Ridgeway Rehabilitation & Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Bessemer, Alabama.
- Location
- 4201 Bessemer Super Highway, Bessemer, Alabama 35020
- CMS Provider Number
- 015060
- Inspections on file
- 18
- Latest survey
- May 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ridgeway Rehabilitation & Senior Living during CMS and state inspections, most recent first.
A resident with a history of sexually inappropriate behavior was left unsupervised in a common area and engaged in sexual abuse of another resident, despite known risks and recent medication changes. Staff failed to provide required supervision and did not complete behavior monitoring as directed. In separate incidents, two residents were subjected to physical abuse by other residents with behavioral histories, and care plans lacked clear supervision directives. Facility policies for abuse prevention and individualized care planning were not followed, leading to multiple substantiated abuse events.
A resident with severe cognitive impairment and a history of behavioral disturbances underwent a GDR of a psychotropic medication without adequate or consistent monitoring for behaviors. Staff failed to follow documentation protocols, and the care plan lacked specific monitoring parameters. Incomplete and inaccurate behavior documentation occurred, and the resident subsequently sexually abused another resident, resulting in Immediate Jeopardy and substandard quality of care.
The facility failed to manage and document behavioral health needs for residents with a history of aggressive and sexually inappropriate behaviors, resulting in an incident where a resident was found unsupervised and engaged in inappropriate sexual contact with another resident. Staff did not consistently document or monitor target behaviors as required, and care plans lacked clear directives for supervision, leading to further incidents of aggression between residents.
The facility employed a Dietary Manager who had not yet completed the required coursework or obtained Certified Dietary Manager (CDM) status, despite serving meals to all residents. The Dietary Manager was still in the process of finishing her training and certification at the time of the survey, which did not meet the facility's job requirements for the position.
Surveyors observed multiple instances of disrepair and uncleanliness in resident rooms and common areas, including unpainted walls, broken blinds, damaged windowsills, chipped furniture, and broken ceiling tiles. Several residents confirmed these issues had persisted for extended periods. The Maintenance Director was unaware of most problems until shown by surveyors, indicating a breakdown in the facility's process for reporting and addressing environmental concerns.
Surveyors found that several hallway handrails were missing end caps, broken, or entirely absent in multiple areas, including near the nurses' stations and between office doors. The MTD and DON confirmed the importance of handrails for resident safety and acknowledged the deficiencies, with some issues persisting for several weeks.
A resident's sponsor was not notified of a room change as required by facility policy. Interviews with the SSD and DON confirmed that Social Services was responsible for this notification, but the sponsor stated she was not informed of the move.
A resident with chronic kidney disease and a physician order for regular dialysis was not accurately coded as receiving dialysis on their quarterly MDS assessment. The Regional MDS Coordinator confirmed the resident was receiving dialysis and that the omission was an oversight during assessment completion.
A resident with a history of benign prostatic hyperplasia and cystitis experienced a delay in laboratory testing after a physician ordered a urinalysis and culture and sensitivity due to increased confusion. Although a nurse documented collecting the specimen, the laboratory never received it, and the test remained pending. Ten days later, another urinalysis was performed, but it was contaminated and no further workup was completed.
A resident with multiple medical conditions was left in a bed with a non-functioning head of bed (HOB) for at least two days due to delayed communication between staff and maintenance. The bed's malfunction prevented proper positioning for care and feeding, and key staff, including the DON and MTD, were not promptly informed of the issue.
The facility did not include the total actual hours worked by RNs, LPNs, MACs, and CNAs on daily nurse staffing posting forms for several days, as required by policy. The posted forms only listed the number of staff scheduled, without reflecting actual hours worked or staff absences, a deficiency confirmed by the DON and observed on multiple occasions.
The facility failed to comply with food safety and hygiene standards, as the Dietary Manager did not wear a beard guard while handling food, and residents were served on paper plates due to a temporary shortage of dinnerware. Additionally, the kitchen stove hood and vents were dirty with grease and dust, posing a risk to food safety.
A resident with COPD did not have their nebulizer equipment maintained according to facility policy, which required storing the mask in a Ziploc bag and changing the tubing weekly. Over four days, the mask was observed uncovered, and the tubing had not been changed since December. Staff confirmed these practices could lead to infection risks.
The facility failed to maintain an effective pest control program, resulting in rodent droppings and roaches in various areas, including the kitchen and resident bathrooms. Residents reported sightings of mice, rats, and roaches over the past six months. The facility's policies on pest control and maintaining a safe environment were not effectively implemented, affecting the quality of life for residents.
The facility failed to provide a safe and homelike environment, as evidenced by a stained privacy curtain, a detaching smoke detector, a hole in the hallway wall, and missing floor tiles. These issues were observed over several days, affecting multiple residents and common areas, and were acknowledged by the facility's staff as deficiencies.
A CNA was observed standing while feeding a resident with severe cognitive impairment and upper extremity impairment, contrary to the facility's policy of maintaining resident dignity. The facility's policy requires staff to be seated at the resident's level during feeding to prevent the resident from feeling rushed.
A resident with a diagnosis of Pulmonary Embolism was receiving the anticoagulant Eliquis, but this was not accurately coded in their Quarterly MDS assessment. The MDS Coordinator confirmed the oversight, which affected the accuracy of the resident's medication records during the assessment period.
A resident at risk for pressure ulcers developed a Stage II ulcer on the back of their right leg, which was not identified during routine skin inspections by CNAs. The ulcer was discovered during a body audit by the Treatment Nurse and an LPN, despite prior assessments not documenting any concerns. The RN supervisor and DON confirmed that CNAs should have been inspecting and documenting skin conditions during care.
A resident experienced a fall in their room due to water on the floor from a leaking AC unit. The incident was documented as an un-witnessed fall, with the resident reporting slipping on the water. Nursing staff confirmed the presence of water and noted that a sheet had been placed to catch the leak, but it was insufficient. The fall was deemed avoidable by the RN who prepared the incident report.
A CNA failed to perform hand hygiene after removing gloves following a feeding task with a resident requiring substantial assistance. This action was observed and confirmed through interviews with the CNA, DON, and RDCO, highlighting a breach in the facility's hand hygiene policy aimed at preventing cross-contamination and infection.
Failure to Protect Residents from Sexual and Physical Abuse
Penalty
Summary
The facility failed to protect residents from sexual and physical abuse perpetrated by other residents. One resident with a history of sexually inappropriate behavior, including vulgar comments and obscene language, was found unsupervised in the activity room with another resident, with his hand on the other resident's breast. The resident who committed the act had a documented history of sexual remarks and behaviors, as well as diagnoses including Paranoid Schizophrenia, Vascular Dementia, Bipolar II Disorder, and Borderline Personality Disorder. Despite this history and a recent reduction in antipsychotic medication, the facility did not implement or document enhanced supervision or monitoring, and staff failed to complete required behavior monitoring documentation. The care plan for this resident did not provide clear direction regarding supervision requirements, and staff interviews confirmed that residents were left unsupervised in the activity room, contrary to facility policy. Additionally, the facility failed to protect two other residents from physical abuse. In one incident, a resident with severe cognitive impairment and a history of aggressive behavior struck another resident in the face following a dispute over a bedside table. The care plan for the aggressive resident did not specify the level of supervision required to ensure the safety of others. Staff interviews and facility records confirmed that the incident resulted in physical injury and was substantiated as physical abuse. In another incident, a resident with a history of behavioral issues hit another resident on the arm, but details of this event were not fully elaborated in the provided excerpt. The facility's policies required ongoing oversight, supervision, and individualized care planning for residents with behaviors that could lead to conflict or abuse. However, the facility did not ensure that these policies were implemented as written. Staff interviews revealed a lack of awareness regarding supervision requirements, and documentation showed that behavior monitoring was incomplete or missing. The failure to provide adequate supervision and to follow established care planning and monitoring protocols directly contributed to the incidents of abuse.
Failure to Monitor Behaviors During Psychotropic Medication Dose Reduction Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure adequate and consistent monitoring for behaviors during a Gradual Dose Reduction (GDR) of a psychotropic medication for a resident with a history of behavioral disturbances. The resident, who had diagnoses including paranoid schizophrenia, vascular dementia, bipolar II disorder, and borderline personality disorder, underwent a dose reduction of Seroquel. Despite this change, there was no documented system in place to specify the timeframe or provide clear instructions to staff on how to monitor for behaviors during the GDR process. Documentation by Certified Nursing Assistants (CNAs) and nurses in the Electronic Medication Administration Record (EMAR) was incomplete and did not accurately reflect whether the resident exhibited behaviors or escalation of behaviors during this period. The care plan for the resident did not include parameters for monitoring the resident's condition following the medication adjustment. CNA mood and behavior documentation was frequently missing or incomplete, with many shifts left blank and unclear use of documentation codes. Nursing staff also failed to follow the specified instructions for behavior monitoring in the EMAR, often using check marks instead of the required 'Y' or 'N' responses, and there were no behavior monitoring notes documented in the progress or nursing notes during the critical period after the dose reduction. Fifteen days after the dose reduction, the resident with a known history of sexually inappropriate behaviors sexually abused another resident. The lack of proper monitoring and documentation during the GDR process was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death to residents. This resulted in the citation of Immediate Jeopardy and substandard quality of care related to freedom from abuse, neglect, and exploitation.
Failure to Manage and Document Behavioral Health Needs Resulting in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that residents with behavioral health needs received appropriate care and supervision, resulting in unmanaged behaviors that compromised the safety and privacy of other residents. One resident with diagnoses including Schizophrenia, Bipolar Disorder, and a history of sexually inappropriate behavior was found unsupervised in the activity room with another resident, during which an incident of inappropriate sexual contact occurred. Staff did not consistently document the presence or absence of target behaviors as outlined in the care plan, and behavior monitoring was incomplete or inaccurately recorded. Additionally, the facility did not establish or communicate the required level of supervision when a Gradual Dose Reduction (GDR) of psychotropic medication was attempted for this resident. Interviews with staff revealed inconsistent reporting and documentation of the resident's behaviors, including sexually inappropriate comments and verbal aggression. Certified Nursing Assistants (CNAs) and other staff members reported observing behaviors such as cursing, refusal of care, and inappropriate remarks, but these were not always documented or communicated according to facility policy. The care plan for the resident included interventions for monitoring and managing behaviors, but these interventions were not effectively implemented or tracked, leading to a failure in managing the resident's risk to others. A second resident with a history of psychotic and mood disturbances exhibited combative behaviors, including hitting another resident. The care plan for this resident did not provide clear direction regarding the level of supervision required to ensure safety. Staff interviews indicated that while interventions such as removing the resident from situations and de-escalation were used, there was a lack of proactive measures and documentation to prevent incidents. These deficiencies affected multiple residents and were substantiated through record reviews, staff interviews, and direct observation.
Unqualified Dietary Manager Employed
Penalty
Summary
The facility failed to employ a qualified Dietary Manager to oversee the food and nutrition service, which had the potential to affect all 60 residents receiving meals from the kitchen. The Dietary Manager was hired with the understanding that she would complete the required dietary manager course and obtain certification, but at the time of hire and during the survey, she had not yet completed the necessary coursework or obtained Certified Dietary Manager (CDM) status. The Dietary Manager had completed some coursework in Food Safety and Management and was in the process of finishing the final module required to be eligible for the CDM exam. Despite having 25 years of LTC foodservice experience and previous experience as a dietary manager, the Dietary Manager did not meet the facility's stated job requirements for education and certification at the time of employment. The Registered Dietitian confirmed that the Dietary Manager was hired before completing the required training and certification, and that she was still in the process of finalizing her coursework and applying for the CDM exam during the survey period. The deficiency was identified through interviews, review of the employee file, and direct observation.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as required by its own policy and regulatory standards. Multiple observations by surveyors revealed numerous areas in both resident rooms and common areas that were in disrepair or unclean. Specific deficiencies included unpainted and plastered walls, chipped paint, missing or broken window blinds, damaged windowsills, chipped furniture, broken and stained ceiling tiles, detaching trim, holes in walls, and missing floor tiles. These issues were present in the rooms of several residents and throughout both units of the facility. Interviews with residents confirmed that some of these environmental deficiencies had been present for extended periods, with one resident stating that a hole in the wall had existed since their admission approximately three months prior. The Maintenance Director (MTD) acknowledged the need for repairs during walkthroughs with the surveyor and indicated that many of the issues had not been previously reported to him. The MTD stated that staff were expected to enter repair needs into the facility's work order system (TELS), but he was unaware of most of the deficiencies until they were pointed out by the surveyor. The facility's policy on maintaining a safe and homelike environment requires prompt reporting and repair of furniture and environmental issues. However, the lack of timely communication and follow-up resulted in prolonged periods where residents lived in rooms and used common areas that did not meet the standards for safety, cleanliness, and comfort. The MTD admitted that the current state of the environment would not be considered homelike.
Failure to Maintain and Secure Hallway Handrails
Penalty
Summary
Surveyors observed multiple deficiencies related to hallway handrails throughout the facility. Several handrails were missing plastic end cap pieces, including those in front of the nurses' station on Unit One, near the respiratory supply closet, and near the social services office. Additional observations revealed a broken handrail outside a resident room and missing end caps outside other resident rooms. The Maintenance Director confirmed awareness of these issues, noting that some handrails had been missing or broken for at least three weeks to a month. Further inspection identified missing sections of handrails between specific office doors and next to the nurses' station on Unit Two. The Maintenance Director provided measurements for the missing handrail sections and acknowledged the absence of handrails in these areas. Both the Maintenance Director and the Director of Nursing stated that handrails are important for resident safety, particularly for those who require assistance with ambulation, as they provide support and help prevent falls. The observations and staff interviews confirmed that the facility failed to ensure that handrails were properly installed and maintained in all required hallway areas.
Failure to Notify Resident's Sponsor of Room Change
Penalty
Summary
The facility failed to notify the sponsor or representative of a resident when the resident experienced a room change on 10/18/2024. According to the facility's policy titled 'Notification of Changes,' the facility is required to contact the resident's physician and notify the resident's representative when such changes occur. Interviews with the Social Service Designee (SSD) and the Director of Nursing (DON) confirmed that the responsibility for notifying family members of room changes lies with Social Services, and that notification should occur before the move. The SSD admitted to not notifying the resident's sponsor, and the sponsor confirmed that she was not informed of the room change. This deficiency was identified during the investigation of a specific complaint and affected one of the sampled residents.
Failure to Accurately Code Dialysis on MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's quarterly Minimum Data Set (MDS) assessment accurately reflected the receipt of dialysis treatment. The resident, who had diagnoses including dependence on renal dialysis and chronic kidney disease, was readmitted to the facility and had physician orders for renal dialysis three times per week. Despite this, the quarterly MDS assessment with an Assessment Reference Date (ARD) of 01/28/2025 was not coded to indicate that the resident received dialysis. During an interview, the Regional MDS Coordinator confirmed that the resident was receiving dialysis at the time and acknowledged that the omission was an oversight during the completion of the assessment. The failure to accurately document the dialysis treatment on the MDS assessment was identified through observations, interviews, and record review.
Failure to Provide Timely Laboratory Services for Urine Testing
Penalty
Summary
The facility failed to provide timely laboratory services for a resident who had a physician's order for a urinalysis (UA) and culture and sensitivity (C&S) on 07/19/2024. The resident, who had a history of benign prostatic hyperplasia and cystitis, was noted to be more confused on the day the order was placed, prompting the nurse to obtain a urine specimen as ordered. However, the laboratory never received the specimen, and the collection remained pending in their system. Ten days later, another UA was performed, but the results indicated probable urogenital contamination and no further workup was done. This delay and failure to process the initial laboratory order resulted in the resident not receiving timely diagnostic testing as required.
Failure to Maintain Resident Bed in Safe Operating Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's bed was maintained in a safe and functional condition at all times. The resident, who had diagnoses including dementia, anxiety, intellectual disabilities, and gastrostomy status, was observed on multiple occasions with the head of bed (HOB) in a flat position due to a malfunctioning bed. Certified Nursing Assistant (CNA) #23 reported that the bed had been broken since the previous day, and the Maintenance Director (MTD) was not informed until a day later. The resident remained in the non-functioning bed for at least two days, during which time the HOB could not be elevated for care or feeding. Interviews with staff revealed a lack of timely communication regarding the bed's malfunction. CNA #23 was unsure when the issue was reported to maintenance, and the MTD stated he was not informed until the day after the problem was first noticed. The Director of Nursing (DON) also confirmed she had not been notified of the issue. Staff acknowledged the importance of a functioning bed, particularly for residents who require the HOB to be elevated during feeding to prevent choking or aspiration, and for general safety and care needs.
Failure to Post Actual Nursing Staff Hours on Daily Staffing Forms
Penalty
Summary
The facility failed to ensure that the total hours actually worked by nursing staff were included on the daily nurse staffing posting forms for five specific days during the survey period. Observations on multiple days revealed that the posted forms listed the number of Registered Nurses (RN), Licensed Practical Nurses (LPN), Medication Assistant Certified (MAC), and Certified Nursing Assistants (CNA) scheduled to work each shift, but did not include a section for the total hours actually worked. This omission was consistent across all observed forms for the affected days, and the forms did not reflect staff absences or actual hours worked as required by the facility's own policy. An interview with the Director of Nursing (DON) confirmed that the posted forms were missing the required information regarding actual hours worked for RNs, LPNs, and CNAs. The DON acknowledged that the facility's policy mandates the inclusion of this information and that it is important for knowing how many staff were present during each shift. The deficient practice was observed on five out of eleven days during the survey and had the potential to affect all 61 residents residing in the facility.
Non-Compliance with Food Safety and Hygiene Standards
Penalty
Summary
The facility failed to adhere to its policy on personal hygiene and food safety standards, as evidenced by the Dietary Manager (DM) not wearing a beard guard while handling food in the kitchen on multiple occasions. Observations on 01/06/2025 and 01/08/2025 revealed the DM without a beard guard, even while placing macaroni salad into bowls. The DM acknowledged the importance of wearing a beard guard to prevent hair contamination in food but admitted to not wearing one on several days. This non-compliance with the facility's dress code policy posed a risk of food contamination for all 52 residents receiving meals from the kitchen. Additionally, the facility did not consistently serve meals on proper dinnerware, as observed on 01/06/2025, when four out of nine residents in the dining room were served on paper plates. A resident confirmed the frequent use of paper plates, expressing a preference for nicer plates. A Dietary Aide explained that paper plates were used due to a temporary shortage of dinnerware, although the DM later stated there was no shortage and that residents should not be served on paper plates unless they were in isolation or sick. Furthermore, the kitchen stove hood and vents were found to be dirty with grease and dust, which the DM acknowledged had not been cleaned, potentially affecting food safety and proper venting.
Failure to Maintain Nebulizer Equipment as per Policy
Penalty
Summary
The facility failed to maintain the nebulizer equipment for a resident, identified as RI #8, in accordance with their policy titled Nebulizer Therapy. The policy required that nebulizer masks be stored in a Ziploc bag to prevent contamination, and that the tubing be changed weekly. However, over the course of four days, from January 6 to January 9, 2025, the nebulizer mask was repeatedly observed not being stored in a Ziploc bag, and the tubing had not been changed since December 22, 2024. This oversight was confirmed through observations and interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Infection Preventionist (IP), both of whom acknowledged the potential for infection due to these lapses. RI #8, who was admitted to the facility with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), was prescribed daily nebulizer treatments with Ipratropium-Albuterol Solution. Despite the clear guidelines outlined in the facility's policy, the nebulizer mask was left uncovered, and the tubing was not replaced as scheduled. The LPN confirmed that the tubing should have been changed on Sunday evenings, and the IP highlighted the risk of bacterial growth when equipment is not stored or maintained properly. These failures in following the established protocol for respiratory care equipment maintenance directly contributed to the deficiency identified during the survey.
Pest Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of rodent droppings and roaches in various areas. Observations by surveyors revealed rodent droppings in the Dietary Manager's office, the dry storage room in the kitchen, and the nurses' medication room. The Dietary Manager confirmed the presence of rat droppings, which posed a contamination risk. Additionally, adhesive strips with dead roaches were found in a resident's bathroom and the kitchen, indicating a significant pest issue. Residents reported sightings of mice, rats, and roaches in their rooms, bathrooms, and hallways over the past six months. During a Resident Council Group Meeting, multiple residents confirmed these sightings, with one resident specifically mentioning seeing a large roach the previous day. The facility's failure to address these pest issues led to numerous complaints from residents, highlighting the ongoing problem. The facility's policies on pest control and maintaining a safe and homelike environment were not effectively implemented. The Maintenance Director acknowledged a gap beneath an exit door that could allow rodents to enter the building. Despite the facility's policies, the presence of pests and the residents' complaints indicate a failure to provide a clean and comfortable environment, affecting the quality of life for the residents.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several observations made by surveyors. In one instance, a privacy curtain in a resident's room was found to be stained with a brown substance, which was later identified by the Housekeeping Supervisor as resembling a bowel movement. This stain remained on the curtain over multiple days, indicating a lack of timely cleaning and maintenance. Additionally, a smoke detector in another resident's room was observed to be detaching from the ceiling, posing a potential safety hazard as noted by the Maintenance Director. Further deficiencies were observed in the common areas of the facility. A hole the size of a baseball was found in the hallway wall adjacent to a resident's room, which the Maintenance Director acknowledged should not be present and detracted from the homelike appearance of the environment. Moreover, two tiles were missing from the floor outside another resident's room, creating a potential tripping hazard. These issues were identified during the investigation of specific complaint/report numbers, affecting three residents and one medication room within the facility.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) adhered to the policy of promoting and maintaining resident dignity during meal assistance. On July 30, 2024, CNA #7 was observed standing while feeding a resident, identified as RI #6, during the lunch meal. This action was contrary to the facility's policy, which emphasizes treating residents with respect and dignity, including being seated at the resident's level during feeding to avoid making the resident feel rushed. RI #6, who was admitted with diagnoses including Cognitive Communication Deficit, Dysphagia, and a need for substantial assistance with eating, was affected by this practice. The resident's Quarterly Minimum Data Set (MDS) assessment indicated severely impaired cognition and upper extremity impairment, necessitating maximal assistance with eating. Interviews with CNA #7, the Director of Nursing, and the Regional Director of Clinical Operations confirmed that standing while feeding a resident is a dignity issue and staff should be seated at the resident's eye level.
Inaccurate MDS Assessment for Anticoagulant Medication
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident, identified as RI #12, in their Quarterly Minimum Data Set (MDS) assessment. The deficiency was identified during a review of the resident's records and an interview with the MDS Coordinator. RI #12, who was admitted to the facility with a diagnosis of Pulmonary Embolism without Acute Cor Pulmonale, had been receiving an anticoagulant medication, Eliquis, as per physician's orders since March 2024. However, the MDS assessment with an Assessment Reference Date of July 2, 2024, did not reflect that the resident received this medication during the assessment period. The MDS Coordinator acknowledged that the resident was receiving Eliquis during the seven-day look-back period and that it should have been coded in the MDS assessment. The oversight was attributed to a failure in accurately coding the medication, which is crucial for ensuring that all relevant parties are aware of the medications a resident is receiving. This error affected one of the 26 sampled residents whose MDS assessments were reviewed, highlighting a lapse in the facility's assessment process.
Failure to Identify Stage II Pressure Ulcer
Penalty
Summary
The facility failed to identify a Stage II pressure injury on the back of a resident's right leg during a body audit conducted by the Treatment Nurse and a surveyor. The resident, who was assessed as being at risk for developing pressure ulcers, had a Quarterly Minimum Data Set assessment indicating this risk. However, a Shower Audit/Skin Assessment form dated prior to the discovery did not document any injury or area of concern on the resident's leg. The Certified Nursing Assistant (CNA) assigned to the resident did not recall inspecting the back of the resident's right leg during care, which contributed to the oversight. The deficiency was further highlighted when the Treatment Nurse and another LPN identified the pressure ulcer during a body audit, despite not being informed of the open area beforehand. The RN supervisor and the Director of Nursing both acknowledged that CNAs should have been inspecting the resident's skin during care and documenting any findings on the shower sheets. The failure to identify the pressure ulcer in a timely manner was a result of inadequate skin inspections by the CNAs, as confirmed by interviews with facility staff.
Resident Fall Due to Leaking AC Unit
Penalty
Summary
The facility failed to ensure a safe environment for Resident Identifier (RI) #7, resulting in a fall due to water on the floor from a leaking air conditioner (AC) unit in the resident's room. The incident was documented in an incident report titled 'Un-witnessed Fall,' where the resident was found on the floor beside the bed. The resident reported slipping on water from the leaking AC unit, which was confirmed by the nursing staff present at the scene. The resident experienced soreness and redness but no broken skin or head injury. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and a Registered Nurse (RN), corroborated the presence of water on the floor due to the leaking AC unit. The CNA noted that a sheet had been placed on the floor to catch the leaking water, but it was insufficient to prevent the fall. The RN, who prepared the incident report, stated that the fall was avoidable and attributed it to the water on the floor. This deficiency was identified during the investigation of a complaint, affecting one of the five residents sampled for falls.
Failure to Perform Hand Hygiene After Glove Removal
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by a Certified Nursing Assistant (CNA) after feeding a resident. The CNA, identified as CNA #7, was observed on 07/30/2024 feeding a resident diagnosed with Dysphagia and requiring substantial assistance with eating. After completing the feeding task, CNA #7 removed her gloves and exited the resident's room without performing hand hygiene, which is a violation of the facility's hand hygiene policy. Interviews conducted with CNA #7, the Director of Nursing (DON), and the Regional Director of Clinical Operations (RDCO)/Infection Control Nurse confirmed the deficiency. CNA #7 acknowledged that she should have sanitized her hands after removing her gloves to prevent cross-contamination. Both the DON and RDCO emphasized the importance of sanitizing hands immediately after glove removal to prevent infection and cross-contamination, aligning with the facility's policy that states hand hygiene must be performed after glove removal.
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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