The Health Center At Research Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntsville, Alabama.
- Location
- 5275 Millennium Drive, Huntsville, Alabama 35806
- CMS Provider Number
- 015458
- Inspections on file
- 12
- Latest survey
- June 18, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Health Center At Research Park during CMS and state inspections, most recent first.
A resident with a history of aggressive behavior and cognitive impairment was not properly supervised upon returning from the hospital, leading to an incident where they attempted to smother another resident with a pillow. The facility's failure to implement its abuse prevention policy resulted in a deficiency at the immediate jeopardy level.
A resident with a history of aggressive behavior and cognitive impairment returned from the hospital without a plan to ensure safety, leading to an incident where the resident attempted to smother another resident. The facility failed to conduct a nursing assessment or implement necessary interventions, violating its Behavioral Health Services policy.
A resident with a history of dementia and major depressive disorder exhibited aggressive behaviors and suicidal ideations, leading to hospitalization. Upon return, the LTC facility failed to implement necessary interventions or conduct a nursing assessment, resulting in a critical incident where the resident attempted to harm another resident.
The facility failed to provide meals according to the planned menu, affecting residents' nutrition. Hot water was added to pureed foods to extend volume, and incorrect portion sizes were served for various diet textures. Additionally, orange slices were served instead of apple slices for CCHO diets without approval. Staff acknowledged the discrepancies, and the Registered Dietitian confirmed the importance of adhering to menu specifications.
The facility failed to prevent cross-contamination and ensure proper sanitization in its kitchen. Staff moved from handling dirty to clean dishes without washing hands, used a cloth to dry trays instead of air drying, and blocked access to a handwashing sink. The dish machine's final rinse did not reach the required temperature, and staff recorded expected rather than actual temperatures. These deficiencies affected all residents receiving meals.
A facility failed to maintain and reconcile controlled medication records for two residents, resulting in missing oxycodone tablets. The medications were signed for by a nurse but not properly documented or secured, leading to their disappearance. Despite the missing medications, neither resident missed a dose of their pain medication.
A resident admitted with serious health conditions did not receive a baseline care plan within 48 hours as required by the facility's policy. Interviews with the MDS Coordinator and DON confirmed the absence of the care plan, with responsibility attributed to the admitting nurse.
The facility failed to provide proper respiratory care for two residents. One resident's oxygen therapy lacked a physician's order, and the tubing was not labeled or dated. Another resident's nebulizer mask was not stored in a plastic bag when not in use, violating infection control protocols. Staff interviews confirmed these practices were not followed, leading to deficiencies in care.
The facility failed to ensure proper hand hygiene and storage of resident hygiene supplies, leading to potential cross-contamination. Unlabeled bath basins were found in a shared bathroom, and an LPN did not perform hand hygiene after cleaning a wound. These actions violated the facility's infection control policies.
A resident with dementia and major depressive disorder was transferred to the hospital due to aggressive behaviors, but the facility failed to notify the resident's representative. The representative learned of the transfer from the hospital social worker and contacted the facility afterward, discovering the resident had been hospitalized for several days without her knowledge.
A registered nurse (RN) at a long-term care facility failed to protect a resident's property by placing the resident's temazepam in her pocket and leaving the facility. The RN was later found with the medication during a K-9 search at her other job, leading to her arrest for possession and theft. The resident could not recall refusing the medication, and the facility's policy on abuse prohibition was violated.
The facility failed to report an allegation of physical abuse involving a resident within the required two-hour timeframe to the state agency. Staff became aware of the incident early in the morning but did not report it to the Alabama Department of Public Health until several hours later, exceeding the policy's reporting requirement. This deficiency affected one of the three sampled residents reviewed for abuse concerns.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. During lunch, one resident exhibited aggressive behavior, including verbal and physical abuse towards staff, and expressed suicidal and homicidal ideations. This resident was sent to the hospital but returned to the facility without proper supervision. Early the next morning, the resident was found in another resident's room, attempting to smother them with a pillow. The resident who committed the abuse had a history of aggressive behavior and cognitive impairment, as indicated by their medical records. Despite this, the facility did not adequately supervise the resident upon their return from the hospital. The incident was witnessed by a CNA, who intervened and separated the residents. The facility's failure to supervise the resident upon their return from the hospital led to the incident of abuse. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the lack of supervision and the subsequent incident. The facility's noncompliance with federal requirements resulted in a situation that was likely to cause serious harm to residents. The deficiency was identified as a result of a complaint investigation and was determined to be at the immediate jeopardy level.
Removal Plan
- Resident's #334 and #335 were separated by the CNA.
- Resident #334 was assessed by the Charge Nurse, with no injuries noted.
- The Psychiatric Nurse Practitioner assessed Resident #334 and documented in a provider note with no negative findings. Resident #334 was assessed by the Nurse with no negative findings.
- Resident #335 was placed on one on one by the Charge Nurse until resident transferred to the hospital by HEMSI and ultimately discharged.
- Resident interviews were conducted by the Social Services Director and Activity Coordinator with a BIMS of 13 or greater regarding physical or verbal abuse by another resident with no negative findings.
- Residents with a BIMS of 12 or less, a body audit was completed by the Director of Nursing and Charge Nurse with no negative findings.
- Alabama Department of Health, Adult Protective Services, and law enforcement were notified of the reported events by the Administrator.
- Resident interviews were conducted by the Social Services Director with a BIMS of 13 or greater regarding abuse by anyone with no negative findings.
- Residents with a BIMS of 12 or less, a body audit was completed by the Director of Nursing, Staffing Coordinator, and Charge Nurse with no negative findings.
- Charge Nurse made notifications to the practitioners and responsible parties for resident #334 and #335.
- Clinical Record Review was initiated and completed by the Director of Clinical Education and Regional Nurse Managers to include clinical notes, event notes, and daily skilled notes to identify any potential residents for instances of physical abuse, with no unknown new findings.
- Inservice was provided by the Assistant President of Operations and the Regional Nurse Manager to the Administrator, DON, Staffing Coordinator, Social Services, and Receptionist/CNA on the Abuse Policy Protocol, updated Behavior Health Services Policy, and interventions related to abuse, aggressive, distress and combative behaviors and suicidal/homicidal ideation. Education was also provided regarding staff unavailable to receive education will not be permitted to work until required education is completed.
- The Staffing Coordinator was designated as responsible for ensuring staff are educated on abuse prohibition plan, behavioral health services policy, and list of interventions for behaviors.
- Inservice was provided by the DON, Staffing Coordinator, Social Services, and Receptionist/CNA on the Abuse Policy Protocol, updated Behavior Health Services Policy, and interventions related to abuse, aggressive, distress, and combative behaviors and suicidal/homicidal ideation to all staff.
- Staff unavailable to receive education will not be permitted to work until the required education is completed.
- 73 out of 77 employees have been educated.
- Competency and validation questions were answered by staff currently working to ensure competency verbalized from education received.
- The Regional Nurse Manager placed signage in break rooms, nurses stations, and behavior communication binders that list interventions for behaviors including abuse, aggressive, distress and combative behaviors and suicidal/homicidal ideation.
- Adhoc QAPI was conducted to include Administrator, Director of Nursing, Senior President of Operations, Assistant President of Operations, Regional Nurse Manager, Assistant President of Clinical Operations, Regional Nurse Manager to discuss resident to resident altercation event, education, root cause, and interventions.
- The Medical Director was notified of the immediate jeopardy citations by the Assistant President of Operations.
- A Root cause analysis was conducted by the Administrator, Regional Director of Operations, Assistant President of Clinical Operations, Regional Nurse Manager, Directors of Nursing, Assistant President of Quality, Director of Clinical Education. Root cause was identified as ineffective training and education related to behavioral health services.
- QAPI meeting was conducted to include Administrator, Director of Nursing, Staffing Coordinator, Dietary Manager, Activity Coordinator, Treatment Nurse, Receptionist, MDS Coordinator, Social Service Director, Business Office Manager, Maintenance Director, Regional Nurse Manage, Assistant President of Operations, Regional Nurse Manager, Medical Director, Assistant President of Clinical Operations, Senior President, and Director of Clinical Education regarding Immediate Jeopardy citations, Abuse and Behavior Health Services policy review, education, interventions for immediate removal plan, Medical Director notification, facility assessment updated/reviewed and root cause analysis determined.
- Abuse Prohibition Plan reviewed with no recommendation for changes.
- The Behavior Health Services Policy reviewed with recommendation made to include suicidal and homicidal ideation's under procedures- to include risk factors, triggering events, examples used to harm self. Definition of Suicidal Ideation added to provide clarification of terminology related to behavioral health services.
- Updated Intervention list attachment included in the updated Behavior Health Policy for behaviors to include immediate action steps to implement related to abuse, aggressive, distress, combative, and Suicidal and Homicidal Ideations.
- The facility assessment plan was revised to include suicidal ideations.
- A Governing Body meeting was held to include the Administrator, Director of Nursing, Assistant President of Operations, Assistance President for Clinical, Senior President of Operations, and Regional Nurse Managers to discuss the corrective action plans to address the immediate concerns for F 600 for Resident's #334 and #335 and all current residents have the potential to be affected. The Medical Director agreed with the current action plan and had no new recommendations.
- Facility implemented all corrective Actions.
Failure to Implement Behavioral Health Interventions for Aggressive Resident
Penalty
Summary
The facility failed to ensure necessary behavioral health care and services were provided to a resident, identified as RI #335, who exhibited physically and verbally aggressive behaviors, as well as homicidal and suicidal ideations. On one occasion, RI #335 was sent to the hospital emergency room after being physically and verbally abusive to staff and expressing homicidal and suicidal ideations. Upon returning from the hospital, the facility did not develop a plan to ensure the safety of other residents, nor were any new orders or interventions implemented. The deficiency was highlighted when a Certified Nursing Assistant (CNA) witnessed RI #335 in another resident's room, attempting to smother the resident with a pillow. This incident occurred shortly after RI #335's return from the hospital, during which time no nursing assessment was conducted, and no interventions were put in place to address the resident's aggressive behaviors. Interviews with facility staff revealed that there was an expectation that the hospital would have kept RI #335, and as a result, no immediate interventions were planned upon the resident's return. The facility's policy on Behavioral Health Services was not adhered to, as it mandates that necessary behavioral health care services be person-centered and reflect the resident's goals for care while ensuring safety. Despite RI #335's history of aggressive behavior and cognitive impairment, the facility did not implement appropriate interventions or conduct a comprehensive assessment upon the resident's return from the hospital, leading to a situation that posed a risk of serious harm to other residents.
Removal Plan
- Resident #335 was redirected from the Dining room by the Administrator after yelling, throwing things and grabbing at staff.
- Social services made referrals for Psych services related to physical and verbally abusive behaviors and suicidal ideation. Charge Nurse sent RI #335 to the ER and transported by HEMSI.
- Resident #335 returned from the hospital by HEMSI with no new orders. Labs were drawn at the ER. Per ER records resident denied any complaints, denied suicidality and homicidal ideations.
- Resident's #334 and #335 were separated by the CNA.
- Resident #334 was assessed by the Charge Nurse, with no injuries noted.
- The Psychiatric Nurse Practitioner assessed Resident #334 and documented in a provider note with no negative findings. Resident #334 was assessed by the Nurse with no negative findings.
- Resident #335 was placed on one on one by the Charge Nurse until resident transferred to the hospital by HEMSI and ultimately discharged.
- Resident interviews were conducted by the Social Services Director and Activity Coordinator with a BIMS of 13 or greater regarding physical or verbal abuse by another resident with no negative findings.
- Residents with a BIMS of 12 or less, a body audit was completed by the Director of Nursing and Charge Nurse with no negative findings.
- Alabama Department of Health, Adult Protective Services, and law enforcement were notified of the reported events by the Administrator.
- Resident interviews were conducted by the Social Services Director with a BIMS of 13 or greater regarding abuse by anyone with no negative findings.
- Residents with a BIMS of 12 or less, a body audit and observation for abuse and behaviors was completed by the Director of Nursing, Staffing Coordinator, and Charge Nurse with no negative findings.
- Resident interviews using a Resident Psychosocial Health Questionnaire were conducted by Social Services Director with BIMS of 13 or greater to determine resident's mood, behaviors, and thoughts such as anxiety, agitation, depression, suicidal and homicidal ideations, with no new negative findings.
- Charge Nurse made notifications to the practitioners and responsible parties for resident #334 and #335.
- Clinical Record Review was initiated and completed by the Director of Clinical Education and Regional Nurse Managers to include clinical notes, event notes, and daily skilled notes to identify any potential residents for instances of allegations of potential/actual abuse, aggressive, distress, and combative behaviors, and suicidal and homicidal ideations, with no new unknown findings.
- Inservice was provided by the Assistant President of Operations and the Regional Nurse Manager to the Administrator, DON, Staffing Coordinator, Social Services, and Receptionist/CNA on the Abuse Policy Protocol, updated Behavior Health Services Policy, and interventions related to abuse, aggressive, distress and combative behaviors, and suicidal/homicidal ideation. Education was also provided regarding staff unavailable to receive education will not be permitted to work until required education is completed.
- The Staffing Coordinator was designated as responsible for ensuring staff are educated on abuse prohibition plan, behavioral health services policy, and list of interventions for behaviors.
- Inservice was provided by the DON, Staffing Coordinator, Social Services, and Receptionist/CNA on the Abuse Policy Protocol, updated Behavior Health Services Policy, and interventions related to abuse, aggressive, distress, and combative behaviors, and suicidal/homicidal ideation to all staff. Staff unavailable to receive education will not be permitted to work until the required education is completed. 73 out of 77 employees have been educated.
- Competency and validation questions were answered by staff currently working to ensure competency verbalized from education received.
- The Regional Nurse Manager placed signage in break rooms, nurses stations, and behavior communication binders that list interventions for behaviors including abuse, aggressive, distress and combative behaviors, and suicidal/homicidal ideation. This communication binder is used as a communication tool for staff to note resident behaviors, new or changes. This communication binder is brought to morning QA by a member of the Behavior Committee and reviewed during QA to determine appropriate interventions.
- Regional Nurse Manager inserviced the DON, Staffing Coordinator and Risk Manager that upon return from a transfer when ER deems residents appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a behavioral assessment should be conducted. This form will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations.
- The DON, Staffing Coordinator, and Risk Manager in-serviced Nursing Staff that upon return from a transfer when ER deems residents appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a behavioral assessment should be conducted using the Resident Return from Transfer Behavior assessment form. This form will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations. Nursing Staff unavailable to receive education will not be permitted to work until the required education is completed. 20 out of 22 Nurses have been educated.
- Adhoc QAPI was conducted to include Administrator, Director of Nursing, Senior President of Operations, Assistant President of Operations, Regional Nurse Manager, Assistant President of Clinical Operations, Regional Nurse Manager to discuss resident to resident altercation event, education, root cause, and interventions.
- The Medical Director was notified of the immediate jeopardy citations by the Assistant President of Operations.
- A Root cause analysis was conducted by the Administrator, Regional Director of Operations, Assistant President of Clinical Operations, Regional Nurse Manager, Directors of Nursing, Assistant President of Quality, Director of Clinical Education. Root cause was identified as ineffective training and education related to behavioral health services.
- QAPI meeting was conducted to include Administrator, Director of Nursing, Staffing Coordinator, Dietary Manager, Activity Coordinator, Treatment Nurse, Receptionist, MDS Coordinator, Social Service Director, Business Office Manager, Maintenance Director, Regional Nurse Manage, Assistant President of Operations, Regional Nurse Manager, Medical Director, Assistant President of Clinical Operations, Senior President, and Director of Clinical Education regarding Immediate Jeopardy citations, Abuse and Behavior Health Services policy review, education, interventions for immediate removal plan, Medical Director notification, facility assessment updated/reviewed and root cause analysis determined.
- Behavior Health Services Policy reviewed with recommendation made to include suicidal and homicidal ideations under procedures- to include risk factors, triggering events, examples used to harm self. Definition of Suicidal Ideation added to provide clarification of terminology related to behavioral health services.
- Updated Intervention list attachment included in the updated Behavior Health Policy for behaviors to include immediate action steps to implement related to abuse, aggressive, distress, and combative behaviors, and Suicidal and Homicidal Ideations.
- The facility assessment plan was revised to include suicidal ideations.
- A Governing Body meeting was held to include the Administrator, Director of Nursing, Assistant President of Operations, Assistance President for Clinical, Senior President of Operations, and Regional Nurse Managers to discuss the corrective action plans to address the immediate concerns for F 600, F 740, F 741 and F 867 for Resident's #334 and #335 and all current residents in the facility have the potential to be affected. The Medical Director agreed with the current action plan and had no new recommendations.
- This Behavior Communication binder is brought to morning QA by a member of the Behavior Committee and reviewed during QA to determine any new or changes in behaviors, intervention implementation and appropriateness and will be revised as necessary.
- Upon return from a transfer when ER deems resident appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a Resident Return from Transfer Behavior assessment will be conducted. This will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations. For any resident discharged and readmitted a readmission assessment is already part of the readmission process and is completed to include an abuse and behavior section. Nursing Staff was educated that upon return from a transfer when ER deems residents appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a behavioral assessment should be conducted using the Resident Return from Transfer Behavior assessment form. This form will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations. Nursing Staff unavailable to receive education will not be permitted to work until the required education is completed. 20 out of 22 Nurses have been educated.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to ensure sufficient staff with the necessary competencies and skills to address the behavioral health needs of a resident, identified as RI #335, who exhibited aggressive behaviors and suicidal and homicidal ideations. On one occasion, RI #335 was physically and verbally abusive to staff and expressed suicidal and homicidal thoughts, leading to their transfer to a hospital. Upon returning from the hospital, the facility did not develop or implement interventions to ensure the safety of the resident or provide additional supervision. Staff observed that RI #335 was acting unusually, not cooperating, and not responding to redirection as they had previously. Despite these observations, no actions were taken to ensure the safety of the residents. A critical incident occurred when RI #335 was found in another resident's room, attempting to smother them with a pillow. This incident highlighted the facility's noncompliance with the requirement to have competent staff to meet the behavioral health needs of residents, as outlined in the State Operations Manual, Appendix PP, 483.40 Behavioral Health at F 741. Interviews with staff revealed that a nursing assessment was not completed when RI #335 returned from the hospital, as they had not been gone for over 24 hours. The Director of Nursing acknowledged that an assessment should have been conducted, which would have triggered necessary interventions such as one-on-one supervision. The lack of a nursing assessment and subsequent interventions contributed to the facility's failure to address the behavioral health needs of RI #335 adequately.
Removal Plan
- Resident #335 was redirected from the Dining room by the Administrator after yelling, throwing things and grabbing at staff.
- Social services made referrals for Psych services related to physical and verbally abusive behaviors and suicidal ideation. Charge Nurse sent R1#335 to the ER and transported by HEMSI.
- Resident #335 returned from the hospital by HEMSI with no new orders. Labs were drawn at the ER. Per ER records resident denied any complaints, denied suicidally and homicidally.
- Resident's #334 and #335 were separated by the CNA.
- Resident #334 was assessed by the Charge Nurse, with no injuries noted.
- The Psychiatric Nurse Practitioner assessed Resident #334 and documented in a provider note with no negative findings. Resident #334 was assessed by the Nurse with no negative findings.
- Resident #335 was placed on one on one by the Charge Nurse until resident transferred to the hospital by HEMSI and ultimately discharged.
- Resident interviews were conducted by the Social Services Director and Activity Coordinator with a BIMS of 13 or greater regarding physical or verbal abuse by another resident with no negative findings.
- Residents with a BIMS of 12 or less, a body audit was completed by the Director of Nursing and Charge Nurse with no negative findings.
- Alabama Department of Health, Adult Protective Services, and law enforcement were notified of the reported events by the Administrator.
- Resident interviews were conducted by the Social Services Director with a BIMS of 13 or greater regarding abuse by anyone with no negative findings.
- Residents with a BIMS of 12 or less, a body audit and observation for abuse and behaviors was completed by the Director of Nursing, Staffing Coordinator, and Charge Nurse with no negative findings.
- Resident interviews using a Resident Psychosocial Health Questionnaire were completed by Social Services Director with BIMS of 13 or greater to determine resident's mood, behaviors and thoughts such as anxiety, agitation, depression, suicidal and homicidal ideation, with no new negative findings.
- Charge Nurse made notifications to the practitioners and responsible parties for resident #334 and #335.
- Clinical Record Review was initiated and completed by the Director of Clinical Education and Regional Nurse Managers to include clinical notes, event notes, and daily skilled notes to identify any potential residents for instances of potential/actual abuse, aggressive, distress, and combative behaviors, and suicidal and homicidal ideation that might require Behavioral Health services, with no new unknown findings.
- Inservice was provided by the Assistant President of Operations and the Regional Nurse Manager to the Administrator, DON, Staffing Coordinator, Social Services, and Receptionist/CNA on the Abuse Policy Protocol, updated Behavior Health Services Policy, and interventions related to abuse, aggressive, distress, and combative behaviors and suicidal/homicidal ideation. Education was also provided regarding staff unavailable to receive education will not be permitted to work until required education is completed.
- The Staffing Coordinator was designated as responsible for ensuring staff are educated on abuse prohibition plan, behavioral health services policy, and list of interventions for behaviors.
- Inservice was provided by the DON, Staffing Coordinator, Social Services, and Receptionist/CNA on the Abuse Policy Protocol, Behavior Health Services Policy, and interventions related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideation to all staff. Staff unavailable to receive education will not be permitted to work until the required education is completed. 73 out of 77 employees have been educated.
- Competency and validation questions were answered by staff currently working to ensure competency verbalized from education received.
- The Regional Nurse Manager placed signage in break rooms, nurses stations, and behavior communication binders that list interventions for behaviors including abuse, aggressive, distress, and combative behaviors, and suicidal/homicidal ideation. This communication binder is used as a communication tool for staff to note resident behaviors, new or changes. This communication binder is brought to morning QA by a member of the Behavior Committee and reviewed during QA to determine appropriate interventions.
- Regional Nurse Manager inserviced the DON, Staffing Coordinator and Risk Manager that upon return from a transfer when ER deems residents appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideation's a behavioral assessment should be conducted. This form will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideation's.
- The DON, Staffing Coordinator, and Risk Manager inserviced Nursing Staff that upon return from a transfer when ER deems residents appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideation a behavioral assessment should be conducted using the Resident Return from Transfer Behavior assessment form. This form will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideation. Nursing Staff unavailable to receive education will not be permitted to work until the required education is completed. 20 out of 22 Nurses have been educated.
- Adhoc QAPI was conducted to include Administrator, Director of Nursing, Senior President of Operations, Assistant President of Operations, Regional Nurse Manager, Assistant President of Clinical Operations, Regional Nurse Manager to discuss resident to resident altercation event, education, root cause, and interventions.
- The Medical Director was notified of the immediate jeopardy citations by the Assistant President of Operations.
- A Root cause analysis was conducted by the Administrator, Regional Director of Operations, Assistant President of Clinical Operations, Regional Nurse Manager, Directors of Nursing, Assistant President of Quality, Director of Clinical Education. Root cause was identified as ineffective training and education related to behavioral health services.
- QAPI meeting was conducted to include Administrator, Director of Nursing, Staffing Coordinator, Dietary Manager, Activity Coordinator, Treatment Nurse, Receptionist, MDS Coordinator, Social Service Director, Business Office Manager, Maintenance Director, Regional Nurse Manage, Assistant President of Operations, Regional Nurse Manager, Medical Director, Assistant President of Clinical Operations, Senior President, and Director of Clinical Education regarding Immediate Jeopardy citations, Abuse and Behavior Health Services policy review, education, interventions for immediate removal plan, Medical Director notification, facility assessment updated/reviewed and root cause analysis determined.
- Abuse Prohibition Plan reviewed with no recommendation for changes.
- Behavior Health Services Policy reviewed with recommendation made to include suicidal and homicidal ideations under procedures- to include risk factors, triggering events, examples used to harm self. Definition of Suicidal Ideation added to provide clarification of terminology related to behavioral health services.
- Updated Intervention list attachment included in the updated Behavior Health Policy for behaviors to include immediate action steps to implement related to abuse, aggressive, distress, and combative behavior, and Suicidal and Homicidal Ideations.
- The facility assessment plan was revised to include suicidal ideations.
- A Governing Body meeting was held to include the Administrator, Director of Nursing, Assistant President of Operations, Assistance President for Clinical, Senior President of Operations, and Regional Nurse Managers to discuss the corrective action plans to address the immediate concerns for F600, F740, F741, and F867 for Resident's #334 and #335 and all current residents in the facility have the potential to be affected. The Medical Director agreed with the current action plan and had no new recommendations.
- This Behavior Communication binder is brought to morning QA by a member of the Behavior Committee and reviewed during QA to determine any new or changes in behaviors, intervention implementation, and appropriateness and will be revised as necessary.
- Upon return from a transfer when ER deems resident appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a Resident Return from Transfer Behavior assessment will be conducted. This will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations. For any resident discharged and readmitted a readmission assessment already part of the readmission process is completed to include an abuse and behavior section. Nursing Staff educated that upon return from a transfer when ER deems residents appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a behavioral assessment should be conducted using the Resident Return from Transfer Behavior assessment form. This form will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations. Nursing Staff unavailable to receive education will not be permitted to work until the required education is completed. 20 out of 22 Nurses have been educated.
Nutritional Deficiency in Meal Service
Penalty
Summary
The facility failed to ensure that residents received nutrition as planned per the facility's menu, as observed during lunch services on two consecutive days. On the first day, hot water was added to pureed food items to extend their volume, which diluted the nutrients and altered the consistency of the food. Additionally, the portions of chicken and noodles served for various diet textures were less than the amounts indicated on the menu. This discrepancy was observed during the lunch service, where the puree meat scoop was not filled completely, and hot water was added to the puree green beans, making them more liquid than puree. On the second day, the facility's menu indicated specific portion sizes for Chicken Fettuccini and Buttered Noodles, but these items were mixed together and served with a 4-ounce spoodle, which was insufficient according to the menu's requirements. The Kitchen Supervisor and other staff members acknowledged that the portions served were not enough, and the mixing of items led to incorrect serving sizes. Furthermore, residents on Consistent Carbohydrate (CCHO) diets were served orange slices instead of the apple slices specified in the menu, without approval from the Registered Dietitian. Interviews with the Dietary Manager and Registered Dietitian revealed that the staff was trained to follow recipes and portion sizes, but the instructions were not adhered to during meal preparation and service. The Dietary Manager confirmed that adding hot water to stretch pureed food was not acceptable, as it reduced the nutritional value. The Registered Dietitian emphasized that the menus were designed to meet residents' caloric needs, and deviations from the menu without approval could compromise the residents' nutrition.
Cross-Contamination and Sanitization Failures in Kitchen Operations
Penalty
Summary
The facility failed to prevent cross-contamination in its kitchen operations, as observed on June 11, 2024. Staff members were seen moving from handling dirty dishes to clean dishes without washing their hands, which is a violation of hygienic practices. Additionally, a staff member used a cloth to dry multiple wet trays instead of allowing them to air dry, increasing the risk of contamination. The handwashing sink was blocked by a plate lowerator, causing water to splash onto stored plates when staff attempted to wash their hands. Furthermore, a staff member was observed chewing gum in the kitchen, which is against food safety regulations. The facility also failed to ensure proper sanitization of dishware due to inadequate monitoring of dish machine temperatures. On June 11, 2024, the dish machine's final rinse did not reach the required minimum temperature of 180 degrees Fahrenheit, and staff did not record actual temperatures on the dish machine temperature log. Instead, they recorded expected temperatures, which did not reflect the actual conditions. This failure to monitor and record accurate temperatures compromised the sanitization process, potentially affecting all 79 residents receiving meals from the facility's kitchen. Interviews with the Kitchen Supervisor, Dietary Manager, and Registered Dietitian revealed a lack of awareness and understanding of proper food safety practices among staff. The Kitchen Supervisor was unaware of the restrictions on chewing gum in the kitchen, and the Dietary Manager acknowledged the issues with cross-contamination and improper temperature recording. The Maintenance Supervisor confirmed that the dishwashing machine was not reaching the required temperature for the final rinse, and a new booster heater was needed. These deficiencies highlight significant lapses in the facility's adherence to food safety standards, posing a risk to resident health.
Failure to Reconcile and Secure Controlled Medications
Penalty
Summary
The facility failed to maintain and reconcile controlled medication records, specifically oxycodone, for two residents. The issue arose when licensed staff did not add the medication to the control sheets and failed to secure the controlled medications in the narcotic drawer after receiving them from the pharmacy. This deficiency was identified during an investigation of a complaint, where it was found that 60 oxycodone/APAP tablets for one resident and 30 oxycodone tablets for another resident were unaccounted for. The medications were reportedly delivered and signed for by a nurse, but were not found in the facility. The investigation revealed that the nurse who signed for the medications did not follow the proper procedures for documenting and securing the medications. Despite multiple attempts to contact the nurse for clarification, she denied involvement in the missing medications. Interviews with other staff members confirmed that the medications were signed for but not properly documented or secured, leading to their disappearance. The facility was unable to determine what happened to the medications, although it was confirmed that neither resident missed a dose of their pain medication.
Failure to Develop Baseline Care Plan for Resident
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and provided to Resident Identifier (RI) #72 within 48 hours of admission. RI #72 was admitted with diagnoses including Pleural Effusion, Pneumonia, and Chronic Respiratory Failure with Hypoxia. According to the facility's policy titled 'Baseline Careplan,' a baseline care plan should be developed upon a resident's admission to meet professional standards of quality care. However, a review of the medical records revealed that no baseline care plan was created for RI #72 within the required timeframe. Interviews conducted with the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON) confirmed the absence of a baseline care plan for RI #72. The MDSC acknowledged that the baseline care plan should have been initiated within 48 hours and identified the DON as responsible for initiating these plans. The DON, in turn, stated that the admitting nurse was responsible for initiating the baseline care plan. Despite these acknowledgments, the baseline care plan for RI #72 was not located, indicating a lapse in the facility's adherence to its policy and procedures for new admissions.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies in their care. Resident Identifier (RI) #5 did not have a physician's order for oxygen therapy, and the oxygen tubing used was not labeled or dated as required by the facility's policy. Observations over several days confirmed that the oxygen was administered via nasal cannula at three liters per minute without proper documentation or labeling. Interviews with nursing staff revealed that the tubing should have been dated to inform staff of when it was last changed, but this was not done until the surveyor's inquiry prompted the input of the physician's order. Additionally, the facility did not properly store the nebulizer mask for RI #52, who was receiving Duoneb treatments three times a day. The nebulizer mask was repeatedly observed uncovered and not stored in a plastic bag when not in use, contrary to infection control protocols. Interviews with nursing staff confirmed that the mask should have been stored in a zip-locked bag to prevent infection control issues, but this practice was not followed, leading to a deficiency in the resident's respiratory care.
Infection Control Deficiencies in Hand Hygiene and Hygiene Supply Storage
Penalty
Summary
The facility failed to ensure proper hand hygiene and storage of resident hygiene supplies, leading to potential cross-contamination. On two separate occasions, unlabeled bath basins were observed in the shared bathroom of two residents, indicating a failure to adhere to the facility's policy requiring that each resident's hygiene items be labeled and stored separately. A Certified Nursing Assistant confirmed that the basins should be labeled and stored in a clear plastic bag, which was not done in this instance. Additionally, a Treatment Nurse did not perform hand hygiene or change gloves after cleaning a resident's sacral wound and before applying a clean treatment. This was contrary to the facility's hand hygiene protocol, which mandates hand washing between resident contacts and after handling contaminated objects. The Risk Manager/Infection Preventionist confirmed that staff should wash their hands after all care and not touch clean items with contaminated gloves, highlighting a breach in infection control practices.
Failure to Notify Resident's Representative of Hospital Transfer
Penalty
Summary
The facility failed to notify the representative of Resident Identifier (RI) #335 about an incident and subsequent hospital transfer. RI #335, who was admitted with diagnoses of Dementia with Agitation and Major Depressive Disorder, was cognitively impaired with a BIMS score of five out of 15. On 06/24/2023, RI #335 was transferred to the hospital due to increased aggressive behaviors. However, there was no documentation in the Clinical Progress Notes indicating that the representative sponsor was informed of this incident and the transfer. An interview with the representative revealed that she was not notified by the facility but learned of the situation from the hospital social worker, and only then contacted the facility. She stated that RI #335 had been in the hospital for several days before she was made aware of the incident and hospitalization.
Misappropriation of Resident Medication by RN
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property when a registered nurse (RN) placed the resident's temazepam in her pocket and left the facility. The incident was reported to the Alabama State Survey Agency after a Drug Enforcement Agency (DEA) officer found the temazepam in the RN's possession during a K-9 search at her other job. The RN claimed that the resident had refused the medication, and she intended to return or destroy it later but forgot it was in her pocket. This incident was part of an investigation into a facility-reported incident/complaint. The resident involved was admitted to the facility in December 2022 and could not recall refusing the medication when interviewed. The facility's Regional Nurse Manager confirmed that the RN had placed the medication in her pocket, which was considered abuse by misappropriation. The RN admitted to forgetting the medication in her pocket and later placing it in her wallet, leading to her arrest for possession of a controlled substance and theft. The facility's policy on abuse prohibition clearly defines misappropriation of resident property, which the RN violated by her actions.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse within the required two-hour timeframe to the state agency. On the specified date, facility staff reported an allegation of physical abuse involving a resident at 4:30 AM. However, the facility did not report this allegation to the Alabama Department of Public Health (ADPH) until 8:59 AM, exceeding the two-hour reporting requirement outlined in their Abuse Prohibition Plan policy. This deficiency affected one of the three sampled residents reviewed for abuse concerns. The facility's policy, effective since April 2018, mandates that all alleged violations be reported immediately, but not later than two hours after the allegation is made. An interview with the facility's Administrator, who also serves as the Abuse Coordinator, confirmed the understanding that all allegations of abuse should be reported to the ADPH within two hours of discovery. Despite this, the facility did not adhere to the policy, resulting in a delay in reporting the incident.
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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