Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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.
Food storage, temperature monitoring, and dishwashing practices were deficient when a cook and the FSD observed unopened and opened food items in dry storage and the freezer without required dates, a cup was left in the flour bin, evening freezer temperatures were not recorded on the log, and dirty plates with visible debris were used on the tray line. Staff interviews confirmed that opened foods should be labeled and dated, nothing should be in the flour bin except flour, freezer temps should be logged twice daily, and plates should be clean before service.
Open Dumpster Door: A surveyor observed the front-side dumpster door open during a tour of the dumpster area, despite facility policy stating dumpster doors must be closed when not in use. An evening staff member said someone had not closed it and that everyone was responsible for keeping it shut because of rodents and odors. The FSD stated the dumpster should be closed at all times unless in use to keep animals out and for safety reasons.
Oxygen tubing and humidifier equipment were not labeled or dated for four residents receiving respiratory care, and two residents had empty humidifier water bottles. Staff observations found oxygen tubing, humidifier bottles, and a BIPAP mask without dates or labels, while an ADON, LPN, CNA, and DON confirmed the tubing and related equipment were supposed to be changed weekly and labeled so staff would know when they were last changed.
Failure to Report Resident Injury and Swelling A CNA heard a resident say someone ran over his/her foot with a wheelchair and observed swelling, but did not report it to nursing staff. The resident, who had severe cognitive impairment and multiple chronic conditions, was not assessed until several days later when CNAs noticed bruising and swelling to the leg and knee; x-ray then showed an acute proximal tibia fracture. Interviews confirmed the LPNs, RNS, RNUM, CRNP, and DON were not informed when the complaint and swelling were first observed, despite the facility policy requiring accidents and incidents to be promptly reported and investigated.
An LPN gave PRN acetaminophen to a resident with severe cognitive impairment and a care plan for pain without documenting a pain assessment first. The resident had reported knee and back discomfort, but the LPN could not confirm the pain level or whether it was recorded. The DON and CRNP stated pain should be assessed and documented before PRN pain medication is given, with reassessment after administration.
Survey Results Not Accessible or Visible: The facility failed to keep the most recent Survey Results readily available for residents and visitors to review. The surveyor repeatedly observed no Survey Results book posted or visible in the lobby or on the halls, despite signage stating the results were in the front lobby. During a resident council meeting, 10 of 10 residents did not know where to find the Survey Results book, and the SSD stated it should have been in the lobby but was not there.
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.
Food Storage, Temperature Logs, and Dish Cleanliness Deficiencies
Penalty
Summary
Food items in dry storage and the freezer were found without required labels and dates. On 09/07/2025, the surveyor observed a ten-pound bag of spaghetti, enriched macaroni, and raisin bran cereal in dry storage with no open date or use-by date, and two opened bags of peppers and onions in the freezer with no open date or use-by date. During interview, the cook stated the items had been opened by someone and improperly stored, and that items should be labeled and dated as soon as they are used and before storing them. The FSD stated that all opened foods were to be dated and labeled by everyone in the kitchen. A styrofoam cup was observed sitting on top of the flour in the flour bin. The cook stated the white 16-ounce cup was being used to scoop flour, and that nothing should be in the flour bin. He stated that dipping items for flour should be washed, cleaned, sanitized, and stored after use, and that cups should not be left in the flour bin. The FSD also stated that nothing should be in the flour bin except flour. The freezer temperature log was incomplete for the evening shift, with no recorded temperatures for 09/04/2025, 09/05/2025, and 09/06/2025. The cook stated the morning temperature was recorded but not the evening temperature, and that temperatures should be documented twice daily before staff go home. In addition, on the tray line, four dirty plates were pulled and food was served in three of them; black spots were observed in three plates. The cook stated the plates were not clean, and the FSD stated the plates were not inspected properly after cleaning and that stains and food debris were present.
Open Dumpster Door
Penalty
Summary
The facility failed to ensure the front-side door of the trash dumpster was closed, despite a facility policy titled GARBAGE AND TRASH DISPOSAL POLICY stating that dumpster doors must be closed at all times when not in use. During a tour of the dumpster area, the surveyor and the evening staff member observed the dumpster door on the front side was open. In an interview, the evening staff member stated that someone had not closed the dumpster, that everyone in the facility was responsible for keeping it closed, and that it should be closed because of rodents and odors. The FSD later stated that the dumpster should be closed at all times unless in use, that the person using it was responsible for closing it, and that the doors should be closed to keep animals out and for safety reasons.
Oxygen Tubing and Humidifier Bottles Not Labeled or Maintained
Penalty
Summary
The facility failed to ensure oxygen tubing was labeled and dated for four residents receiving respiratory care, and failed to ensure the oxygen concentrator water bottles were not empty for two of those residents. Facility policies titled Oxygen Administration and Oxygen Tubing and Humidification Change Policy required oxygen tubing and humidifier components to be changed weekly, labeled with the date, and maintained with water in the humidifier. The report identified residents with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and obstructive sleep apnea who were receiving oxygen therapy and, for one resident, BIPAP therapy as well. On observation, RI #54 was lying in bed with the oxygen machine on but was not wearing the oxygen mask; the oxygen tubing had no label or date and the humidifier had no water. RI #42 was observed with oxygen infusing via nasal cannula, with no date on the tubing and no water in the humidifier bottle. RI #9 was observed lying in bed with oxygen infusing via nasal cannula; there was no label or date on the oxygen tubing or humidified water bottle, and the BIPAP mask was not labeled or dated. RI #15 was observed lying in bed with oxygen infusing via nasal cannula, with no label or date on the oxygen tubing or humidified water bottle. Interviews with the ADON, LPN, CNA, and DON confirmed the tubing should have been labeled and dated and that oxygen/nebulizer tubing and masks were to be changed weekly. The ADON stated the nurse should place initials and date on the tubing so staff would know when it was changed, and that the humidifier bottle should be changed when it ran out. The DON stated the tubing, humidifier bottles, and masks should be labeled with the resident’s name, date, and initials of the person who changed it, and that the tubing and masks should be stored in a plastic or zip lock bag when not in use.
Failure to Report and Investigate Resident Injury
Penalty
Summary
The facility failed to ensure an incident involving a resident’s reported foot injury was immediately reported to licensed nursing staff and investigated. On 09/05/2025, CNA #5 was assisting RI #20 with care when RI #20 said, “ouch,” and stated that someone had run over his/her foot with a wheelchair. CNA #5 observed minimal swelling to the foot but did not report the resident’s complaint or the swelling to a nurse or supervisor because the resident did not identify who was involved or when it occurred. RI #20 had severe cognitive impairment on the most recent MDS assessment and had diagnoses including COPD, peripheral vascular disease, heart failure, and a history of pain in the right knee. The incident was not brought to the attention of nursing leadership until 09/09/2025, when CNAs bathing RI #20 noticed bruising and swelling to the right knee and leg and called the DON and Assistant DON to the shower room. X-ray results obtained that day revealed an acute proximal tibia fracture, and the physician was notified and the resident was sent to the hospital. The facility’s investigative file included the x-ray report and an administrator-signed summary stating that RI #20 gave two different accounts of what happened, including that someone ran over his/her foot with a wheelchair, and that a CNA had reported swelling on 09/05/2025 but did not report it to the nurse. During interviews, CNA #5 confirmed she had heard RI #20 say someone ran over his/her foot with a wheelchair and had seen minimal swelling, but she did not report it. LPN #6, LPN #7, RNS #8, RNUM #9, the CRNP, and the DON all stated they were not informed on 09/05/2025 about the resident’s pain, swelling, or report of the wheelchair incident. Staff stated that if the event had been reported, the resident would have been assessed and the appropriate nurse, supervisor, or provider notified. The facility policy required all accidents or incidents involving residents to be investigated and reported to the administrator, with prompt initiation and documentation of the investigation by nursing supervision.
Failure to Assess and Document Pain Before PRN Analgesic Administration
Penalty
Summary
The facility failed to ensure an LPN completed a pain assessment for RI #20 before administering PRN acetaminophen on 09/03/2025. Facility policies titled Pain Assessment and Management and Administering Pain Medications required staff to assess pain characteristics, including location, intensity, and other features, before giving pain medication and to document the results of the assessment and the medication’s effect. RI #20 was admitted with diagnoses including COPD, heart failure, and essential hypertension, and the quarterly MDS documented a BIMS score of 1, indicating severe cognitive impairment. RI #20’s care plan identified a potential for pain and directed staff to administer medication as ordered and assess and document effectiveness. The MAR showed RI #20 received 500 mg of PRN acetaminophen on 09/03/2025 and that the medication was documented as effective. During interview, the LPN stated RI #20 had expressed discomfort related to knee and back pain, but she could not remember whether she documented a pain level before giving the medication. She said she believed the pain was no greater than 3 and that she might have documented it in a progress note, but if it was not in the record, she did not document an assessment. The DON stated there was no documentation confirming a pain assessment had been completed, and the CRNP stated the nurse should evaluate pain using a 1 to 10 scale, reassess after medication, and record the pain level.
Survey Results Not Readily Accessible or Visible
Penalty
Summary
The facility failed to ensure the most recent Survey Results were readily accessible and visible for residents and visitors to review. On 09/07/2025, the surveyor entered the facility at 2:00 PM and observed that there were no Survey Results posted, visible, or accessible in the lobby area. Later that day at 3:00 PM, the surveyor observed a bulletin board in the main hallway with Resident Rights information, Grievance Forms and instructions, Ombudsman contact information, and a sign stating that the most recent results were available for review in the front lobby. On 09/08/2025, the surveyor again observed no Survey Results posted in a visible area in the lobby at 8:27 AM and 6:33 PM. On 09/09/2025 at a Resident Council meeting, 10 out of 10 residents were unaware of where to access the Survey Results book. The surveyor also observed both halls of the facility at 9:04 AM and 3:30 PM and found no Survey Results posted or visible on either hall. On 09/10/2025 at 8:38 AM, the surveyor again observed no Survey Results posted in a visible area in the lobby. At 9:05 AM, the Social Services Director stated the Survey Results were posted for families and residents to view and were kept in the front lobby, but when the surveyor and SSD checked the lobby, the SSD said it was supposed to be there and must have been moved.
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.
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What surveyors actually found near you
We read the 1 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mobile
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lynwood Rehabilitation And Healthcare Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Gulf Coast Health And Rehabilitation, Llc | 3.5 mi | ★★★★★ | 0 | 0 |
| Mobile Nursing And Rehabilitation Center | 4.1 mi | ★★★★★ | 0 | 0 |
| Crowne Health Care Of Mobile | 4.7 mi | ★★★★★ | 0 | 0 |
| Springhill Senior Residence | 4.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.