight, communication, and adherence to established protocols, leading to the elopement incident and subsequent Immediate Jeopardy finding. The lack of proper supervision and failure to address security concerns ultimately resulted in the deficiency identified during the survey.
QAPI Committee Oversight on Resident Elopement Incident
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to thoroughly review all factors related to Resident Identifier (RI) #1's elopement on 02/05/2023. RI #1 exited the facility through an unsecured side door without staff's knowledge and was left unsupervised in an unsafe area 2,640 feet from the facility. The QAPI committee did not develop and implement effective plans and interventions to prevent recurrence and ensure the facility's security, potentially impacting all 53 residents. The deficiency was related to State Operations Manual, Appendix PP, S483.75 Quality Assurance and Performance Improvement, and was categorized as Immediate Jeopardy with a scope and severity of L. During interviews with the Director of Nursing and Former Administrator, it was revealed that there was a lack of documentation and evidence of actions taken following RI #1's elopement. The Director of Nursing highlighted the importance of conducting proper notification, investigation, in-services, monitoring of the resident, identifying root causes, and implementing safety measures post-incident. The Former Administrator mentioned the absence of QAPI meeting minutes related to the elopement incident and could not recall specific details about the incident or subsequent actions taken. The QAPI committee composition included key personnel such as the Administrator, Director of Nursing, Social Services, MDS, Activities, and the Medical Director, indicating a multidisciplinary approach to quality improvement.
Elopement Incident Due to Inadequate Supervision and Unsecured Doors
Penalty
Summary
The deficiency identified in the report pertains to a nursing home's failure to adequately supervise and prevent an elopement incident involving Resident Identifier (RI) #1. On 02/05/2023, RI #1 expressed a desire to leave the facility and was administered a one-time dose of Ativan for agitation. Despite this, RI #1 was not supervised after receiving the medication and subsequently left the facility through an unsecured door. An off-duty staff member encountered RI #1 on a busy road near the facility, but did not provide adequate supervision and left RI #1 in an unsafe environment. RI #1 was eventually returned to the facility by another off-duty staff member. The investigation revealed that the facility's non-compliance with regulations related to accident hazards and supervision posed a serious risk to residents' safety. RI #1, who had a history of agitation and cognitive impairment, was able to elope due to inadequate supervision and unsecured exit doors. Staff interviews indicated that RI #1 had exhibited behaviors indicating a desire to leave prior to the incident, and staff members were aware of these concerns. The facility's policies on wandering and elopements highlighted the importance of identifying at-risk residents and preventing unsafe wandering, but these policies were not effectively implemented in RI #1's case. Multiple staff members, including CNAs and the Maintenance Director, acknowledged issues with door security and staff practices that contributed to the elopement incident. The Former Administrator noted that staff did not follow protocol when RI #1 expressed a desire to leave, and the Maintenance Director confirmed that doors were sometimes left unsecured for convenience.
Incident of Verbal and Potential Physical Abuse by CNAs
Penalty
Summary
The report details a concerning incident where Resident Identifier (RI) #3 was subjected to verbal and potential physical abuse by Certified Nursing Assistant (CNA) #16 and CNA #17 at the facility. RI #3, who was admitted with diagnoses of Hemiplegia following Cerebral Infarction, Acute Respiratory Failure, and Vascular Dementia, was found to have been verbally abused by the CNAs during a care interaction on 10/11/2023. The abuse was discovered when RI #3's daughter, who had left her cellphone recording in the room, overheard derogatory statements, threats of punishment, and what sounded like physical harm being inflicted on RI #3. The daughter reported the incident to the Infection Control Nurse (ICN) after listening to the recording. The facility's policy on abuse prevention and response clearly outlines the rights of residents to be free from abuse, including verbal and mental abuse. Despite this policy, the investigation revealed that both CNA #16 and CNA #17 engaged in abusive behavior towards RI #3 during the care interaction. The recorded conversation captured instances of derogatory language, threats, and rough handling of the resident. The facility's Investigative Summary confirmed the verbal and potential physical abuse, with the former Administrator noting the derogatory comments made by the CNAs and the sounds of what appeared to be physical contact with the resident. Multiple interviews conducted with staff and administrators corroborated the incident, with witnesses attesting to the abusive behavior exhibited by CNA #16 and CNA #17 towards RI #3. The Infection Control Nurse, the Former Administrator, the Administrator, and the Social Services Director all acknowledged the severity of the abuse and its potential impact on a reasonable person in a similar situation. RI #3's daughter also provided insights into RI #3's potential emotional distress if he/she had full cognitive awareness of the abusive treatment.
QAPI Meeting Minutes Not Maintained as Per Policy
Penalty
Summary
The facility failed to maintain minutes of all Quality Assurance and Performance Improvement (QAPI) meetings as required by their policy. During an interview with the Administrator, it was revealed that the QAPI minutes were not being signed by members in attendance, leading to concerns about the validation of meetings and attendance tracking.
Environmental Maintenance Deficiencies Observed
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents as evidenced by multiple deficiencies observed during the survey. These deficiencies included missing baseboards in the 400 hall, ceiling tiles missing in the Physical Therapy room, scuffs and holes on the walls, missing handrail pieces in the 400 hall, electrical box hanging from the ceiling in residents' rooms, and exposed ceiling tiles with stains in various areas. The Maintenance Director acknowledged various issues such as missing baseboards due to running out of materials, missing ceiling tiles attributed to falling back into the ceiling, scuff marks from food carts, and handrail ends being pulled off by a resident. Observations revealed cable wires hanging loosely from the ceiling in residents' rooms, with the Maintenance Director mentioning that the wires were not secured properly and should have been addressed. The Maintenance Director also admitted to forgetting about fixing certain areas, such as a missing ceiling tile exposing pipes in the linen room, indicating oversights in maintenance and repair tasks. These deficiencies highlight a lack of attention to detail and timely maintenance practices within the facility, potentially compromising the safety and comfort of the residents.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to accommodate the needs of four residents by not ensuring that their call lights were accessible. During the survey, it was observed that the call lights for residents with diagnoses such as weakness, dysphagia, a history of falling, and muscle weakness were out of reach on multiple occasions. Specifically, the call lights for these residents were found behind their beds or recliners, making it impossible for them to call for assistance. The Maintenance Director confirmed these observations, acknowledging that the call lights were not accessible and posed a risk to the residents in case of an emergency. Interviews with the Director of Nursing (DON) further highlighted the issue, as the DON admitted that residents would be unable to call for help if their call lights were out of reach. The DON emphasized that call lights should always be accessible to ensure residents' needs are met and to prevent potential emergencies. The deficiency was identified during the investigation of a complaint/report and affected four out of 34 sampled residents.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the Alabama Department of Public Health (ADPH) within the required two-hour timeframe. On 10/11/2023 at 5:40 PM, facility staff reported an allegation of verbal abuse involving a resident. However, the facility did not report this allegation to ADPH until 8:24 PM on the same day, exceeding the mandated reporting window. This failure was identified during the investigation of complaint/report numbers AL00045846 and AL00047519 and affected one of the fifteen sampled residents reviewed for abuse. The incident involved a resident who was readmitted to the facility on an unspecified date. A family member provided a recording of two Certified Nursing Assistants (CNAs) verbally abusing the resident. Licensed Practical Nurse (LPN) #8 listened to the recording and immediately reported the abuse to the Administrator. Despite this, the report to ADPH was delayed. The facility's policy, updated in August 2022, mandates that any suspicion of serious crimes, including abuse, must be reported within two hours, which was not adhered to in this case.
Failure to Monitor Resident After Administering Ativan
Penalty
Summary
The facility failed to ensure that a resident was properly assessed and monitored by licensed staff after receiving a one-time dose of Lorazepam (Ativan) for agitation. The resident, who had diagnoses of Alcohol Abuse and Anxiety Disorder and a moderate cognitive impairment, became agitated and expressed a desire to leave the facility. The attending physician was contacted and ordered a one-time dose of Ativan. However, there was no documentation indicating that the resident was monitored for effectiveness or adverse effects after the medication was administered. The resident was later found outside the facility, walking on the road, indicating that the medication's effectiveness was not properly assessed. Interviews with the Medical Director and the Director of Nursing revealed that the standard practice was to monitor the resident for effectiveness and side effects within 15 to 30 minutes after administering the medication. Both the Medical Director and the Director of Nursing confirmed that the resident should have been monitored for respiratory changes and changes in mental status, and that this should have been documented in the medical record. The failure to monitor and document the resident's condition after administering Ativan was identified as a deficiency in the facility's practices.
Latest citations in Alabama
A cognitively impaired resident with multiple neurologic and psychiatric diagnoses was sent to a hospital for evaluation of coughing up blood, where a urinalysis initially showed sperm in the urine and the hospital documented concern for possible sexual abuse and requested a rape kit. The ADM reported being notified by hospital staff that semen had been detected and that a rape kit was being performed, and that law enforcement and a DHR representative were involved, but there was no documentation of these calls and no evidence the allegation of abuse was reported to the State Agency within the required 2-hour timeframe per the facility’s Abuse Policy. This failure to report and lack of documentation resulted in a cited deficiency related to abuse reporting requirements.
A resident’s family reported that the resident had fallen and developed a new bruise on the left side of the face. An LPN, an RN/unit manager, the DON, the ADON, and the Administrator all became aware of the alleged unwitnessed fall and observed or were informed of the facial bruise, with nursing staff documenting findings such as a raised bruised knot and a light purple bruise extending from the cheek to the eyebrow. Despite a facility policy requiring prompt investigation and completion of an incident/accident report for all resident accidents or incidents, no incident report was completed by any of the involved staff, even though several acknowledged that one should have been done and that they were responsible for doing so.
A hospice resident with multiple serious diagnoses received PRN Lorazepam and Morphine that were signed out by an LPN on the controlled substance inventory record, but the corresponding doses were not documented on the MAR as required by facility policy. During interviews, the LPN reported administering the medications and admitted she only documented on the MAR most of the time, while the ADON confirmed that PRN controlled substances must be recorded on both the MAR and the narcotic sign-out sheet and verified the missing MAR entries. This resulted in incomplete documentation of controlled medication administration and record keeping.
A resident with dementia and an adjustment disorder, care planned as at risk for falls with an intervention to keep the call light within reach, was repeatedly observed lying in bed with the call light on the floor and out of reach over three consecutive survey days. The facility’s call light policy stated the system is to be used to respond to residents’ requests and needs. The assigned CNA and the DON both stated that call lights should be within residents’ reach so they can call for help or tell staff if they need anything, while acknowledging that this resident’s call light had been on the floor.
A resident admitted with a left foot fracture and care planned as needing substantial/maximal assistance with ADLs did not receive documented bathing as scheduled. Facility policy required provision of hygiene services, including showers or complete bed baths, and honoring resident preferences for type and frequency of baths. The resident’s MDS showed dependence for showering/bathing, and the care plan directed staff to assist with baths per schedule and PRN. However, review of documentation for two consecutive months showed no record of showers or self-bathing, despite the DON stating the resident was scheduled for showers three evenings per week and that such care should be recorded on ADL sheets. The DON confirmed there was no documented evidence that the scheduled showers were provided during the resident’s stay.
A resident with multiple medical conditions, including protein-calorie malnutrition and chronic systolic CHF, was observed with a Foley catheter drainage bag placed on a floor mat and left uncovered, contrary to facility policy requiring catheter bags to be covered and properly positioned. An LPN confirmed the bag was not covered and stated it should have been hooked to the bed frame, and the ADON/Infection Control Nurse reported that staff should use a clamp to attach Foley bags to the bed frame. This failure placed the drainage system at risk for contamination and the resident at risk of UTI and did not maintain the resident’s dignity.
The facility failed to prevent multiple forms of abuse and exploitation. A cognitively impaired, wandering resident was not adequately supervised and entered the room of another cognitively impaired resident with a documented history of sexually inappropriate behavior; a CNA later observed that resident fondling the wandering resident’s genitalia, despite prior documentation of repeated sexualized behaviors and no clear supervision directions in the care plan. In a separate event, a staff member posted a photo on social media of a cognitively intact but physically disabled resident soiled with feces, with a derogatory caption, contrary to written policies prohibiting unauthorized resident images and protecting privacy and confidentiality; the resident reported feeling angry and embarrassed. Additionally, a resident with a known history of verbal and physical aggression struck another resident on the arm in the dining room, causing pain, demonstrating inadequate supervision and interventions to prevent resident-to-resident physical abuse.
The facility failed to implement its abuse, neglect, and exploitation policy to prevent and investigate resident‑on‑resident sexual abuse involving two cognitively impaired residents, one with Alzheimer’s disease who wandered into others’ rooms and one with intellectual disability and a documented history of sexually inappropriate behavior. Over several months, staff documented repeated sexually inappropriate acts and aggressive behaviors by the latter resident, yet the resident remained on a memory care unit populated by wandering residents. One evening, a CNA observed this resident with a hand inside another resident’s brief, fondling the genital area. The CNA removed the resident and notified an LPN, but no body audit was performed, and staff reported they had not been instructed on specific supervision of wandering residents. The facility’s investigation was limited to two staff statements, did not include comprehensive interviews or assessments, and concluded the allegation was not substantiated despite acknowledgment that both residents lacked capacity to consent. Leadership, including the abuse coordinator and administrator, could not identify the cause of the incident or effective preventive measures, and surveyors cited Immediate Jeopardy under F607 for failure to establish a safe environment, implement effective protocols, and conduct a thorough abuse investigation.
The facility failed to implement an effective QAPI process after a resident-to-resident sexual abuse incident involving a resident with a known history of sexually inappropriate behavior and another cognitively impaired, wandering resident. Although policies required QAA review of sexual abuse cases to ensure thorough investigation, resident protection, analysis of why the event occurred, and identification of systemic actions, the QAPI Committee did not verify a complete investigation, did not classify the event as abuse, and did not analyze risk factors such as unsupervised wandering and access to other residents’ rooms. The ADM acknowledged that not all aspects of the investigation were documented, did not recall reviewing the investigation before submission to the State Agency, and reported that QAPI did not identify a need for systemic changes, relying instead on separating the residents. The lack of documented QAPI review and failure to identify and address causal and contributing factors resulted in unsafe conditions persisting and led to an Immediate Jeopardy citation at F867.
The facility failed to follow its abuse policy requiring notification of law enforcement for alleged abuse when a staff member observed two residents in a situation documented as sexual abuse, with one resident’s hand inside another resident’s brief. The incident was entered into the state’s online reporting system as sexual abuse, but the report indicated that law enforcement was not notified. In a later interview, the SSD/Abuse Coordinator confirmed that law enforcement should have been contacted for such an allegation and acknowledged that the policy was not followed, affecting two residents reviewed in the abuse sample.
Failure to Timely Report Allegation of Sexual Abuse to State Agency
Penalty
Summary
Failure to timely report an allegation of sexual abuse occurred when the Administrator did not notify the State Agency after being informed by a local hospital that semen had been detected in the urine of a vulnerable, cognitively impaired resident and that a rape kit was requested. The facility’s Abuse Policy, updated 8/2022, required all alleged violations of abuse or neglect to be reported immediately, but not later than two hours, when the alleged violation involves abuse. The resident had diagnoses including Parkinson’s disease, Huntington’s disease, dementia, and schizoaffective disorder, and an MDS BIMS score of 0 indicating severely impaired cognition. The resident was transferred to the hospital for coughing up blood, and the hospital history and physical documented that sperm was noted in the urine and that case management was consulted for possible sexual abuse. A urinalysis on the same date initially showed sperm present in the urine. The Administrator stated he received a phone call from the hospital on or about 10/06/2025 or 10/07/2025 informing him that semen had been detected in the resident’s urine and that a rape kit was needed, and that a detective was referring the matter to the Department of Human Resources. Despite this information, there was no evidence the facility reported the allegation of sexual abuse to the State Agency as required. The Administrator acknowledged there was no documented evidence of the calls from the hospital, including the date and time he was made aware of the rape kit request or the semen finding. Although the urinalysis was later amended to show no sperm present after retesting, the local police department still requested a rape kit, and the Administrator confirmed that abuse allegations were supposed to be reported within a two-hour timeframe. The lack of reporting and documentation constituted the cited deficiency related to the complaint.
Failure to Complete Incident Report After Alleged Fall and Facial Bruise
Penalty
Summary
The deficiency involves the facility’s failure to follow its own "Accidents and Incidents – Investigating and Reporting" policy by not completing an incident/accident report after a family-reported fall and observed facial bruise for Resident #44. The policy requires that all accidents or incidents involving residents on the premises be promptly investigated and documented on a Report of Incident/Accident form, including details such as date and time, nature of injury, circumstances, witnesses, notifications, condition of the resident, and corrective actions. Despite this requirement, no such report was completed for Resident #44 following an allegation of a fall and the discovery of a bruise on the left side of the resident’s face. Resident #44 was admitted on an unspecified date and discharged on 02/10/2026. On that date, the resident’s daughter reported that the resident had fallen and had a new bruise on the left side of the face. LPN #10 stated she was informed that the daughter reported a fall, assessed the resident, and observed a small raised, bruised knot near the left eyebrow, but did not complete an incident report, acknowledging that one should have been done. RN/Unit Manager #7 reported hearing the daughter screaming that the resident had fallen at approximately 7:40 AM, assessed the resident, and noted an unraised bruise on the left side of the face; she confirmed that she did not prepare an incident report and did not find one in the medical record, despite stating that an incident report should have been completed. The DON stated that the daughter had informed her of an unwitnessed fall involving the resident and that the resident had a bruise on the left cheek that could have resulted from hitting the side rail. The DON reported that interviews with RN #4 and CNA #15, supported by signed witness statements dated 02/10/2026, indicated that neither staff member witnessed the resident on the floor or assisted the resident back to bed, and she was unsure whether an incident report had been completed. The ADON stated she was informed of an unwitnessed fall, assessed the resident as confused and lethargic with a light purple bruise from the left cheek to the eyebrow, contacted the NP for an order to send the resident to the hospital, and acknowledged that she should have completed an incident report but did not. The Administrator confirmed he was informed of the bruise and the reported fall, personally observed a light blue bruise from the cheekbone to the midpoint of the eye, and stated that, per policy, an incident report should have been completed, but it was not.
Failure to Document PRN Controlled Medications on MAR
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling and documentation of controlled medications for one hospice resident. The resident, originally admitted on an unspecified date and later admitted to hospice on 02/13/2025, had diagnoses including senile degeneration of the brain, acute respiratory failure with hypoxia, acute ischemic heart disease, and sepsis. Facility policies on Controlled Substances and Administering Medications required that controlled substances be handled and documented in compliance with laws and regulations, including the nurse’s signature on controlled substance records and the initialing of the Medication Administration Record (MAR) after each medication is given. Review of the resident’s Controlled Substance Inventory Record (CSIR) showed that an LPN signed out Lorazepam and Morphine—two doses of each on 01/29/2026 and three doses of each on 01/30/2026. However, review of the resident’s January 2026 MAR revealed no documentation that Lorazepam and Morphine were administered for two doses each day on 01/29/2026 and 01/30/2026, despite the CSIR indicating they had been signed out. During interview, the LPN stated she had administered Morphine and Lorazepam to the resident but could not recall the exact frequency and estimated she documented these administrations on the MAR approximately 85% of the time, acknowledging that documentation only on the controlled substance sheet without corresponding MAR entries would be incomplete. The Assistant Director of Nursing confirmed that facility process required PRN controlled substances to be documented on both the MAR and the narcotic sign-out sheet and verified that there were no MAR entries corresponding to the doses signed out on the CSIR for the specified dates and times. This failure had the potential to affect the resident by limiting the facility’s ability to ensure accurate controlled medication administration, record keeping, and monitoring.
Failure to Keep Resident Call Light Within Reach as Care Planned
Penalty
Summary
The facility failed to ensure a resident’s call light was kept within reach as required by the facility’s “CALL LIGHT” policy and the resident’s care plan. The policy stated the purpose of the call light system was to respond to residents’ requests and needs. The resident, who had dementia and an adjustment disorder with mixed anxiety and depressed mood, had a fall risk care plan initiated on 06/26/2024 that included an intervention to keep the call light within reach and encourage the resident to use it for assistance. On three consecutive survey days, the resident was observed lying in bed with the call light not within reach. On 02/18/2026 at 8:00 AM, the call light was on the floor beneath the bed. On 02/19/2026 at 7:56 AM, the call light was again on the floor beneath the bed while the resident was in bed. On 02/20/2026 at 9:03 AM, the call light was observed on the floor at the head of the bed while the resident was lying in bed. During an interview, the resident’s assigned CNA for the 7–3 shift acknowledged the call light was on the floor and stated that call lights should be within residents’ reach so they can call for help. The DON also stated that call lights should be within residents’ reach so they can tell staff if they need anything.
Failure to Provide and Document Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide scheduled bathing assistance to a resident who was dependent on staff for activities of daily living (ADLs), specifically bathing. Facility policy titled "ADL CARE POLICY AND PROCEDURE" stated that good hygiene and grooming help prevent the spread of infection and promote residents' feelings of self-worth and dignity, and that resident preferences for time of day, type of bath, and frequency of bath should be honored. The policy identified showers, tub baths, and complete bed baths as part of hygiene and grooming services. The resident, admitted with a displaced fracture of the fifth metatarsal bone of the left foot and care planned as requiring limited to total assistance with all ADLs, had an intervention to assist with baths per schedule and as needed. An anonymous complainant reported that the resident had been in the facility for two weeks and had only received two baths. The resident’s MDS with an ARD of 01/19/2026 documented that the resident required substantial/maximal assistance with showering/bathing self. A review of the resident’s Documentation Survey Report for January and February 2026 showed no documentation that the resident received a shower or bathed independently during the admission period. During an interview, the DON stated the resident’s scheduled shower days were Tuesdays, Thursdays, and Saturdays on the 3 PM to 11 PM shift and that staff were to document showers on the ADL sheet. Upon reviewing the ADL sheet, the DON confirmed there was no documented evidence that the resident received scheduled showers from 01/13/2026 to 02/04/2026.
Improper Foley Catheter Drainage Bag Positioning and Lack of Cover
Penalty
Summary
The facility failed to maintain a resident’s urinary drainage bag in accordance with its catheter care policy and professional standards of practice. The facility’s undated Catheter Care policy stated that catheter drainage bags would be covered at all times and that drainage would be located below the level of the bladder to discourage backflow of urine. Resident Identifier (RI) #77, admitted on an unspecified date, had diagnoses including protein-calorie malnutrition, chronic systolic congestive heart failure, and generalized muscle weakness. During an observation on 02/18/2026 at 9:26 AM, RI #77’s urinary drainage bag was seen placed on a blue mat on the floor and uncovered, contrary to the facility’s policy and accepted infection control practices. In a subsequent interview on 02/20/2026 at 11:01 AM, an LPN acknowledged that the catheter bag was not covered and stated that the facility’s protocol was for the Foley catheter drainage bag to be hooked to the bed frame, further acknowledging that placing the catheter bag on the floor could cause infection. Later that day at 12:25 PM, the ADON, who also served as the Infection Control Nurse, stated that staff should use a clamp to hook Foley catheter bags to the resident’s bed frame. The surveyors concluded that the observed practice of leaving the drainage bag uncovered and on the floor placed the drainage system at risk for contamination and the resident at risk of urinary tract infection, and failed to maintain the resident’s dignity as required by the facility’s policy.
Failure to Prevent Resident-to-Resident Abuse and Staff Social Media Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, neglect, and exploitation, including sexual abuse between residents, physical abuse between residents, and mental abuse/exploitation by staff through social media. One resident with Alzheimer’s disease and severe cognitive impairment, who wandered frequently and intruded into other residents’ rooms, was not adequately supervised despite documented wandering episodes and a care plan noting exit-seeking and room entry behaviors. Another resident with myocardial infarction, intellectual disabilities, mood disorder, mild cognitive impairment, and a documented history of sexually inappropriate behavior toward staff and possible other residents was also not care planned with specific directions for supervision. Progress notes over several months documented repeated sexually inappropriate touching and comments toward staff, combative behavior, and the need for two staff for care, yet the care plan did not specify how or when this resident should be supervised. On one evening, a CNA observed the cognitively impaired, wandering resident sitting on the bed of the resident with sexually inappropriate behaviors, and saw the latter with a hand inside the other resident’s brief, fondling the resident’s genitalia. Staff interviews confirmed that both residents lacked the ability to consent to sexual activity and that the contact was non-consensual sexual contact. The CNA who witnessed the event reported having no specific instruction on how to supervise wandering residents beyond photos at the nurses’ station. The unit manager and DON acknowledged that the wandering resident entered other residents’ rooms frequently, that staff were expected to round every two hours or more often, and that more frequent monitoring could have prevented the incident. The administrator stated that the resident with sexually inappropriate behaviors could remain on the memory care unit after allegations of sexual touching because he did not feel the resident posed a threat to others. The facility also failed to protect another resident from mental abuse and exploitation when a former CNA posted a photograph of the resident in a vulnerable, soiled condition on Snapchat with a derogatory caption. The resident, who had anoxic brain damage and spastic quadriplegic cerebral palsy but intact cognition, later reported feeling angry and embarrassed after being informed of the incident. Facility policies on social media use, cell phones, and confidentiality explicitly prohibited taking, keeping, or distributing unauthorized photographs of residents and described such actions as violations of privacy and confidentiality that could degrade or embarrass residents. A nurse aide witness reported seeing the image on social media, recognized the resident by the room items, and described the picture as showing the resident’s body from armpit to ankle covered in feces, with no face or genitalia visible. Staff interviews confirmed that posting such an image would be considered abuse and a violation of policy and resident privacy. In a separate incident, the facility failed to protect a resident from physical abuse by another resident with a known history of aggressive behaviors, including verbal and physical aggression. A CNA witnessed the aggressive resident hitting another resident on the arm in the dining room. The victim reported that his/her arm hurt after being hit. The aggressive resident’s history of physical aggression was known, but the facility did not provide adequate supervision and interventions to prevent this resident from abusing others. These failures occurred despite facility policies that required screening of residents for behavioral risks, assessment and care planning for behaviors that might lead to conflict or neglect, training staff on behavioral symptoms that increase risk of abuse, and implementing policies and procedures to prevent all types of abuse, including sexual, physical, and mental abuse facilitated by technology.
Failure to Implement Abuse Policy and Prevent Resident‑on‑Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy to prevent, identify, and investigate an allegation of sexual abuse involving two cognitively impaired residents. One resident with Alzheimer’s disease had a care plan for wandering, exit seeking, and entering other residents’ rooms, with interventions focused on redirection and a secure care monitor to prevent elopement. Another resident with hemiplegia, unspecified intellectual disabilities, and mild cognitive impairment had a comprehensive care plan identifying a history of attention‑seeking behaviors, combative behavior, verbal abuse, and sexually inappropriate behavior toward staff and possibly other residents, with interventions including administration of medications per MD order and use of two staff for care due to sexually inappropriate episodes. Despite these identified risks and documented behaviors, the facility did not establish or implement effective protocols to prevent sexual abuse between these residents. From December 2024 through February 2025, multiple progress notes documented escalating sexually inappropriate behaviors by the resident with intellectual disability toward staff, including touching female staff inappropriately, grabbing breasts and buttocks, and other aggressive behaviors such as yelling out, throwing items, and being verbally and physically abusive. The Memory Care Unit, where this resident was housed at the time, was described by staff as a unit with wandering residents who had decreased cognition. The wandering resident with Alzheimer’s disease was known to enter other residents’ rooms. On the evening of 02/11/2025, a CNA making rounds observed the wandering resident sitting on the side of the sexually inappropriate resident’s bed, with the latter’s hand inside the wandering resident’s brief, fondling the genital area. The CNA immediately removed the wandering resident from the room and reported the incident to an LPN. The LPN did not perform a body audit on either resident, and the CNA reported she had not been instructed on how to supervise wandering residents beyond recognizing their photos at the nurses’ station. The facility’s investigation did not follow its own written procedures for abuse investigations. The investigative file contained only two staff statements (from the CNA and the LPN) and did not include interviews with all potentially involved or knowledgeable staff, nor did it document a body assessment of either resident. The Abuse Coordinator’s closing report concluded the incident was “not substantiated” sexual abuse, citing insufficient evidence regarding which resident initiated the contact and the absence of observed distress, despite acknowledging that neither resident had the ability to consent. In subsequent interviews, the Abuse Coordinator stated they had no identified cause for the incident because neither resident could explain what happened and acknowledged that staff did not observe the wandering resident entering the room because they were in other residents’ rooms providing care. The Abuse Coordinator also stated that, given both residents lacked capacity to consent, there was nonconsensual sexual contact on 02/11/2025. The Administrator reported he did not recall reviewing the investigation findings before submission to the State Agency and could not identify what could have been done to prevent the abuse. The surveyors determined that the facility failed to establish a safe environment, failed to implement protocols to prevent sexual abuse among residents with known wandering and sexually inappropriate behaviors, and failed to conduct a thorough investigation to accurately determine that abuse occurred and the cause of the incident, resulting in Immediate Jeopardy under F607. Additional documentation after the incident showed that the resident with sexually inappropriate behaviors continued to exhibit similar behaviors toward staff throughout 2025, including inappropriate touching and aggressive actions, with periodic notes indicating that such behaviors had increased in frequency. Interviews with the Memory Care Unit manager confirmed awareness of the resident’s ongoing sexually inappropriate behaviors and refusal of medications, and acknowledged that when the resident was later returned to the Memory Care Unit, that unit continued to house more wandering, confused residents than other units. The manager also confirmed there was no staff specifically assigned to monitor wandering residents, and that the primary intervention was general redirection. Staff interviews, including with an RN who characterized the 02/11/2025 event as abuse, further supported that the facility did not implement targeted supervision or environmental controls to prevent recurrence of sexual abuse between residents with known risk factors, despite the facility’s written policy requiring identification, ongoing assessment, care planning, monitoring, and establishment of a safe environment with protocols for preventing sexual abuse.
Failure of QAPI Oversight After Resident-to-Resident Sexual Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective Quality Assurance and Performance Improvement (QAPI) program in relation to a resident-to-resident sexual abuse incident. The facility’s QAPI plan and abuse policy required that cases of physical or sexual abuse be reviewed by the Quality Assurance and Assessment (QAA) Committee to ensure a thorough investigation, protection of residents, analysis of why the situation occurred, identification of contributing risk factors, and determination of whether systemic actions were needed. Despite these written policies, the QAPI Committee did not review the sexual abuse incident in a manner that verified a thorough investigation, did not classify the incident as abuse, and did not analyze why it occurred. The report states that the incident involved a resident with a documented history of sexually inappropriate behavior toward staff and another resident who wandered without supervision. The facility failed to analyze contributing risk factors, including the presence of wandering, cognitively impaired residents on the same unit as a resident with known sexually inappropriate behaviors. The QAPI Committee did not identify or address the lack of supervision that allowed wandering residents to enter other residents’ rooms without supervision. The Administrator later stated that the incident was discussed in QAPI, including who was involved, what happened, and how the facility would do things differently, but acknowledged that not all aspects of the investigation were in the documentation. The Administrator reported that QAPI did not determine that systemic changes were needed, explaining that the mental capacity of both residents led the team to believe that separation of the residents was sufficient. The Administrator also indicated he did not recall reviewing the investigation before it was submitted to the State Agency and was unsure what could have been done to prevent the abuse. The facility did not provide documentation showing that the allegation of resident-on-resident abuse was reviewed to ensure the investigation identified contributing or causal factors to be corrected and prevent recurrence. These failures in QAPI oversight and follow-through allowed unsafe conditions to persist and placed residents at risk for serious harm, leading surveyors to cite Immediate Jeopardy at F867 for QAPI/QAA improvement activities.
Failure to Report Alleged Sexual Abuse to Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse to local law enforcement as required by its own abuse policy. According to the facility’s written policy on Abuse, Neglect and Exploitation, revised 01/01/2024, sexual abuse is defined as non-consensual sexual contact of any type with a resident, and the policy requires reporting all alleged violations to the administrator, state agency, adult protective services, and other required agencies, including law enforcement when applicable, within specified timeframes. On 02/11/2025 at approximately 7:30 PM, a staff member observed one resident standing over another resident’s bed with the second resident’s hand down the first resident’s brief, and this was documented in the Online Incident Reporting System as an incident of sexual abuse. The Online Incident Reporting System entry for this event indicated that the incident type was “Abuse – Sexual” and that the incident was not reported to any law enforcement agency. During an interview on 01/18/2026 at 4:47 PM, the Social Service Director, who also served as the Abuse Coordinator, stated that law enforcement should be notified when abuse is alleged and acknowledged that law enforcement was not notified of the 02/11/2025 incident. The Social Service Director further stated that the facility’s abuse policy was not followed and expressed that the concern with not reporting the allegation to law enforcement was that vulnerable residents were at risk. This failure to report affected two of six residents sampled for abuse and was cited as a result of complaint investigation #471525.
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