Merry Wood Lodge
Inspection history, citations, penalties and survey trends for this long-term care facility in Elmore, Alabama.
- Location
- 280 Mt Hebron Road, Elmore, Alabama 36025
- CMS Provider Number
- 015019
- Inspections on file
- 12
- Latest survey
- October 17, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Merry Wood Lodge during CMS and state inspections, most recent first.
A resident with dementia and behavioral disturbances physically and verbally abused two other residents in separate incidents. The facility failed to provide adequate supervision and interventions, allowing these incidents to occur. Despite the resident's history of disruptive behavior, the care plan was not updated to prevent further abuse.
The Administrator failed to implement the Abuse Policy effectively, leading to a deficiency in handling an incident where a CNA grabbed a resident's wrists, resulting in bruising. The incident was not reported promptly, and the investigation was inadequate, failing to determine the cause of the bruising. The Administrator did not substantiate the abuse allegation, allowing the CNA to return to work without appropriate corrective actions. This deficiency was cited as Immediate Jeopardy, indicating potential harm to all residents.
The facility's QAPI committee failed to adequately review and analyze an abuse allegation involving a resident, leading to an Immediate Jeopardy citation. The committee did not identify physical abuse nor address concerns related to the identification, reporting, investigation, and protection regarding the allegation. The Administrator made the decision on whether to substantiate the abuse allegation without full agreement from the QAPI members, and the facility's policy for reviewing abuse allegations was not followed.
Two residents with severe cognitive impairments were reportedly abused by CNAs in separate incidents. One resident was roughly handled, resulting in bruising, while another was pushed back into bed after grabbing a CNA's collar. Despite witness accounts and visible injuries, the facility's investigations did not substantiate the abuse, citing inconsistent accounts and lack of intent to harm.
A facility failed to implement its abuse policy after a CNA reported grabbing a resident's wrists to prevent being hit. The incident was not reported to the Administrator, and no protective measures were taken until the resident's family reported it days later. The Administrator did not substantiate the abuse allegation, and the CNA continued working with the resident. The facility's non-compliance with federal regulations was determined to have caused, or was likely to cause, serious harm to residents.
The facility failed to thoroughly investigate allegations of staff-to-resident and resident-on-resident abuse, as well as injuries of unknown origin. A CNA admitted to grabbing a resident's wrists, resulting in bruising, but the facility did not substantiate the abuse claim. Other incidents lacked proper documentation and monitoring, leading to a citation for non-compliance with federal regulations.
The facility's kitchen floor was found to be sticky and unclean, with an unidentified black substance present, during inspections by a surveyor and the Dietary Manager. The Director of Operations acknowledged the issue, noting that the floors were old and required a deep clean, as regular cleaning methods were ineffective.
The facility failed to properly dispose of refuse, as a burn pile with discarded cardboard boxes was found near the dumpster area. This was against the facility's policies and the 2017 U.S. Public Health Service Food Code, which require refuse to be stored in a way that prevents access by pests. The Dietary Manager and Administrator confirmed the improper disposal and acknowledged the potential fire hazard and pest attraction risk, affecting all 98 residents.
The facility inaccurately reported weekend staffing data to CMS for the second quarter of 2024, triggering a deficiency for excessively low weekend staffing. The issue arose from the submission of staffing data based on time clock punches, which did not account for salaried staff working weekends. This led to a discrepancy between actual staffing levels and reported data.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect the rights of two residents, identified as RI #22 and RI #21, from verbal and physical abuse by another resident, RI #101. RI #101, who was admitted with dementia and behavioral disturbances, was involved in two separate incidents of abuse. On the first occasion, RI #101 hit RI #22 in the chest during a lunch meal in the dining area. Witnesses reported that RI #22 raised their hands in self-defense, indicating fear and distress. Despite the facility's policy to prevent abuse and provide adequate supervision, the measures in place were insufficient to prevent this occurrence. The following day, after the 15-minute monitoring checks for RI #101 had ended, another incident occurred where RI #101 verbally and physically abused RI #21. RI #101 called RI #21 derogatory names and hit them in the face while they were in the day area watching television. Witnesses described the situation as one that would make a person feel scared and unsafe. The facility's failure to provide continuous supervision and effective interventions allowed this second incident to occur shortly after the monitoring period ended. The facility's investigative files and witness statements confirmed that both incidents were deliberate acts of aggression by RI #101, who had a history of disruptive behavior. Despite this history, the facility did not implement new interventions or update RI #101's care plan to prevent further occurrences of abuse. The lack of adequate supervision and failure to intervene in a timely manner contributed to the deficiency, affecting the safety and well-being of the residents involved.
Failure to Implement Abuse Policy and Conduct Thorough Investigation
Penalty
Summary
The Administrator of the facility failed to implement the Abuse Policy effectively, leading to a deficiency in handling an incident involving a Certified Nursing Assistant (CNA) and a resident. On July 1, 2023, CNA #14 reported to a Licensed Practical Nurse (LPN) that she had grabbed the wrists of Resident Identifier (RI) #398 to prevent the resident from hitting her. However, this incident was not reported to the Administrator, and no protective measures were taken until July 6, 2023, when discolorations were noted on the resident's arms and wrists. The Administrator did not substantiate the allegation of physical abuse, despite the CNA's admission of grabbing the resident's wrists. The facility's investigation into the incident was inadequate, as it failed to determine the cause of the bruising on the resident's wrists. The investigation consisted of interviews and skin assessments but did not include a thorough examination of the events leading to the bruising. The Administrator did not document an interview with the resident, which contributed to the incomplete investigation. As a result, the facility allowed the CNA to return to work without taking appropriate corrective actions. The deficiency was cited as Immediate Jeopardy, indicating that the facility's noncompliance with federal regulations had the potential to cause serious harm to residents. The Administrator's failure to ensure the Abuse Policy was implemented and to conduct a thorough investigation of the abuse allegation had the potential to affect all residents in the facility. This deficiency was identified during the investigation of a Facility Reported Incident, highlighting the need for proper oversight and adherence to abuse prevention policies.
Removal Plan
- Educate the Nursing Home Administrator on implementing Abuse policies and procedures, reporting alleged violations, thoroughly investigating alleged incidents, and center's response to the results of the investigations.
- Emphasize the Administrator's responsibility of operationalizing policies and procedures that prohibit abuse, neglect, involuntary seclusion, injuries of unknown source, exploitation, and misappropriation of property.
- Ensure the Administrator understands his role in operationalizing and overseeing policies within the Center, specifically the Abuse Prohibition Policy.
- Administrator will lead in the investigation process, follow up with outstanding activities needed for a thorough investigation, and ensure each reportable event is taken to the QAPI committee for review.
- Train the Administrator to notify Market Clinical Lead of each occurrence and keep them abreast of the progress of the investigation and protection of the resident.
- Review the complete investigation by the Market Clinical Lead to collaborate on the thoroughness of the investigation and ensure correct determinations are made.
- Review allegations of Abuse and Neglect to ensure policies were implemented and allegations were reported and thoroughly investigated.
- Host an AD HOC Quality Assurance Performance Improvement meeting with key personnel to review the Abuse Prohibition policy and procedure.
- Review staff on resident incidents by the Center QAPI Committee to determine if correct determination was made and if appropriate corrective action has been taken.
- Interview residents regarding rough treatment from staff and complete skin assessments for any signs of abuse.
- Re-educate staff members regarding Abuse Prohibition Policy including the ability to prevent abuse, identify signs and evidence of abuse, and report abuse.
- Educate Administrator regarding conducting thorough investigations and protecting residents during the investigation.
- Instruct Administrator to review all reportable events with Market Clinical Lead prior to finalizing investigation protocols.
- Educate QAPI committee regarding thoroughly reviewing all reportable events during the QAPI process for thoroughness of the investigation and appropriateness of the determination.
- Review remaining incidents that were previously unverified/unsubstantiated by the Center QAPI Committee, and review corrective actions for verified incidents.
Failure in QAPI Committee's 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 involving a resident, identified as RI #398. The committee did not identify physical abuse against the resident nor address concerns related to the identification, reporting, investigation, and protection regarding the allegation of physical abuse reported to the State Agency. This failure was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death to residents, leading to an Immediate Jeopardy citation. The deficiency was highlighted during an interview with the Director of Nursing (DON), who explained that abuse was not consistently discussed in QAPI meetings unless an issue had occurred. The DON revealed that the Administrator (ADM) made the decision on whether to substantiate the abuse allegation without full agreement from the QAPI members. The incident involving RI #398, where a Certified Nursing Assistant (CNA) reportedly grabbed the resident's arm, was reviewed, but the ADM decided not to substantiate the allegation despite evidence suggesting abuse had occurred. Further interviews revealed that the ADM, responsible for managing daily operations and ensuring adherence to policies, did not communicate abuse allegations to the Governing Body as required. The facility's policy mandated a review of all reported abuse allegations through the QAPI process, which included assessing interventions and the effectiveness of investigations. However, this process was not followed, leading to the deficiency being cited as a result of the investigation of a Facility Reported Incident.
Removal Plan
- A QAPI meeting was held which included a review of reportables.
- The Market Clinical Advisor and Market Clinical Lead reviewed allegations of Abuse and the Quality Assurance Performance Improvement Committee meeting minutes to ensure allegations of abuse were analyzed.
- The Market President educated the Nursing Home Administrator on the Quality Assurance Performance Improvement process to include systematic identification, reporting, investigation, analysis, and prevention of abuse or allegations of abuse.
- The Market President and Market Clinical Advisor educated the Quality Assurance Performance Improvement Committee on the Abuse Prohibition policy and procedure.
- Education included emphasizing the importance of analyzing as a team the reportable events of the Center.
- Governing body to include Market President, Market Clinical Advisor, Clinical Lead, Nursing Home Administrator, and Director of Nursing reviewed the Quality Assurance Performance Improvement process.
- The Center QAPI Committee met to discuss staff on resident incidents after the incident occurring.
- Accused CNA no longer works at Merry [NAME] Lodge, her last day of work at the Center.
- 47 residents were interviewed regarding rough treatment from staff and 42 residents skin assessments were completed for any signs of abuse, none were noted.
- 110 staff members were re-educated regarding Abuse Prohibition Policy.
- Administrator was educated regarding conducting thorough investigations and protecting residents during the investigation.
- Administrator was also instructed to review all reportable events with Market Clinical Lead prior to finalizing investigation protocols.
- QAPI committee was educated regarding thoroughly reviewing all reportable events during the QAPI process.
- The Center QAPI Committee reviewed the remaining incidents that were previously unverified/unsubstantiated.
- The review determined the appropriate corrective action had been implemented for 8 incidents, despite being initially unverified/unsubstantiated.
Failure to Protect Residents from Abuse by CNAs
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two separate incidents involving physical abuse by Certified Nursing Assistants (CNAs). In the first incident, a resident with severe cognitive impairment and physical disabilities, including cerebral infarction and hemiplegia, reported being roughly handled by a CNA, resulting in bruising on the wrists. The resident's family members corroborated the account, noting the resident's complaints of mistreatment and visible bruises. Despite these reports, the facility's investigation concluded that the CNA's actions were not abusive, attributing the bruising to the CNA's attempt to prevent the resident from hitting her. In the second incident, another resident with Alzheimer's Disease and severe cognitive impairment was reportedly pushed back into bed by a CNA after grabbing the CNA's collar. Witnesses described the CNA's actions as rough, involving shaking the resident and causing the resident to hit the footboard of the bed. The facility's investigation did not substantiate the abuse, despite witness accounts and the CNA's admission that the situation could have been handled differently. The CNA was placed on administrative leave, but the facility did not classify the incident as abuse due to inconsistent accounts. Both incidents highlight the facility's failure to substantiate allegations of abuse and protect residents from harm. The facility's investigations were unable to confirm abuse, despite evidence and witness testimonies suggesting otherwise. The facility's policy on abuse prohibition was not effectively enforced, leading to a lack of accountability and protection for the residents involved.
Failure to Implement Abuse Policy Following Incident
Penalty
Summary
The facility failed to implement its abuse policy following an incident of staff-to-resident physical abuse. A Certified Nursing Assistant (CNA) reported to a Licensed Practical Nurse (LPN) that she had grabbed a resident's wrists to prevent being hit. This incident was not reported to the Administrator, and no protective measures were taken until the resident's family reported the incident several days later. The resident was found to have red and purple discolorations on their arms and wrists. The facility's Administrator did not substantiate the allegation of physical abuse, despite the CNA's admission of grabbing the resident's wrists. The CNA was allowed to continue working at the facility, providing care to the same resident in the days following the incident. The facility's investigation was delayed, and the incident was not reported to the appropriate authorities in a timely manner. The facility's non-compliance with federal regulations was determined to have caused, or was likely to cause, serious harm to residents. The Immediate Jeopardy was cited in reference to the failure to develop and implement policies to prevent abuse, neglect, and exploitation. The facility's abuse policy required immediate reporting and protective measures, which were not followed in this case.
Removal Plan
- Center Social Worker notified the Administrator.
- CNA #14 was placed on administrative leave pending the results of the investigation.
- The Social Services Director and/or designee interviewed residents deemed as interviewable regarding Staff being rough with the residents. No concerns were identified.
- Licensed Nurses completed skin assessment on residents identified with severe cognitive impairment to identify suspicion of Abuse. No additional concerns were identified.
- The Nurse Practice Educator and/or designee initiated 100% re-education with employees in all disciplines on Abuse Prohibition policy and procedure, including the definition, types of Abuse, prevention and supervision, identification, reporting of abuse, and trauma.
- Education was completed with all staff present in the Center and for all staff available via telephone communication.
- The Nurse Practice Educator and/or designee will ensure employees unable to be reached after 3 attempts, those with scheduled time off, on leave of absence, vacation, or PRN will be re-educated prior to returning to duty.
- New hires will be educated on Abuse Prohibition policy during the orientation process by the Nurse Practice Educator or Director of Nursing Services.
- Market President educated the Nursing Home Administrator on the implementation of the Abuse Prohibition policy and procedure to include screening of potential hires; training of employees; prevention of occurrences; identification of possible incidents or allegations which need investigation; conducting thorough investigations of incidents and allegations; protection of residents during investigations; and reporting of incidents, investigations, and center response to the results of the investigations.
- Education included ensuring the Administrator knows and understands that abuse is identified as the individual acts deliberately, the actions of the individual were deliberate in nature and not dependent on the intent of the individual.
- Administrator has been educated regarding protecting residents by ensuring the accused individual does not have access to repeat the abuse. The accused employee is to be placed on administrative leave pending the results of the investigation.
- Education also included ensuring the administrator knows his role and responsibility in implementing the abuse policy including investigations, identification, reporting, protection and involvement of QAPI.
- Administrator knows that staff not reporting abuse is a failure to follow policy and corrective action must be taken up to and including termination of employment.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident physical abuse involving a Certified Nursing Assistant (CNA) and a resident with severely impaired cognition. The incident occurred when the CNA reportedly grabbed the resident's wrists to prevent being hit, resulting in bruising. Despite the CNA's admission of grabbing the resident, the facility did not substantiate the abuse allegation, and the CNA was allowed to continue working. The investigation did not determine the cause of the bruising, and protective measures were delayed. Additionally, the facility did not adequately investigate several other incidents, including resident-on-resident abuse and injuries of unknown origin. In one case, a resident was hit by another resident in the dining area, but the facility did not document interviews or substantiate abuse due to a lack of intent to harm. In another instance, a resident was found with bruising and hip pain, but the facility failed to obtain witness statements from staff who provided care during the relevant period. The facility's investigation processes were found lacking in documentation and thoroughness, as evidenced by the absence of recorded interviews and failure to monitor residents for aggressive behavior following incidents. These deficiencies were identified during a survey, which cited the facility for non-compliance with federal regulations regarding freedom from abuse, neglect, and exploitation.
Removal Plan
- Educated the Nursing Home Administrator on the implementation of the Abuse Prohibition policy and procedure.
- Trained Administrator on steps to a thorough investigation, including identification of alleged occurrences, reporting, protecting residents, assessing for injury, performing and documenting interviews, and reviewing pertinent documentation.
- Developing appropriate conclusions and actions to prevent future occurrences.
- Center QAPI Committee met to discuss staff on resident incidents and reviewed identified events for correct determination and appropriate corrective action.
- Accused CNA no longer works at the facility.
- 47 residents were interviewed regarding rough treatment from staff and 42 residents had skin assessments completed for signs of abuse.
- 110 staff members were re-educated regarding Abuse Prohibition Policy.
- Educated Administrator regarding conducting thorough investigations and protecting residents during investigations.
- Instructed Administrator to review all reportable events with Market Clinical Lead prior to finalizing investigation protocols.
- QAPI committee educated regarding thoroughly reviewing all reportable events during the QAPI process for thoroughness of the investigation, appropriateness of the determination, and any further corrective actions.
Unsanitary Kitchen Floor Conditions
Penalty
Summary
The facility failed to maintain the kitchen floor in a clean and sanitary manner, as observed during inspections conducted by a surveyor and the Dietary Manager. During the initial inspection, the kitchen floor was found to be sticky, with an unidentified black substance present in both the center and corners of the floor. A follow-up inspection confirmed that the floor remained unclean and sticky, with the black substance still visible in various sections. The Director of Operations acknowledged the issue, noting that the floors were old and required attention. He mentioned that a monthly deep clean was being considered, but was unsure of the last time such a cleaning had occurred. The Director explained that regular mopping and sweeping had been ineffective in addressing the problem areas, and a new cleaning schedule would be implemented to maintain clean, non-sticky floors.
Improper Disposal of Refuse Near Dumpster Area
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as evidenced by the presence of a burn pile near the dumpster area. This burn pile contained multiple discarded cardboard boxes, which were not disposed of in accordance with the facility's policies or the 2017 U.S. Public Health Service Food Code. The code specifies that refuse should be stored in receptacles or waste handling units to prevent access by insects and rodents, and that refuse areas should be maintained free of unnecessary items and kept clean. The facility's own policies also require that trash be removed on a scheduled basis and that the surrounding area of external receptacles be free of debris. During an inspection, the Dietary Manager confirmed the presence of the burn pile and acknowledged that cardboard should not be stacked there, as it could attract pests. The Administrator also confirmed the use of the burn pile for burning old furniture and debris, but stated that cardboard should be disposed of in the dumpsters. The Administrator recognized the potential fire hazard posed by the burn pile's proximity to the dumpsters and the facility. This situation had the potential to attract rodents and pests, affecting all 98 residents living in the facility.
Inaccurate Weekend Staffing Data Submission
Penalty
Summary
The facility failed to report accurate staffing data to the Centers for Medicare & Medicaid Services (CMS) for the second quarter of 2024, specifically regarding weekend staffing levels. The Payroll Based Journal (PBJ) Staffing Data Report indicated excessively low weekend staffing, which triggered a deficiency. Interviews with the former Staffing Manager revealed that assignment sheets did not show low staffing on weekends, contradicting the PBJ report. The former Staffing Manager was responsible for ensuring adequate staffing levels according to the census. Further investigation with the Vice President of Product Management, who was responsible for submitting PBJ data, revealed that the data was submitted based on time clock punches without distinguishing nursing staff. This method may have led to the low weekend staffing trigger, as staff working during the week were not recorded as working on weekends. The Administrator confirmed that salaried staff, who did not punch in, might have worked on weekends, leading to inaccurate reporting. The deficiency highlights the need for accurate staffing data to demonstrate adequate staffing levels on weekends.
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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