Mobile Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mobile, Alabama.
- Location
- 7020 Bruns Drive, Mobile, Alabama 36695
- CMS Provider Number
- 015379
- Inspections on file
- 17
- Latest survey
- June 27, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Mobile Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of falls, cognitive impairment, and significant physical limitations was transferred by a CNA without the required two-person assistance or use of a mechanical lift, contrary to the resident's care plan. During the transfer, the resident fell and sustained a right femur fracture. Staff interviews confirmed the CNA acted alone and did not follow established protocols.
The facility did not provide a private area for Resident Council meetings, instead holding them in the dining room where staff frequently entered and were within hearing distance of residents' discussions. Several residents, including those with intact and moderate cognition, reported that staff continued to enter the meeting space despite signage, and the facility's policy requiring privacy for these meetings was not followed.
A resident with a history of Bipolar disorder and depression was prescribed multiple psychotropic medications, but staff did not monitor or document the side effects or efficacy of these medications as required by facility policy. Interviews with the DON, a unit manager, and an LPN confirmed the absence of monitoring orders and documentation until nearly a month after the medications were started.
Two residents did not have comprehensive care plans addressing their specific needs: one with end stage renal disease receiving hemodialysis lacked a dialysis care plan, and another with chronic pain and moderate cognitive impairment did not have a pain management care plan, despite having active orders for pain medications. Facility staff acknowledged these omissions and confirmed that care plans should have been in place.
A resident with a history of venous insufficiency and thrombocytopenia was prescribed apixaban, but staff did not monitor or document side effects or efficacy of the anticoagulant until an order was added nearly a month later. Interviews with the DON, a unit manager, and an LPN confirmed that monitoring should have occurred and been documented, but was not done during this period.
A resident with severe cognitive impairment and a history of falls was repeatedly found with their call light out of reach, despite care plan interventions and facility policy requiring accessibility. Staff and leadership confirmed the expectation that call lights be within reach, but observations and interviews revealed the call light was often wrapped around the bed enabler, making it inaccessible to the resident.
A resident with a history of dysarthria alleged that an RN pushed and cursed at them during care. The RN did not report the abuse allegation as required by facility policy, and the incident only came to light when the resident's family member informed staff. This resulted in a delay in notifying the state survey agency within the mandated timeframe.
A facility failed to thoroughly investigate a sexual abuse allegation involving a resident with intact cognition and heart failure, as required by policy. Although a male CNA was identified as working during the relevant shifts, there was no evidence he or other male staff were interviewed, and the investigation lacked documentation of attempts to contact them.
A resident with an anxiety disorder did not receive prescribed alprazolam at bedtime on several occasions because the medication order was never sent to the pharmacy. Nursing staff documented the medication as unavailable and did not escalate the issue, while the pharmacy confirmed no order was received. The DON later verified the order was not faxed, resulting in the resident not receiving the medication as prescribed.
A resident with multiple comorbidities developed a perineal rash that was observed and reported by a CNA to two different LPNs on separate occasions. Both LPNs provided cream but did not document the skin issue or notify a physician, and no record of the rash was found in the medical chart. The DON and Executive Director confirmed that documentation and assessment were expected but not completed.
Failure to Follow Transfer Protocols Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan and daily care guide during a transfer, resulting in a fall and injury. The resident, who had a history of falls, cerebral palsy, autistic disorder, osteoporosis, morbid obesity, and moderate cognitive impairment, was care planned for two-person assistance with a mechanical lift for all transfers. Despite these documented requirements, a certified nursing assistant (CNA) attempted to transfer the resident alone and without the mechanical lift, after the resident expressed reluctance to use the lift. During the transfer from wheelchair to bed, the CNA held onto the back of the resident's pants as the resident attempted to stand and pivot, but the resident fell to the floor. The incident resulted in the resident sustaining a right femur fracture, as confirmed by x-ray. The CNA's actions were in direct violation of the resident's care plan and facility protocols, which required two-person assistance and use of a mechanical lift for transfers due to the resident's significant fall risk and physical limitations. Interviews with facility staff, including the LPN, Quality Assurance/Infection Preventionist, Director of Nursing Services, and Executive Director, confirmed that the resident required two-person assistance with a mechanical lift and that the CNA acted alone during the transfer. The CNA was subsequently terminated for failure to follow policy and procedure. The incident was identified as affecting one of four sampled residents reviewed for accidents.
Failure to Provide Private Space for Resident Council Meetings
Penalty
Summary
The facility failed to provide a private meeting space for the monthly Resident Council meetings, as required by their own policy. Observations revealed that the meetings were held in the dining area, where there was no signage to indicate a meeting was in progress, and staff members entered the room to access the employee break room. During these meetings, staff were within hearing distance of the residents' discussions, and kitchen staff continued to work with the doors open. Residents reported that they were not aware the meetings should be held in a private area and did not know staff should not enter during the meetings. Multiple residents confirmed that staff continued to enter the dining room during Resident Council meetings, even when a sign was posted on the door. One resident, with intact cognition as indicated by a BIMS score of 14, stated they had previously informed the facility about this issue. Another resident, with moderate cognitive impairment, also reported that staff entered the dining room to eat lunch during the meetings. The facility's policy required meetings to be scheduled in an area that promotes privacy, but this was not followed, resulting in a lack of privacy for the Resident Council meetings.
Failure to Monitor Psychotropic Medication Side Effects and Efficacy
Penalty
Summary
The facility failed to monitor the side effects and efficacy of psychotropic medications for one resident who was admitted with a history of Bipolar disorder and depressive episodes. Upon admission, the resident was prescribed clonazepam for anxiety, escitalopram oxalate for depression, and quetiapine fumarate for Bipolar disorder. Despite facility policy requiring routine review and monitoring of residents on psychotropic medications, there was no evidence that staff monitored or documented the effectiveness or side effects of these medications from the time of admission until nearly a month later. Interviews with facility staff, including the Director of Nursing Services, the South Unit Manager, and a Licensed Practical Nurse, confirmed that there was no order or documentation for monitoring the resident's psychotropic medication use prior to the later date. The medication administration records also showed that while the medications were administered as ordered, there was no documentation of monitoring for side effects or efficacy during this period. The deficiency was identified through record review and staff interviews, which revealed a lack of compliance with both facility policy and expected practice regarding psychotropic medication monitoring.
Failure to Develop Comprehensive Care Plans for Dialysis and Pain Management
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for two residents with specific clinical needs. One resident with end stage renal disease and dependent on hemodialysis was admitted with orders for dialysis three times per week, but there was no evidence of a care plan addressing dialysis in the resident's records. The MDS Coordinator acknowledged that a dialysis care plan is typically completed but was unsure why it was missed in this case. The Executive Director confirmed the expectation that a dialysis care plan should have been in place for this resident. Another resident with a diagnosis of chronic pain, moderate cognitive impairment, and active orders for both scheduled and as-needed oxycodone with acetaminophen, also lacked a care plan addressing pain management. The MDS Coordinator could not locate a pain-related care plan for this resident and did not know how it was missed. Both the Executive Director and the Director of Nursing Services stated their expectations that care plans should be completed to address residents' needs, including pain management.
Failure to Monitor Anticoagulant Medication for Side Effects and Efficacy
Penalty
Summary
The facility failed to monitor the side effects and efficacy of an anticoagulant medication for a resident with a history of venous insufficiency and thrombocytopenia. The resident was admitted and prescribed apixaban, an anticoagulant, with orders to administer the medication for blood clot prevention. However, there was no order in place for staff to monitor the resident for side effects or efficacy of the anticoagulant until nearly a month after the medication was started. Review of the medication administration record (MAR) confirmed that while the medication was administered as ordered, there was no documentation of monitoring for side effects or effectiveness during this period. Interviews with the Director of Nursing Services (DNS), the South Unit Manager, and a Licensed Practical Nurse confirmed that monitoring for anticoagulant use should have been documented but was not done prior to the addition of the monitoring order. The DNS and other staff acknowledged the absence of both an order and documentation for monitoring the resident for adverse reactions or effectiveness of the anticoagulant medication until the oversight was identified and corrected.
Call Light Not Kept Within Reach for Resident with Cognitive Impairment
Penalty
Summary
A deficiency was identified when a resident's call light was not kept within reach, contrary to facility policy and the resident's care plan. The resident, who had a diagnosis of autistic disorder and severe cognitive impairment as indicated by a BIMS score of 7, was admitted with a history of falls and had interventions in place requiring the call light to be accessible. Multiple observations showed the call light wrapped around the bed enabler, out of the resident's reach, and both the resident and staff confirmed that the resident could not access the call light when needed. The resident reported that staff typically left the call light in this inaccessible position, and staff interviews confirmed this was not in accordance with expected practice. Staff, including a CNA and an LPN, acknowledged that the call light should have been within the resident's reach and that the resident was unable to reposition it independently. The DON and Executive Director both stated their expectation that call lights be accessible to residents at all times and that staff should check the call light's placement during each room entry. Despite these expectations and documented interventions, the call light was repeatedly found out of reach during the survey.
Failure to Timely Report Alleged Abuse by Staff
Penalty
Summary
The facility failed to ensure that staff reported an allegation of abuse involving a resident with a history of dysarthria following cerebral infarction. The resident, who was cognitively able to make daily decisions with modified independence, alleged that a registered nurse pushed and cursed at them during a skin examination. The resident reported this incident to a family member, who then informed the unit manager. However, the registered nurse involved did not report the allegation to any supervisor or manager as required by facility policy. Facility policy mandates that all alleged violations involving abuse must be reported immediately, but no later than two hours after the allegation is made, to the administrator and appropriate authorities. In this case, the facility did not become aware of the allegation until the family member reported it the following morning, resulting in a delay in notifying the state survey agency. Interviews confirmed that the nurse did not follow the required reporting procedures, and the director of nursing services acknowledged that the allegation should have been reported within the specified timeframe.
Failure to Interview Key Staff in Sexual Abuse Allegation Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of sexual abuse involving a resident with intact cognition and a diagnosis of acute chronic diastolic heart failure. The allegation, reported by a hospital case manager, stated that a male staff member inserted his thumb into the resident's rectum multiple times while a female staff member spanked the male staff member. The resident could not specify the exact date and time of the incident but indicated it occurred late at night. The facility's abuse prevention policy required an investigation to be initiated for any findings of potential abuse or neglect, including determining cause and effect and protecting the alleged victim during the investigation. Despite identifying a male CNA who worked the relevant shifts, the facility's investigation file contained no evidence that any male staff were interviewed. The Executive Director acknowledged that although a male staff member was identified, there was no documentation of attempts to contact him, nor was this information included in the investigation report. The identified CNA confirmed he was not contacted or informed about the investigation. The Director of Nursing Services stated that she would have expected any involved male staff to be interviewed or contacted as part of the investigation.
Failure to Provide Prescribed Medication Due to Ordering Lapse
Penalty
Summary
The facility failed to provide prescribed medication to a resident with a diagnosis of anxiety disorder. The resident was admitted with an order for alprazolam 0.5 mg at bedtime for anxiety. Documentation in the medication administration record (MAR) showed that the medication was not administered on multiple occasions, with staff using a code indicating 'other, see progress notes.' Progress notes from several LPNs consistently indicated that the alprazolam was either not available, not in stock, or still awaited from the pharmacy. The pharmacy delivery records showed no evidence that the medication was received for the resident during the relevant period. Interviews with nursing staff revealed that they were aware the medication was not available and that it had not been delivered, but they did not take further action beyond waiting for the medication. One LPN stated she did not contact anyone and simply waited for the medication. The pharmacist confirmed that the pharmacy never received an order for alprazolam for the resident, and the Director of Nursing Services stated the order was never faxed to the pharmacy. The Executive Director stated that nurses were expected to follow up with the pharmacy and report missing medications to the DNS, but this did not occur.
Failure to Document and Assess Resident's Skin Condition
Penalty
Summary
The facility failed to ensure proper documentation and assessment of a resident's skin condition, specifically regarding a rash in the perineal area. The resident, who had a history of hemiplegia, congestive heart failure, diabetes mellitus, atrial fibrillation, and gastrointestinal diseases, was admitted with intact skin and no noted pressure injuries. However, the medical record contained no evidence of skin concerns in the perineal area, despite later hospital documentation indicating the presence of a perineal rash. Statements from a CNA revealed that she observed a white rash, and later a white and pinkish-red rash, in the resident's perineal area on two separate occasions. Each time, she reported her findings to different LPNs, who provided cream for application but did not document the skin issue or notify a physician. Interviews with the involved LPNs showed a lack of recall or recognition of any significant skin issues, and no documentation was found regarding the reported rash. The DON confirmed that there was no documentation of skin issues in the resident's record and stated that nurses were expected to assess and document any reported changes. The Executive Director also stated that nurses were expected to document their responses to CNA reports. The lack of documentation and follow-up on the reported skin condition led to the deficiency.
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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