Regency Health Care And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntsville, Alabama.
- Location
- 2061 Poole Drive, Nw, Huntsville, Alabama 35810
- CMS Provider Number
- 015372
- Inspections on file
- 16
- Latest survey
- August 21, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Regency Health Care And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of recurrent UTIs did not receive prompt treatment after exhibiting symptoms of a UTI. Despite a CRNP ordering a urinalysis, the urine sample was delayed, and the antibiotic was not administered in a timely manner. The resident was later hospitalized with urosepsis and septic shock, leading to their death. Facility staff failed to adhere to policies on urine sample collection and antibiotic administration, contributing to the delay in treatment.
A resident with a history of UTIs experienced symptoms such as decreased urinary output and confusion, but the facility delayed obtaining a urine specimen and administering antibiotics. The Quality Assessment and Assurance Committee failed to identify these delays as concerns, leading to the resident's hospitalization for urosepsis and septic shock.
A resident with liver disease did not receive prescribed medications, Rifaximin and Lactulose, upon admission to an LTC facility. The facility failed to order Rifaximin and did not stock Lactulose, leading to missed doses and elevated ammonia levels. The DON and CRNP acknowledged the importance of medication availability, highlighting a deficiency in pharmaceutical services.
A resident with Cerebral Atherosclerosis and Vascular Dementia was unable to access their call light on two occasions due to improper placement, contrary to facility policy. The call light was observed out of reach, first on the wall and then across the resident's abdomen. A CNA confirmed the inaccessibility, and the DON stated that call lights should always be within reach.
A resident did not receive prescribed Rifaximin medication due to unavailability, and the facility failed to notify the CRNP as required. The CRNP was only partially informed about the missed doses, and there was no documentation of notification for the second missed dose. This deficiency was identified during a complaint investigation.
A facility failed to complete and transmit a discharge MDS assessment for a resident discharged on a specified date. The facility's policy requires completion and transmission of the assessment within 14 days. The MDS Coordinator admitted the oversight, attributing it to another system in place, and acknowledged the responsibility of MDS Coordinators for timely submissions.
A facility failed to accurately code MDS assessments for two residents, one regarding CPAP use and another for continence status. A resident's long-term CPAP use was not documented, and another resident was inaccurately coded as always continent despite documented incontinence. Staff acknowledged these discrepancies, which did not accurately reflect the residents' needs.
A resident was admitted with specific medical conditions, but the facility failed to develop an accurate baseline care plan. The plan incorrectly included catheter care, despite documentation showing the resident was continent and did not have a urinary catheter. An LPN relied on hospital records without verifying information with the resident's family, leading to discrepancies in the care plan. The DON also misunderstood the resident's needs, contributing to the inaccurate documentation.
A resident's representative was not included in the care planning process, contrary to facility policy. The resident, who was cognitively impaired and had multiple diagnoses, was admitted without the representative being informed or involved in care planning. The DON confirmed the lack of documentation regarding the representative's participation.
A resident was observed with an intravenous saline lock in place for several days beyond the intended duration, despite an order for a one-time administration of normal saline. Interviews with facility staff confirmed the saline lock was not meant to remain, and there was no documentation indicating site maintenance, posing a risk for infection.
A resident with a self-care performance deficit due to a displaced fracture and impaired balance was found with long, unclean fingernails containing dried blood and dirt, posing an infection risk. Despite facility policies requiring assistance with personal hygiene, observations and interviews revealed a failure to maintain the resident's grooming, leading to a cited deficiency.
A resident with Chronic Kidney Disease was at risk of UTIs due to improper incontinent care by CNAs, who failed to follow the facility's perineal care policy. CNA #20 was observed wiping from back to front and not changing gloves or performing hand hygiene, while CNA #21, in training, was unaware of proper hand hygiene protocols. The Infection Preventionist confirmed the risk of infection due to these practices.
A resident's medical record lacked times for verbal/telephone orders and documentation for a urine specimen obtained via catheter. An LPN documented a late entry for a medication dose without indicating it was late. The DON acknowledged the absence of documentation and stated there was no place to record times for verbal orders.
A resident's clothing was improperly handled, left uncovered on a door knob outside their isolation room, contrary to facility policy and CDC guidelines. This posed a risk of cross-contamination, as confirmed by staff interviews.
Delayed Treatment of UTI Leads to Resident's Hospitalization and Death
Penalty
Summary
The facility failed to provide prompt treatment for a resident, identified as RI #180, who exhibited signs and symptoms of a urinary tract infection (UTI). Despite a Certified Registered Nurse Practitioner (CRNP) ordering a urinalysis (UA) for the resident, the urine sample was not collected and sent to the lab until several days later. The preliminary lab results were delayed, and the CRNP was not notified of the UA results until days after the initial order. Consequently, the first dose of the prescribed antibiotic was not administered until much later, despite the resident experiencing dysuria and other symptoms. RI #180 had a history of recurrent UTIs and urinary incontinence, and was admitted to the facility with multiple diagnoses, including unspecified protein-calorie malnutrition and type two diabetes mellitus. The resident's family had informed the facility staff about the resident's frequent UTIs and expressed concerns about the resident's symptoms, which included back pain and painful urination. However, the facility staff provided inconsistent reasons for the delay in testing and treatment, and the family was not included in a baseline care plan to discuss these concerns. The facility's policies on urine sample collection and antibiotic stewardship were not followed, leading to a delay in obtaining and processing the urine sample, and in administering the prescribed antibiotic. The resident was eventually transferred to the emergency room and admitted to the Intensive Care Unit with urosepsis and septic shock, where the resident later expired. Interviews with facility staff revealed a lack of adherence to the facility's policies and procedures, contributing to the delay in treatment and the resident's subsequent hospitalization and death.
Removal Plan
- The Administrator or designee notified the facility Medical Director of the incident.
- The Director of Nursing (DON) or designee used a verification checklist to ensure all abnormal urinalysis (UA) results were reported to the provider appropriately.
- The Nurse Practitioner will receive emails directly from the lab for electronic review of all lab results.
- The resident's medical record was reviewed to ensure timely treatment and recovery from infection.
- Two LPNs were provided one-on-one education on the facility's revised Urine Sample Collection policy.
- The Urine Sample Collection Policy was revised to specify actions if unable to obtain a midstream clean-catch on the first attempt.
- Notify physician if unable to obtain a urine sample within 12 hours.
- Instructions were received regarding timely medication administration, added as section 7 of the policy.
- All facility nurses were educated on the revised Urine Sample Collection Policy.
- The DON or designee will utilize a verification checklist to ensure prompt treatment.
- Arranged for the contract laboratory to email results of all lab work to CRNP for electronic review and flag physical copies for provider review.
Failure to Address UTI Symptoms Leads to Resident Hospitalization
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAAC) failed to thoroughly review all factors related to a resident's hospitalization. The resident, identified as RI #180, was admitted with a history of unspecified protein-calorie malnutrition, type two diabetes mellitus without complications, and retention of urine. The resident experienced decreased urinary output, urine odor, blood-tinged urine, and increased confusion, which were indicative of a urinary tract infection (UTI). Despite these symptoms, there was a delay in obtaining a urine specimen, notifying the Certified Registered Nurse Practitioner (CRNP) of the urinalysis results, and administering the prescribed antibiotic. The QAAC reviewed the incident report after the resident's fall and identified the need to treat the UTI. However, the committee did not identify the delay in treatment as a concern, nor did they address the systemic issues that led to the delay. The resident's urinalysis results were not promptly communicated, and the initial dose of the prescribed antibiotic, Levofloxacin, was not administered until several days later. This delay in treatment contributed to the resident's transfer to the emergency room and subsequent admission to the Intensive Care Unit (ICU) for urosepsis and septic shock. Interviews with facility staff revealed that the QAAC did not identify any concerns with the treatment of the resident's UTI. The facility's Infection Preventionist stated that urine specimens should be collected immediately, and antibiotics should be started within 24 hours unless otherwise specified. Despite these guidelines, the QAAC's documentation indicated no concerns, and the hospitalization was deemed unavoidable. The facility's failure to promptly address the resident's UTI symptoms and administer timely treatment resulted in a serious deficiency, as determined by the surveyors.
Removal Plan
- The Administrator or designee notified the facility Medical Director of the incident.
- The Director of Nursing (DON), Administrator and Assistant Director of Nursing (ADON) reviewed all Quality Assurance (QA) Committee meeting minutes, as well as reviewing rehospitalization records for months where no QAPI meeting was held.
- A Root Cause Analysis (RCA) was conducted for all rehospitalizations related to urinary tract infection (UTI) to determine if further investigation/action was needed.
- The Laboratory Services and Reporting Policy was revised by the Administrator, DON, and ADON.
- Section 7 of the Laboratory Services and Reporting Policy was revised to say, 'Immediately notify the ordering physician, or nurse practitioner of critical finding.'
- Section 8 was added to the Laboratory Services and Reporting Policy to say, 'Nurse practitioner will be notified of resulted labs for review electronically and nurse will place physical copy in chart for review at the providers next visit to the facility.'
- The DON or designee educated all RNs and LPNs that inform providers of lab results, on facility's revised Laboratory Services and Reporting policy.
- The DON or designee spoke with facility Medical Director and CRNP regarding process change for prompt notification of lab results.
- Arranged for the contract laboratory to email results of all lab work results to CRNP for electronic review.
- The Urine Sample Collection Policy was revised by the Administrator, DON, and Assistant Director of Nursing (ADON).
- Section 4-vi. of the Urine Sample Collection Policy was revised to say, 'If unable to obtain midstream clean-catch on first attempt, may obtain a catheterized specimen.'
- Section 6 of the Urine Sample Collection Policy was revised to say, 'Notify physician if unable to obtain a urine sample within 12 hours.'
- Section 7 was added to the Urine Sample Collection Policy regarding timely administration of medication.
- The DON or designee educated all facility nurses that perform urine collections on facility's revised Urine Sample Collection Policy.
- The DON or designee will continue to utilize verification checklist at least twice per week, to ensure all residents receive prompt treatment.
- The Quality Assessment and Assurance Policy was revised by the Administrator and DON.
- Section 4.d. of the Quality Assessment and Assurance Policy was revised to include contributing factors in corrective plans of action.
- Section 4.f. was added to the Quality Assessment and Assurance Policy to utilize Root Cause Analysis Tools.
- The Administrator completed an education course through Relias Online Training, titled The Use of Root Cause Analysis.
- The Administrator educated the QA Committee on F-867 Quality Assessment and Assurance, facility's revised Quality Assessment and Assurance Policy, and how to conduct an RCA.
Medication Availability and Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for a resident with liver disease, identified as RI #330, upon admission. The resident was prescribed Rifaximin and Lactulose to manage their liver condition, but missed several doses of these medications. The resident's hospital discharge summary indicated that they were to resume these medications, but the facility did not have them available, leading to missed doses on multiple occasions. Interviews and record reviews revealed that the facility did not order Rifaximin for the resident, and the Lactulose was not stocked as a backup medication. The Licensed Practical Nurse (LPN) reported that the Lactulose was not available on the medication cart, and the Director of Nursing (DON) acknowledged that the medications should have been available on the day of admission. The facility's pharmacy did not receive an order for Rifaximin, and the family was asked to bring the medication, which they did after a delay. The resident's ammonia levels were significantly elevated, which could be attributed to the missed doses of Lactulose. The facility's failure to ensure the availability and administration of the prescribed medications resulted in a deficiency, as the resident's medical needs were not adequately met. The Certified Registered Nurse Practitioner (CRNP) expressed concern over the missed doses and emphasized the importance of having medications available for residents upon admission.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as RI #15, by not ensuring the accessibility of the call light on two separate occasions during a five-day survey. The facility's policy, titled 'Call Lights: Accessibility and Timely Response,' mandates that call lights be within reach of residents at all times to ensure timely staff response. However, observations revealed that the call light for RI #15 was out of reach, first being hung on the wall and later positioned across the resident's abdomen, making it inaccessible. RI #15, who was readmitted to the facility with diagnoses including Cerebral Atherosclerosis and Vascular Dementia, was unable to reach the call light due to its improper placement. A Certified Nursing Assistant (CNA) confirmed that the resident could not access the call button in its observed locations and stated it should be clipped to the resident's shirt or blanket. The Director of Nursing (DON) also acknowledged that the call light should always be within reach and never placed behind the bed, as this would prevent the resident from alerting staff to their needs.
Failure to Notify CRNP of Unavailable Medication
Penalty
Summary
The facility failed to notify the Certified Registered Nurse Practitioner (CRNP) when medication was unavailable for administration to a resident, identified as RI #330. The resident was discharged from the hospital with a prescription for Rifaximin, to be administered twice daily. However, the medication was not available for administration on two consecutive days, and the facility did not inform the CRNP as required by their policy. The Director of Nursing acknowledged that the physician should have been notified, but there was no documentation to confirm that this notification occurred. The CRNP expected to be informed if medication was unavailable, but was only aware of the first missed dose and believed the family would provide the medication. The CRNP was not informed of the second missed dose on the same day and was only made aware of the missed doses on the following day. There was no documented evidence that the CRNP was notified about the missed doses on the second day. This deficiency was identified during the investigation of a complaint, affecting one of the 31 sampled residents.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that a discharge Minimum Data Set (MDS) Assessment was completed and transmitted for a resident who was discharged on 05/14/2024. According to the facility's policy titled MDS 3.0 Completion, a discharge assessment must be completed using the discharge date as the Assessment Reference Date (ARD) and transmitted to the designated CMS system within 14 days of completion. However, a review of the resident's MDS assessments revealed that the discharge assessment had not been completed or transmitted. During an interview on 07/30/2024, the MDS Coordinator/Registered Nurse acknowledged that the discharge assessment should have been completed on the discharge date but was overlooked due to another system being in place. The MDS Coordinators were responsible for ensuring timely submission of discharge MDS assessments.
Inaccurate MDS Coding for CPAP Use and Continence
Penalty
Summary
The facility failed to ensure accurate coding in the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in documenting their care needs. For one resident, the MDS assessment did not accurately reflect the use of a Continuous Positive Airway Pressure (CPAP) machine, despite the resident's long-term use of the device for sleep apnea. The resident confirmed the use of the CPAP machine, and the MDS Coordinator acknowledged the oversight, noting that the inaccurate coding failed to identify the resident's needs properly. Another resident's MDS assessment inaccurately documented continence status. The resident was coded as always continent of bowel and bladder, despite nursing notes indicating episodes of incontinence during the assessment period. Both the MDS Coordinator and the LPN involved in the assessment recognized the discrepancy, acknowledging that the MDS did not accurately portray the resident's continence status. The Director of Nursing also confirmed the inaccuracy, highlighting the inconsistency with the resident's admission assessment.
Inaccurate Baseline Care Plan for Resident
Penalty
Summary
The facility failed to ensure an accurate baseline care plan was developed for a resident identified as RI #180. The resident was admitted with diagnoses including unspecified protein-calorie malnutrition, type two diabetes mellitus without complications, and retention of urine. The baseline care plan summary, dated 12/13/2023, incorrectly included catheter care, despite the admission MDS indicating the resident was always continent of bowel and bladder and did not have a urinary catheter. The baseline care plan was signed by an LPN who stated he used the history and physical and discharge summary to gather information but did not communicate with the resident's family or representative about the care plans. Interviews with the LPN and the DON revealed discrepancies in the documentation and understanding of the resident's needs. The LPN admitted to not remembering if he contacted the resident's family and relied solely on hospital records and nurse reports. The DON believed the resident had a Foley catheter, which was discussed during the baseline care plan meeting, but the admission assessment documented otherwise. This miscommunication and lack of verification with the resident's representative led to the inaccurate baseline care plan, affecting the resident's immediate care needs upon admission.
Failure to Include Resident Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a care plan conference was scheduled to include the resident representative of a resident identified as RI #180. The facility's policy, titled Care Planning-Resident Participation, mandates that residents and their representatives be informed and involved in care planning and treatment decisions. However, the facility did not notify or involve RI #180's representative in the care planning process. This oversight was identified during a review of the resident's care plan and confirmed through interviews with the resident's representative and the Director of Nursing (DON). RI #180 was admitted to the facility with diagnoses including unspecified protein-calorie malnutrition, type two diabetes mellitus without complications, and retention of urine. The resident's Minimum Data Set indicated a Brief Interview for Mental Status score of five out of 15, suggesting cognitive impairment. The resident's representative reported that upon admission, they were not allowed to accompany the resident to their room and were not informed or invited to participate in a care plan meeting. The DON acknowledged the importance of family involvement in care planning but confirmed that there was no documentation of the family being invited or attending a care plan meeting for RI #180.
Failure to Remove Intravenous Saline Lock
Penalty
Summary
The facility failed to ensure that a resident, identified as RI #23, had an intravenous saline lock removed after the completion of a prescribed normal saline infusion. The resident was admitted with multiple diagnoses, including Parkinson's Disease, Chronic Obstructive Pulmonary Disease, Type Two Diabetes Mellitus, and Acute Embolism and Thrombosis of Deep veins. A review of the resident's order summary revealed an order for a one-time administration of Sodium Chloride Solution 0.9% at 100 ml/hr for dehydration, with no order for a saline lock to remain in place. Despite this, the resident was observed with the saline lock in place for several days beyond the intended duration. Interviews with facility staff, including a Registered Nurse and a Certified Registered Nurse Practitioner, confirmed that the order was only for a one-day administration of normal saline, and the saline lock was not intended to remain. The Director of Nursing acknowledged that there was no documentation on the Medication Administration Record to indicate that the site was maintained after the saline was completed, highlighting a risk for infection due to the lack of monitoring. The deficiency was identified during a recertification survey, affecting one of the 31 sampled residents.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to ensure that a resident's fingernails were kept clean and cut, which was a deficiency in providing necessary assistance for activities of daily living (ADLs). The resident, identified as having a self-care performance deficit due to a displaced fracture of the right femur and impaired balance, required partial to moderate assistance for personal hygiene. Observations revealed that the resident had long fingernails with a brown, black, and red substance underneath, identified by a registered nurse as dried blood and dirt. Additionally, the resident's toenails were thick, and there was a small red sore on the tip of a toe. Interviews with the RN and the Director of Nursing (DON) highlighted that the presence of black dirt under fingernails posed a risk for infection and that hand hygiene should be maintained before and after meals. The DON stated that if a resident refused care, it should be documented in the nurse's notes, and efforts should be made to encourage care or involve family members. The facility's policy on ADLs emphasized maintaining grooming and personal hygiene, but the observations and interviews indicated a failure to adhere to these guidelines, resulting in the cited deficiency.
Improper Incontinent Care Increases UTI Risk
Penalty
Summary
The facility failed to ensure proper incontinent care for a resident, identified as RI #335, which increased the risk of urinary tract infections (UTIs). During a survey, CNA #20 was observed wiping bowel movement from the resident's buttocks and anus area to the front of the perineal area, contrary to the facility's policy that mandates wiping from front to back. Additionally, CNA #20 did not change gloves or perform hand hygiene throughout the process, which is a breach of infection control protocols. The resident, who had a diagnosis of Chronic Kidney Disease, was at risk due to these improper care practices. Interviews with CNA #20 and CNA #21 revealed a lack of adherence to proper perineal care procedures, with CNA #20 acknowledging the risk of infection from not changing gloves and not washing hands. CNA #21, who was in training, was unaware of the necessity to wash or sanitize hands after handling soiled briefs. The facility's Infection Preventionist confirmed the risk of introducing bacteria from improper wiping techniques and lack of glove changes. The facility's policy on perineal care was not followed, leading to potential cross-contamination and infection control issues.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for Resident Identifier (RI) #180, as evidenced by several deficiencies in documentation. The medical record did not include the times for verbal or telephone orders received on three separate dates. Additionally, there was a lack of documentation regarding the collection of a urine specimen obtained via catheter, including who performed the procedure and how the resident tolerated it. Furthermore, a dose of levofloxacin was documented as administered on a later date without indicating it was a late entry, violating the facility's policy on timely and accurate documentation. Interviews with staff revealed that the Licensed Practical Nurse (LPN) responsible for documenting the late entry did so at the request of the Infection Control Nurse, several days after the medication was administered. The Director of Nursing (DON) acknowledged the absence of documentation for the urine specimen collection and stated that there was no designated place to record the time for verbal or telephone orders, which was deemed unnecessary. These lapses in documentation affected one of the 31 sampled residents, highlighting a failure to adhere to the facility's policies on maintaining accurate and timely medical records.
Improper Handling of Resident Clothing in Isolation
Penalty
Summary
The facility failed to ensure proper handling of resident clothing to prevent potential cross-contamination, specifically for a resident diagnosed with COVID-19. On the specified date, clothing was observed hanging on the door knob of the resident's room, which was in isolation, and was uncovered. This was contrary to the facility's policy and CDC guidelines, which require that clothing be stored in the resident's closet or drawers to prevent contamination. The clothing was left on the door knob by laundry staff, as confirmed by a registered nurse, who acknowledged that this practice posed a risk of contamination. Interviews with the Laundry Supervisor, Infection Preventionist, and Director of Nursing further confirmed that the clothing should have been delivered into the resident's room while wearing PPE, and stored appropriately. The clothing was supposed to remain covered until it was placed inside the room. The staff's failure to adhere to these procedures resulted in a potential risk of cross-contamination, as the clothing was left exposed on the door knob of a resident's room under isolation precautions.
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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