Magnolia Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Gardendale, Alabama.
- Location
- 420 Dean Drive, Gardendale, Alabama 35071
- CMS Provider Number
- 015133
- Inspections on file
- 18
- Latest survey
- June 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Magnolia Ridge during CMS and state inspections, most recent first.
The facility failed to ensure staff were properly trained and followed procedures for reporting abuse, managing behaviors, and administering medications. A resident's behavioral issues and missed medication doses were not communicated or addressed in a timely manner, and staff documented missed IV antibiotic doses as administered without evidence. The DON and Administrator were unaware of these issues until identified by surveyors, and there was no documented training or clear protocols for critical clinical tasks.
The facility did not have a governing body responsible for policy implementation and management, nor did it appoint a properly licensed administrator to manage operations, resulting in a deficiency in organizational leadership.
The facility did not designate a physician to serve as medical director, resulting in a lack of oversight for the implementation of resident care policies and coordination of medical care.
Surveyors found that three residents experienced significant medication errors, including missed antipsychotic injections, failure to administer scheduled oral medications after a resident's request, and multiple missed or improperly documented IV antibiotic doses. Staff did not consistently follow up, notify providers, or document actions as required, resulting in unaddressed medication omissions and discrepancies.
A resident with a recent hip surgery and on anticoagulant therapy experienced ongoing bleeding from a surgical incision and a significant drop in hemoglobin. Despite these changes, the physician was not notified as required, and the CRNP managed the case without direct physician involvement. The lack of timely physician notification persisted even as the resident's condition worsened, leading to a critical drop in hemoglobin and hospital transfer.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with complex medical needs did not receive IV antibiotics as ordered, with multiple doses documented as administered by staff who were not present or not qualified, and documentation was completed days after the scheduled times. Facility records and staff interviews confirmed that medication administration and documentation did not follow professional standards or facility policy, resulting in a serious deficiency in care.
A resident requiring long-term IV antibiotics did not receive timely and appropriate administration of prescribed medications due to missed physician orders, lack of qualified staff, and improper documentation practices. Several doses of IV antibiotics were missed or documented by staff not present, and the resident's PICC line was not flushed according to standards. The facility also failed to provide adequate education to licensed staff on IV therapy procedures, resulting in Immediate Jeopardy for substandard quality of care.
A resident receiving IV antibiotics for sepsis and a chronic infection did not have consistent RN coverage for scheduled 12:00 AM doses. Several doses were either undocumented or documented by an RN not present in the facility at the time, and the facility relied on verbal rather than written scheduling for RN coverage. This resulted in a deficiency related to insufficient nursing staff and improper medication administration documentation.
The facility did not provide necessary behavioral health care and services to residents who required them, resulting in unmet behavioral health needs.
A deficiency was cited when a resident’s drug regimen included medications that were not clinically indicated or were excessive, without proper justification documented.
The facility did not set up an ongoing quality assessment and assurance group, resulting in the lack of a systematic process to review quality deficiencies and develop corrective plans of action.
Multiple residents experienced physical, mental, and verbal abuse by both staff and other residents, including incidents where a CNA threw a metal ashtray at a resident, a dietary aide threatened two residents, and residents physically assaulted each other, resulting in injuries and hospitalizations. Staff failed to report abuse promptly, and care plans for residents with behavioral issues did not specify necessary supervision or interventions, leading to substantiated findings of abuse and neglect.
A CNA witnessed another CNA throw a metal ashtray at a resident with moderate cognitive impairment and did not report the incident immediately, while another CNA delayed reporting after being informed by the alleged perpetrator. This failure to follow abuse reporting protocols allowed the alleged perpetrator to continue working and have access to residents, resulting in Immediate Jeopardy for the facility.
A resident, experiencing confusion from a UTI, exited the facility unsupervised and was found in a wheelchair near a road by a PTA, who failed to immediately intervene. The resident was later brought back by two LPNs. The facility could not determine how the resident exited the secured door, and staff did not follow protocols for immediate intervention, resulting in a deficiency for inadequate supervision and failure to prevent elopement.
The facility failed to implement and update behavioral health care plans for several residents with known behavioral disturbances, leading to incidents where staff responded inappropriately to aggression, care plans were not revised after altercations, and supervision was inadequate for residents with escalating behaviors. These failures resulted in injuries to multiple residents and demonstrated a lack of adherence to established protocols for managing behavioral health needs.
The facility did not serve correct food portions as required by its menu and policies, with staff using incorrect scoop sizes and serving less than the required amounts for items such as Mandarin Orange Sections and various pureed foods. Dietary staff misunderstood scoop measurements, leading to under-portioning, and the issue was confirmed by both the Dietary Manager and Registered Dietitian. This deficiency had the potential to affect all residents receiving meals from the kitchen.
Surveyors observed that food was stored less than 6 inches from the floor, sandwiches for resident snacks were not labeled with required 'use by' dates, and staff were unaware of proper labeling procedures. Meal trays were transported on open carts with incompletely covered plates, and soup bowls lacked lids, leaving food exposed. Additionally, a damaged handwashing sink with no cold water was used by staff for at least a month, hindering proper hand hygiene.
Essential kitchen equipment, including ice machines, a handwashing sink, a dishwashing machine, and a plate lowerator, were not properly maintained. Air filters on ice machines were found dirty, a handwashing sink was broken and lacked cold water, the dishwashing machine's heated rinse was inoperable due to a blown fuse, and the plate lowerator had been out of service for over a year. Staff continued to use the broken handwashing sink, and communication lapses delayed repairs, potentially affecting all residents receiving meals.
A nurse removed and signed out controlled medications for multiple residents, including narcotics and other scheduled drugs, but did not administer them or document their administration. The medications were not found in the medication carts, and several residents reported not receiving their prescribed doses. Staff interviews and record reviews confirmed the medications were missing, violating facility policies on medication administration and protection of resident property.
Multiple residents did not receive their scheduled medications, including controlled substances and other critical drugs, during an overnight shift when a nurse signed out but failed to administer or document the medications as required by facility policy. Staff and residents confirmed the missed doses, and the eMAR reflected the omissions.
A resident with anxiety and agitation had their Ativan dose reduced as part of a gradual dose reduction, but the family and responsible party were not notified of this significant medication change, contrary to facility policy. Interviews and record review confirmed the lack of notification.
A resident's medication information was left visible on an unlocked eMAR screen atop a medication cart while an LPN was away assisting another resident. This action was in direct violation of facility policy requiring health information to be kept private and not left unattended in public areas.
A scraped and dirty exit door with an unknown black substance was observed in view of residents, and multiple bathrooms had missing ceiling tiles for an extended period, with one resident reporting the issue had persisted for about a month. Maintenance staff confirmed the tiles were removed to address a leak and acknowledged the area was not homelike.
A resident and their representative filed a grievance about a CNA's conduct, leading to instructions that the CNA should not provide further care to the resident. Despite this, the CNA was again assigned to the resident, and the grievance was not fully resolved due to lack of communication among staff.
Two residents had inaccuracies in their MDS assessments: one was incorrectly coded as receiving tracheostomy care and ventilator support when not receiving these services, and another was not properly identified as having a Serious Mental Illness per PASRR Level II documentation. These errors were confirmed by the Clinical Reimbursement Coordinator.
A resident with a prior diagnosis of depression received a new diagnosis of PTSD, but staff did not complete a new Level I PASRR as required. The Social Service Director confirmed responsibility for this process and acknowledged the omission during surveyor interviews.
A resident with chronic respiratory failure and moderate cognitive impairment was observed receiving oxygen therapy with an empty humidification bottle on multiple occasions. Facility policy required the humidification bottle to be changed every seven days and when the oxygen tubing was changed, but this was not done, resulting in the resident receiving non-humidified oxygen.
Laundry staff distributed residents' personal clothing on uncovered racks, contrary to facility policy requiring clothing to be covered during transport to prevent cross-contamination. Both the staff member and the District Manager for Environmental Services acknowledged that clothing should be covered, and the failure to do so affected all residents observed for infection control.
The facility did not accurately report direct care staffing data to CMS for one quarter, as administrative staff who provided direct patient care on weekends were not recorded as such, resulting in the PBJ report showing excessively low weekend staffing.
Failure of Administrative Oversight in Behavior Management and Medication Administration
Penalty
Summary
The facility failed to provide adequate administrative oversight and guidance to ensure that staff were aware of and implemented policies and procedures related to abuse reporting, behavior management, medication administration, and pre-admission screening. Interviews and record reviews revealed that staff did not consistently document or communicate resident behaviors, particularly those involving mental illness or behavioral symptoms, which led to incidents of verbal abuse and roommate incompatibility that were not addressed in a timely manner. Additionally, there was a lack of documented training and clear processes for staff regarding the administration and documentation of intravenous antibiotics and other medications, resulting in missed doses that were inaccurately recorded as administered. Specific incidents included staff being aware of a resident's derogatory language and behavioral issues but failing to communicate or address these behaviors until further verbal abuse occurred. There were also instances where missed doses of intravenous antibiotics were documented as given, despite discrepancies in the medication supply and lack of evidence that the medications were actually administered. The Director of Nursing and Administrator were unaware of these omissions until identified by the survey team, and there was no documented training or written protocols for staff on critical clinical procedures such as IV antibiotic administration and PICC line care. The Administrator and Director of Nursing were unable to clearly articulate their oversight responsibilities or demonstrate effective monitoring of staff compliance with documentation, behavior management, and medication administration. The lack of effective communication, documentation, and oversight created an environment where serious injury, harm, impairment, or death to residents was possible, leading to the citation of Immediate Jeopardy under federal regulations. The deficient practices had the potential to affect all residents in the facility.
Failure to Establish Governing Body and Appoint Licensed Administrator
Penalty
Summary
The facility failed to establish a governing body that is legally responsible for setting and implementing policies for managing and operating the facility. Additionally, the facility did not appoint a properly licensed administrator to oversee the management of the facility. These actions resulted in a deficiency related to the facility's organizational structure and leadership responsibilities.
Failure to Designate a Medical Director
Penalty
Summary
A deficiency was identified due to the facility's failure to designate a physician to serve as the medical director. This physician is responsible for the implementation of resident care policies and the coordination of medical care within the facility. The absence of a designated medical director resulted in noncompliance with regulatory requirements for oversight of resident care policies and medical care coordination. No additional details regarding specific residents, staff, or events were provided in the report.
Failure to Prevent Significant Medication Errors for Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure three residents were free from significant medication errors. One resident with a history of schizophrenia, bipolar disorder, insomnia, and severe dementia with agitation did not receive their prescribed monthly paliperidone (Invega) injections on two consecutive months. Documentation showed the medication was not available on the scheduled date, and there was no clear written communication or follow-up to ensure the dose was administered the following day. Additionally, when the resident refused the medication in the subsequent month, there was no documentation that the physician or nurse practitioner was notified, as required by facility policy. The resident subsequently exhibited increased behavioral issues, including threats and physical aggression, which staff acknowledged could be related to missed medication doses. Another resident with diagnoses including epilepsy, hypertension, and colitis did not receive their scheduled morning medications after requesting to take them post-breakfast. The LPN did not return to administer the medications after the resident finished eating and did not notify the physician, family, or DON of the omission. The resident later experienced elevated blood pressure and reported that they had not refused the medications but simply wanted to take them after eating due to previous adverse effects. The nurse confirmed she did not offer the medications again and failed to follow up as required. A third resident, who returned from the hospital with a PICC line and orders for intravenous antibiotics, did not receive all prescribed doses of Piperacillin-Tazobactam (Zosyn). Documentation in the electronic medication record indicated that several doses were either recorded as administered days after they were due, documented by staff not present at the time, or by staff not qualified to administer the medication. Pharmacy records showed a discrepancy between the number of doses delivered and those administered, with a significant number of unused doses found in the medication room. The medical director and other staff were not notified of the missed doses until after the resident was transferred back to the hospital for complications related to infection.
Failure to Notify Physician of Significant Change in Condition and Critical Lab Results
Penalty
Summary
The facility failed to ensure timely and appropriate notification of a physician when a significant change in a resident's condition was identified. A resident with a history of atrial fibrillation and a recent surgical repair of a left femur fracture was admitted to the facility and subsequently experienced ongoing bleeding from the surgical incision site. Despite continued bleeding that required frequent dressing and linen changes, and a hemoglobin level that dropped to 7.7 g/dL, the physician was not notified as required by facility policy. Instead, the Certified Registered Nurse Practitioner (CRNP) was notified, and orders were obtained to hold the resident's anticoagulant (Eliquis) and obtain laboratory tests, but the physician was not directly informed of the abnormal lab results or the ongoing bleeding. Interviews with nursing staff revealed that the decision to notify the physician or CRNP was left to nursing judgment, and there was confusion regarding the policy for physician notification. The resident's medical record indicated that the CRNP was consulted and provided orders, but the attending physician and the orthopedic surgeon were not made aware of the critical lab values or the extent of the bleeding. The physician later stated that he would have wanted to be notified of the hemoglobin drop and would not have resumed the anticoagulant as was done. The lack of direct physician notification persisted even as the resident's condition deteriorated, with further drops in hemoglobin and eventual transfer to the hospital for symptomatic anemia and hypotension. The facility's failure to notify the physician of significant changes in the resident's condition, including ongoing surgical site bleeding and critically low hemoglobin levels, was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death. This resulted in the citation of Immediate Jeopardy under F580 - Notify of Change (Injury/Decline/Room, Etc.), as the deficient practice directly affected the resident's safety and care.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Accurately Administer and Document IV Medications
Penalty
Summary
Licensed staff at the facility failed to implement physician orders and adhere to professional standards of nursing practice in the administration and documentation of intravenous (IV) medications for a resident with diagnoses including vascular dementia and cerebral infarction. Over a period of time, staff documented the administration of Zosyn and Daptomycin IV antibiotics in the resident's medical record inaccurately. Specifically, there were multiple instances where doses were documented as administered days after the scheduled time, and in some cases, by staff who were not present or qualified to administer the medication. For example, a registered nurse and the former director of nursing documented doses as given on dates when they were not clocked in, and a licensed practical nurse documented administration of IV medications despite not being qualified or having actually administered them. The facility's own policies and the Alabama Board of Nursing standards require that medications be administered and documented at the time of administration, with any late entries clearly identified as such. However, the electronic medication administration records (EMAR) and audit reports revealed that documentation was not timely, accurate, or consistent with these standards. Some entries lacked the required date and time, and there was no proper use of late entry documentation. Interviews with staff confirmed that some documentation was made in error, and staff did not always follow the facility's policy for correcting such errors. Additionally, the facility's medication inventory did not match the number of doses documented as administered, raising further concerns about the accuracy of medication administration and documentation. These failures were identified through interviews, record reviews, and policy analysis, and were determined to have caused, or were likely to cause, serious injury, harm, impairment, or death to residents. The deficiency was cited under F658 for failure to ensure services provided met professional standards of quality, specifically in the area of comprehensive resident-centered care planning and medication administration documentation.
Failure to Ensure Safe IV Antibiotic Administration and Documentation
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) antibiotics for a resident who required long-term IV therapy following hospital discharge. Upon the resident's re-admission, there was a lack of timely physician orders for the prescribed IV antibiotics, resulting in missed doses of Piperacillin-Tazobactam (Zosyn) and Daptomycin. The facility's staff did not implement a process to ensure that the necessary orders were obtained and that the antibiotics were administered as scheduled, leading to several missed doses over multiple days. Additionally, the facility did not adhere to its own policies and professional standards regarding the administration and documentation of IV medications. There were multiple instances where staff documented the administration of IV antibiotics either late, by unqualified personnel, or by staff who were not present in the facility at the time the medication was scheduled to be given. Some doses were documented as administered days after the scheduled time, and in some cases, the documentation was completed by staff who were not on duty during the relevant shifts. Furthermore, there were periods when no registered nurse (RN) was scheduled to be present to administer the IV antibiotics, resulting in additional missed doses. The facility also failed to provide adequate education and training to all licensed staff responsible for administering IV medications, including proper care and flushing of the resident's peripherally inserted central catheter (PICC) line. Documentation showed that the PICC line was not flushed according to standards of care and physician orders, and there was no evidence of specific training provided to staff on IV therapy procedures. These failures were determined to have caused, or were likely to cause, serious harm to the resident, resulting in the citation of Immediate Jeopardy under F694 for Parenteral/IV Fluids.
Failure to Ensure RN Staffing for IV Medication Administration
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was consistently scheduled to administer a resident's 12:00 AM dose of intravenous (IV) antibiotic, Piperacillin-Tazobactam (Zosyn). Six doses of the resident's Zosyn scheduled for 12:00 AM were either not documented as administered or were documented days later by an RN who was not clocked in at the time the doses were scheduled. The Electronic Medication Administration Record (EMAR) showed that the 12:00 AM dose on one date was not administered, and the EMAR did not indicate the actual time of administration or when the documentation was entered. Additionally, a review of the RN's timecard revealed that she was not present in the facility during several shifts when she documented medication administration. Interviews with facility staff revealed that the process for ensuring an RN was scheduled to administer IV antibiotics was verbally communicated and not documented in writing. The Director of Nursing (DON) stated that RNs were scheduled to be in the building at certain times, but the 12:00 AM dose was assigned to an RN who was not present during those shifts. The Staffing Coordinator confirmed that there was no RN scheduled to be at the facility during the 12:00 AM shift on several dates when the medication was due. The affected resident was being treated for sepsis with shock and a chronic postoperative infection. The facility's records indicated that 56 doses of Zosyn were delivered for the resident, but only 42 doses were documented as administered. The failure to ensure sufficient RN staffing and proper medication administration and documentation led to the cited deficiency under F725 for sufficient nursing staff.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and records indicating that the required behavioral health interventions and supports were not provided to residents who needed them. As a result, residents with behavioral health needs did not receive the appropriate care and services as required by regulations.
Unnecessary Drugs in Resident Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents’ drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated, excessive in duration, or duplicative, without adequate justification documented in the medical record.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process to identify, review, and address quality issues within the facility. The lack of such a group meant that quality deficiencies were not consistently monitored or evaluated, and no structured approach was in place to develop or implement corrective actions.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from physical, mental, and verbal abuse perpetrated by both staff and other residents. In one incident, a resident with a history of behavioral disturbances verbally abused a CNA, who responded by throwing a heavy metal ashtray at the resident. The resident then threw the ashtray back, striking another resident and causing injury. Staff present did not immediately report the CNA's actions, and the CNA continued to work subsequent shifts, leaving residents unprotected. Witness statements and interviews confirmed that the CNA initiated the physical altercation, and the incident was substantiated as abuse and mistreatment. Additional incidents involved staff verbally abusing residents, including a dietary aide who threatened two residents during an argument in the kitchen and dining room. Witnesses confirmed the staff member used threatening language, and the incident was substantiated as verbal abuse. In another case, a resident with known behavioral health needs physically abused a roommate, resulting in a painful broken finger and hospital admission. The care plan for the resident with behavioral issues did not specify the level of supervision required to ensure the safety of others. Further deficiencies were identified when a resident stabbed a roommate in the hand with an ink pen, causing a laceration that required hospital treatment. The resident who committed the act had a documented history of verbal outbursts and challenging behaviors, but the care plan lacked clear interventions or supervision levels to manage these risks. In each case, the facility's failure to prevent and promptly address abuse resulted in physical and psychosocial harm to residents, as substantiated by investigations and witness accounts.
Failure to Immediately Report Alleged Abuse Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that allegations of abuse were reported immediately by staff to a supervisor or the Administrator, as required by policy. On 07/25/2023, a Certified Nursing Assistant (CNA) witnessed another CNA throw a metal ashtray weighing over one pound at a resident but did not report the incident immediately, stating later that fear was the reason for not reporting. Another CNA was informed of the incident via a phone call from the alleged perpetrator but also failed to report the allegation until the following day, after confirming the details in a second conversation. As a result of these failures to report, the CNA who threw the ashtray continued to work in the facility and had access to the resident involved and other residents until the end of her shift the next day. The facility's abuse policy required immediate reporting of suspected abuse to a supervisor, who would then notify the Administrator. However, both the witness and the staff member who received the report did not follow this protocol, delaying the facility's awareness and response to the incident. The resident involved had a history of Alzheimer's Disease, Dementia with Behavioral Disturbance, Schizoaffective Disorder, Bipolar Disorder, Psychosis, Anxiety Disorder, and Major Depressive Disorder, and was assessed as moderately cognitively impaired. The delay in reporting meant that the alleged perpetrator remained in the facility, which was determined to have caused or was likely to cause serious injury, harm, impairment, or death to residents, resulting in the citation of Immediate Jeopardy for failure to report alleged violations.
Resident Elopement Due to Inadequate Supervision and Failure to Intervene
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact but experiencing confusion due to a urinary tract infection, exited the facility in a wheelchair without staff knowledge or supervision. The resident was later observed by a Physical Therapy Assistant (PTA) across the street from the facility, near a road. Instead of immediately intervening, the PTA parked his vehicle and entered the facility to notify nursing staff, leaving the resident unsupervised in an unsafe area. Upon notification, two LPNs located the resident approximately 100 feet from the property line and assisted the resident back into the facility. The facility's investigation was unable to determine how the resident exited the secured front door, as it was locked at the time and the receptionist, who typically monitors the entrance, had not yet started her shift. There was no signage at the front door to alert staff or visitors not to allow residents to exit unsupervised, and the facility's policy allowed residents not identified as elopement risks to go outside to the front porch unsupervised. The resident involved had not previously been identified as an elopement risk and was not listed in the facility's elopement book. Interviews with staff revealed that the expectation was for staff to remain with any resident found off the premises and to notify the facility immediately. However, the PTA acknowledged not following this protocol. The facility's policies required staff to intervene and redirect confused or at-risk residents attempting to leave and to provide immediate assistance in the event of an incident, but these procedures were not followed in this case, resulting in the resident being left unsupervised outside the facility.
Failure to Implement and Update Behavioral Health Care Plans Resulting in Resident Harm
Penalty
Summary
The facility failed to ensure that staff implemented and followed behavior management care plan approaches for residents with behavioral health needs, resulting in multiple incidents of verbal and physical aggression. In one instance, a resident with diagnoses including Alzheimer's Disease, Dementia with Behavioral Disturbance, Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder exhibited verbal outbursts and cursing while in the smoking area. Instead of following the care plan intervention to calmly redirect the resident, a CNA responded by throwing an ashtray at the resident, escalating the situation. The resident then threw the ashtray back, injuring another resident. Staff interviews confirmed that the CNA's actions were inappropriate and aggravated the resident's behavior, and that staff were aware of the resident's behavioral history and the correct protocols for de-escalation, which were not followed during the incident. In another case, a resident with Vascular Dementia and a history of behavioral disturbances was involved in an altercation with a staff member, resulting in verbal abuse. Despite the incident, the resident's care plan was not reviewed or updated to include additional interventions to manage the behaviors. Subsequently, the same resident was involved in a physical altercation with a roommate, resulting in a fractured finger. Documentation revealed that the resident had exhibited frequent behavioral symptoms, including agitation and verbal aggression, and that staff were aware of these behaviors but failed to document or update care plans following incidents, which could have informed future interventions and staff awareness. A third incident involved a resident with Depression and Post-Traumatic Stress Disorder who exhibited escalating behaviors such as yelling, cursing, throwing objects, and refusing care. The resident ultimately stabbed a roommate with a pen, causing injury that required hospital evaluation. The resident's care plans did not address physical aggression, night terrors, flashbacks, or the level of supervision needed to ensure the safety of others. Progress notes documented ongoing behavioral issues, but care plans lacked specific interventions or guidance for staff to manage these risks. Staff interviews indicated awareness of the resident's behavioral challenges, but the necessary care planning and supervision were not in place to prevent harm.
Failure to Serve Correct Food Portions According to Menu and Policy
Penalty
Summary
The facility failed to ensure that correct food portions were served to residents, as required by their own policies and menu guidelines. During meal observations, it was noted that residents were served less than the required portion sizes for several menu items. Specifically, Mandarin Orange Sections were served in 2-ounce portions instead of the required 4 ounces, and various pureed items at lunch were served using scoops that did not match the portion sizes specified on the menu and production sheets. The staff used a #8 scoop (4 ounces) for items that required 8 ounces, and a #12 scoop (2.6 ounces) for items that required 1/2 cup (4 ounces), resulting in under-portioning of food items such as Puree Stew, Mashed Potatoes, Puree Bread, and salads. Interviews with dietary staff and the Dietary Manager revealed a lack of understanding regarding the correct scoop sizes and their corresponding portion amounts. The staff believed that the scoop numbers directly correlated to ounces, leading to consistent under-serving of food. The Portion Control Chart posted in the kitchen was not effectively referenced or understood by the staff, contributing to the ongoing issue. The Registered Dietitian confirmed that the portions served were less than required and stated that this would result in residents not receiving enough calories and nutrients. The deficiency had the potential to affect all 132 residents receiving meals from the facility's kitchen, as the incorrect portion sizes were observed during regular meal service. The facility's policies required that menus and portion sizes be followed to meet residents' nutritional needs, but these procedures were not adhered to during the observed meal services.
Deficient Food Storage, Labeling, Meal Distribution, and Hand Hygiene Practices
Penalty
Summary
The facility failed to comply with food safety and sanitation standards as outlined in its own policies and the FDA Food Code. During multiple observations, surveyors found that meat was being thawed on a shelf only 3.5 inches from the floor in a walk-in cooler, contrary to the requirement that food be stored at least 6 inches above the floor. Additionally, sandwiches prepared for resident snacks were labeled only with the preparation date and not with a required 'use by' date, and staff were unaware of the correct labeling procedure. These practices were confirmed through interviews with dietary staff and the Dietary Manager, who acknowledged the errors and the potential for cross-contamination and improper food handling. Meal distribution practices were also found to be deficient. During supper service, meal trays were observed being transported on open carts with incompletely covered plates, leaving food exposed due to gaps between the insulated dome lids and the plates. Soup bowls were not covered at all because the facility lacked appropriate lids. Both the Dietary Manager and Registered Dietitian confirmed that this method of transport could result in loss of temperature and possible airborne contamination of the food. Sanitation issues extended to hand hygiene facilities in the kitchen. A handwashing sink was found to be damaged, tilted downward, and unable to drain properly, with no cold water available. Staff, including the Dietary Manager, continued to use this sink for handwashing despite these issues, which had persisted for at least a month. The lack of cold water made the water excessively hot, potentially preventing proper handwashing duration. Both the Dietary Manager and Registered Dietitian recognized the risk of cross-contamination and inadequate hand hygiene due to the sink's condition.
Failure to Maintain Kitchen Equipment and Handwashing Facilities
Penalty
Summary
The facility failed to maintain essential kitchen equipment in good repair, as required by the U.S. FDA 2022 Food Code. During observations, both the kitchen and East Wing ice machines were found with thick grey residue on their air filters, which had not been cleaned as directed by the manufacturer. The filters were labeled to be cleaned twice a month, but staff confirmed they were dirty and had not been maintained. The Senior Regional Maintenance Director acknowledged that regular cleaning of these filters was necessary for regulatory compliance and equipment longevity. A handwashing sink in the kitchen, located between the 3-Compartment Sink and the entrance to the Dishwashing Room, was observed to be tilted downward, loose from the wall, and unable to dispense cold water. Staff reported that the sink had been broken for at least a month, with some stating it had been in disrepair for about three months. The cold water had not been restored after a plumbing repair, resulting in extremely hot water only. Despite these issues, staff continued to use the sink for handwashing, expressing discomfort and concern about potential cross-contamination due to improper drainage and water temperature. Additionally, the dishwashing machine's heated final rinse was not operational due to a blown fuse discovered several months prior, and the machine had been temporarily converted to a chemical sanitizing process. The plate lowerator, intended to keep food warm for residents, had been broken for approximately one and a half years and was not in use. Maintenance staff and management indicated that communication about these equipment failures was inconsistent, with some issues not being reported or addressed in a timely manner. These deficiencies had the potential to affect all residents receiving meals from the facility's kitchen.
Failure to Account for and Administer Controlled Medications
Penalty
Summary
The facility failed to protect multiple residents from the misappropriation of their controlled medications when a registered nurse (RN) removed narcotics and other controlled substances from the medication cart, signed them out on the Controlled Drug Record, but did not administer them to the residents. The nurse, RN #33, signed out medications for several residents during her shift, including pain medications such as Oxycodone, Hydrocodone-Acetaminophen, Gabapentin, Ultram, and Ativan, as well as Lacosamide for seizures. However, these medications were not documented as administered on the Medication Administration Record (MAR), and the residents reported not receiving their prescribed doses. Interviews and record reviews revealed that RN #33 claimed to have pulled all the narcotics, placed them in cups labeled with residents' names, and locked them in the medication cart before leaving her shift early. However, subsequent staff, including an LPN and another RN, did not find any prepared medications in the cart, and the controlled substances could not be located. The Controlled Drug Record showed the medications had been removed, but the MARs did not reflect administration, and residents confirmed they had not received their medications. The facility's policies require that controlled medications be administered immediately after being prepared and that all removals and administrations be properly documented. The affected residents had various medical conditions requiring controlled medications, including chronic pain, epilepsy, and anxiety disorders. The incident involved at least eight residents and two medication carts on the Rehab Hall. The facility's investigation, supported by statements from staff and the medical director, concluded that the medications were missing and could not be accounted for, constituting a violation of the facility's medication administration and abuse prohibition policies.
Failure to Administer and Document Scheduled Medications as Ordered
Penalty
Summary
The facility failed to ensure that eight residents on the Rehab unit received their prescribed medications during the 7 PM to 7 AM shift on 11/13/2024, as ordered by their physicians. According to interviews, record reviews, and facility policy, medications were not administered at the scheduled times, and documentation was not completed as required. The facility's own investigation confirmed that both controlled substances and other medications scheduled for 8 PM, 9 PM, and 10 PM were not given, despite being signed out on the Controlled Drug Record by a nurse who subsequently left the shift unexpectedly. The affected residents had a range of medical conditions, including depression, epilepsy, hyperlipidemia, diabetes, Parkinson's disease, chronic pain, hypotension, constipation, insomnia, anxiety disorder, and vascular dementia. Their medication regimens included critical drugs such as insulin, statins, anticonvulsants, antihypertensives, pain medications, and controlled substances. On the night in question, none of these medications were administered as ordered, and the electronic Medication Administration Record (eMAR) reflected missed doses, with entries left in red to indicate non-administration. Interviews with staff, including a registered nurse and the Director of Nursing, confirmed that the standard practice was not followed. The nurse responsible for the missed doses had signed out narcotics but did not administer them or leave them for others, and did not document administration on the MAR. Residents reported not receiving their medications, and staff discovered the issue when residents inquired about their missed doses. The facility's policies require that medications be administered and documented immediately after administration, and that the person who prepares the medication is the one to administer it, which did not occur in this instance.
Failure to Notify Family of Medication Change
Penalty
Summary
The facility failed to notify the family or responsible party of a resident when there was a significant change in the resident's medication regimen. Specifically, the resident, who had diagnoses including Generalized Anxiety Disorder and Restlessness and Agitation, was admitted with an order for Ativan 1 mg at bedtime. On a later date, the Ativan dosage was decreased to 0.5 mg as part of a gradual dose reduction, as documented in the resident's progress notes and physician orders. Despite facility policy requiring immediate notification of the resident's representative when there is a significant change in treatment, there was no evidence in the medical record or progress notes that the family or responsible party was informed of the medication change. Interviews with the resident's family and responsible party confirmed they were not notified of the decrease in Ativan. A registered nurse also acknowledged that the family should have been notified and that there was no documentation of such notification.
Failure to Secure eMAR Screen Compromises Resident Privacy
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's personal and medical records as required by its own policies and federal regulations. During an evening medication pass, a surveyor observed that the electronic Medication Administration Record (eMAR) screen was left unlocked and visible on top of the medication cart, displaying a resident's medication information. At the time of the observation, the nurse responsible for the medication cart was across the room weighing another resident, leaving the eMAR unattended and accessible to unauthorized individuals. Interviews with the LPN involved confirmed that the eMAR screen was left open and visible, and the nurse acknowledged that this was not in accordance with facility policy, which requires health information to be hidden and not left unattended in public areas. The resident affected had been admitted with a diagnosis of End Stage Renal Disease. The facility's policies specifically state that protected health information must not be left visible or unattended, and the nurse confirmed understanding of the importance of locking the eMAR screen when away from the cart.
Failure to Maintain Safe and Homelike Environment Due to Unaddressed Environmental Deficiencies
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations of environmental deficiencies. Specifically, the exit door at the end of the 100 hall was found to be scraped, dirty, and covered with an unknown black substance, and this door was visible to residents in the area. Additionally, the bathrooms of three residents were observed to have missing ceiling tiles on several occasions, with one resident reporting that the tiles had been missing for about a month. Water stains were also noted in one of the affected ceilings. Interviews with maintenance staff revealed that the ceiling tiles had been removed to investigate a leak that occurred the previous month, and the area remained open as the facility was still working on repairs. The maintenance staff acknowledged that the condition of the bathroom ceiling was not homelike. These deficiencies were documented during the investigation of a specific complaint and were found to affect residents on the 100 hall and those using the impacted bathrooms.
Failure to Resolve Resident Grievance Regarding Staff Assignment
Penalty
Summary
The facility failed to resolve a grievance filed by a resident and the resident's representative regarding the conduct of a CNA. The resident, who was cognitively intact and had diagnoses including cerebral infarction, COPD, and hypertension, reported discomfort with the CNA's tone during care. Following the grievance, the CNA was instructed not to provide further care to the resident, and this was documented in the facility's records. However, the CNA subsequently entered the resident's room and provided care again, contrary to the instructions given and the grievance resolution plan. Interviews with facility staff revealed that the Social Service Director, who served as the Grievance Coordinator, was not aware of the initial grievance and that communication regarding the restriction was not effectively shared among staff. The Assistant Director of Nursing confirmed that the CNA should not have been assigned to the resident after the grievance was filed. The failure to ensure that all relevant staff were informed and that the grievance was fully resolved led to the recurrence of the issue, affecting the resident's right to have grievances addressed without reprisal.
Inaccurate Coding of MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were coded accurately for two residents. For one resident, the quarterly MDS assessment was incorrectly coded to indicate that the resident was receiving tracheostomy care, invasive mechanical ventilation, and non-invasive mechanical ventilation, despite observations on multiple occasions confirming that the resident did not have a tracheostomy in place and was not using a ventilator. The Clinical Reimbursement Coordinator (CRC) acknowledged that this was a coding error and that the assessment did not accurately reflect the resident's condition. For another resident, the annual MDS assessment was inaccurately coded in section A1500, failing to indicate that the resident had a Serious Mental Illness as determined by a PASRR Level II screening. The resident's medical record contained documentation of a PASRR Level II Service Determination confirming the presence of a Serious Mental Illness, but the MDS was marked "No" for this item. The CRC confirmed that the MDS should have been coded "Yes" to accurately reflect the resident's status.
Failure to Complete New PASRR After PTSD Diagnosis
Penalty
Summary
The facility failed to submit a new Level I Preadmission Screening and Resident Review (PASRR) for a resident after a new diagnosis of Post-Traumatic Stress Disorder (PTSD) was documented. The resident was originally admitted with a diagnosis of depression, and the medical record showed the addition of PTSD on 08/30/2024. Upon review of the resident's medical record, surveyors did not find evidence that a new Level I PASRR had been completed following the new diagnosis. The Social Service Director confirmed in an interview that she was responsible for completing a new PASRR when a resident experienced a significant change, such as a new diagnosis, and acknowledged that this was not done for the resident in question.
Failure to Maintain Humidified Oxygen During Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required humidified oxygen. During multiple observations, the resident's oxygen concentrator humidification bottle was found to be empty while oxygen was being administered. The humidification bottle was last dated over a week prior to the observation, and the oxygen tubing had been changed more recently, but the humidification bottle was not replaced at that time as required by facility policy. The resident involved had diagnoses including chronic respiratory failure with hypoxemia and chronic obstructive pulmonary disease, and had a moderate cognitive impairment. According to the facility's policy, oxygen humidifiers are to be changed every seven days or as needed for soiling, and should be changed when the oxygen tubing is changed. The DON confirmed that the policy was not followed, as the humidification bottle was not changed when the tubing was replaced, resulting in the resident receiving oxygen without humidification.
Uncovered Transport of Personal Clothing Creates Infection Control Deficiency
Penalty
Summary
Laundry staff were observed distributing residents' personal clothing on uncovered racks in the facility's East unit, contrary to the facility's policy which requires clothing to be covered during transport to prevent cross-contamination. During interviews, the laundry staff member acknowledged that the clothes should have been covered and noted the absence of a rack cover, suggesting a sheet could have been used as an alternative. The District Manager for Environmental Services confirmed that clothing should be draped or covered when delivered to residents and agreed that transporting uncovered clothing presents a potential for cross-contamination. These actions and inactions resulted in a failure to handle residents' personal clothing in a manner that prevents the possibility of cross-contamination, affecting all residents observed for infection control.
Failure to Accurately Report Direct Care Staffing Data
Penalty
Summary
The facility failed to report accurate direct care staffing data to CMS for the quarter from July 1, 2024, to September 30, 2024. A review of the Payroll Based Journal (PBJ) report for this period revealed that the facility triggered for excessively low weekend staffing. During an interview, the Administrator explained that although administrative staff were on call during weekends and provided direct patient care when scheduled staff did not report for duty, their time was not recorded as direct patient care. This omission led to the PBJ report reflecting inaccurately low weekend staffing levels for the quarter reviewed.
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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