Walker Rehabilitation Center, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Carbon Hill, Alabama.
- Location
- 350 Northeast 4th Street, Carbon Hill, Alabama 35549
- CMS Provider Number
- 015408
- Inspections on file
- 13
- Latest survey
- November 30, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Walker Rehabilitation Center, Inc during CMS and state inspections, most recent first.
The facility's former Administrator failed to ensure the implementation of abuse policies and conduct thorough investigations of abuse allegations, leading to potential harm to residents. Confusion over the role of the abuse coordinator and inadequate training contributed to this deficiency, with missing reports and uninvestigated concerns highlighting the oversight failures.
The facility's governing body failed to ensure proper training and oversight for abuse investigations, leading to confusion about the abuse coordinator's role and inadequate investigation processes. The Administrator received limited training, and the Director of Operations did not participate in QAPI meetings, contributing to noncompliance with federal requirements and potential harm to residents.
The QAPI committee failed to review and address multiple abuse allegations involving several residents. The incidents were not discussed in QAPI meetings, preventing the identification of causal factors and implementation of corrective actions. Interviews with staff revealed that the facility's abuse policy was not fully implemented, leading to noncompliance with regulatory requirements.
The facility failed to protect residents from abuse, resulting in multiple incidents of verbal, physical, and mental abuse by staff and other residents. A CNA verbally abused a resident and withheld a meal tray from another, while another CNA physically abused a resident by hitting them with wipes and restraining their arm. Additional incidents involved rough handling of a resident in a wheelchair and a resident being slapped by another resident. Witnesses often failed to intervene or report the abuse immediately.
The facility failed to implement its abuse prevention policies, resulting in two incidents where CNAs witnessed abuse but did not intervene or report it immediately. In one case, a CNA withheld a meal tray from a resident, and in another, a CNA physically and verbally abused a resident. The facility's investigative files lacked documentation of witness statements, and interviews revealed confusion and inadequate training regarding abuse reporting and investigation.
A facility failed to thoroughly investigate multiple incidents of abuse involving residents and staff. In one case, a CNA verbally abused a resident and withheld a lunch tray from another, while in another incident, a CNA physically abused a resident. Witnesses did not intervene or report the abuse, and the facility's investigations were incomplete, lacking necessary documentation and timely reporting.
A facility failed to report abuse incidents immediately, resulting in delayed intervention. In one case, a resident was verbally and mentally abused by a CNA, witnessed by other staff, but not reported until the next day. In another case, a resident was physically abused, with the incident reported a day later. The facility's noncompliance with reporting requirements led to a citation for Immediate Jeopardy.
The facility failed to follow its policies on dishwashing and temperature recording, leading to wet nesting of trays and domes and unrecorded food temperatures. Observations showed that trays and domes were stacked wet, and a dietary aide admitted to not knowing the policy. Additionally, a cook/dietary aide did not document food temperatures during a meal service, and the dietary manager confirmed the importance of immediate recording.
Certified Medication Aides (CMAs) at the facility improperly administered insulin to residents, which is outside their scope of practice. This affected several residents, with insulin being administered multiple times by four CMAs. Interviews revealed that CMAs were instructed to administer insulin despite lacking the necessary training and authorization. The issue was reported to the Director of Nursing (DON), who confirmed that insulin administration was not within the CMAs' scope of practice.
The facility failed to provide a safe, clean, and homelike environment for several residents, as observed during a survey. Multiple rooms lacked window screens, had holes in windowpanes, and peeling paint on ceilings. Residents reported feeling cold due to these deficiencies. The Maintenance Director acknowledged the issues, and the Administrator confirmed that repairs should be timely, but no corrective actions were mentioned.
The facility failed to post accurate daily staffing information as required by its policy, missing essential details such as the census and total hours worked for nursing staff on multiple days. Observations and interviews revealed that the staffing sheets lacked necessary documentation, and the Director of Nurses acknowledged the policy was not followed, resulting in incomplete staffing information.
Administrator's Failure to Implement Abuse Policies
Penalty
Summary
The facility's former Administrator, ADM #5, failed to provide adequate oversight to ensure the implementation of the facility's abuse policies and did not conduct thorough investigations of abuse allegations. This failure was identified through interviews, record reviews, and a review of the facility's policies. The Administrator's lack of action in ensuring that abuse allegations were thoroughly investigated and that appropriate corrective actions were taken was likely to result in further abuse and serious harm to residents. The deficiency was cited under 483.70 Administration at F 835-Administration. Interviews revealed that there was confusion regarding the role of the abuse coordinator, with ADM #5 initially being told that the Director of Nursing (DON) was the coordinator, but later informed that it was his responsibility. ADM #5 admitted to not recalling interviewing other residents or staff during abuse investigations, which is a critical step in identifying unreported concerns. The DON stated that she was not trained on abuse investigations and only observed the previous DON completing incident reports. Additionally, there were missing five-day reports for certain residents, which were the responsibility of ADM #5 to submit to the State Agency. The Director of Operations (DO) confirmed that the Administrator was always the designated abuse coordinator and was responsible for the five-day reports. However, ADM #5 received very limited training from the DO, who only spent one day at the facility with him and provided a checklist that was reportedly missing from his folder. This lack of training and oversight contributed to the failure in implementing the facility's abuse policies and conducting thorough investigations, affecting all residents in the facility.
Removal Plan
- The facility's Administrator resigned, and the new Administrator was hired.
- The Director of Operations trained the new administrator on the abuse policy.
- The Director of Operations provided one on one in-service education to the Administrator regarding the abuse policy being implemented and including conducting thorough investigations, collecting and retaining witness statements to determine a clear time of occurrence of events to ensure all staff respond appropriately and preserve all evidence such as videos of the incidents as applicable.
- The facility's abuse policy was discussed in the QAPI Committee Meeting with the Administrator understanding the responsibilities regarding the policy being implemented.
- Abuse in-services were held for all staff in all departments including nursing, therapy department, dietary, environmental services, and management. 75 employees were in-serviced.
Inadequate Training and Oversight in Abuse Investigations
Penalty
Summary
The governing body of the facility failed to provide adequate oversight to ensure that the facility's Abuse Coordinators, including the Administrator, were properly trained in conducting thorough investigations, identifying contributing factors, and taking corrective actions to prevent further abuse. This lack of oversight was evident as the facility's Abuse Policy did not include a process for coordination with the Quality Assurance and Performance Improvement (QAPI) program, which is essential for ensuring that all allegations of abuse are thoroughly investigated and appropriate corrective actions are taken. Interviews revealed confusion regarding the designation of the abuse coordinator, with the Administrator initially being told that the Director of Nursing was the coordinator, only to later be informed that it was his responsibility. The Administrator reported receiving limited training from his supervisor, the Director of Operations, who confirmed that she had not provided physical proof of investigations and had not participated in QAPI meetings. This lack of training and oversight contributed to the facility's noncompliance with federal requirements, which was determined to have caused or was likely to cause serious harm to residents. The deficiency was identified during the investigation of several Facility Reported Incidents and complaints. The Director of Operations admitted to not personally overseeing the QAPI Committee's handling of reported incidents of abuse, further highlighting the lack of effective governance and oversight. This failure had the potential to affect all residents residing in the facility, as the necessary processes and training were not in place to prevent and address abuse effectively.
Removal Plan
- Administrator resigned and the new administrator was hired.
- All residents have the potential to be affected by the deficient practice. The owner is a member of the governing body. The Director of Clinical Services trained the Director of Operations on the abuse policy and how to conduct a thorough investigation, how to identify contributing factors and how to take corrective action to prevent further abuse.
- The Director of Operations trained the new administrator on the abuse policy on how to conduct a thorough investigation, how to identify contributing factors, and how to take corrective actions to prevent further abuse. The Director of Operations updated the abuse policy to include the process for coordination within the QAPI program.
- Facility abuse policy was discussed in QAPI meeting. Actions taken by the QAPI committee include the 24-hour report book and 24-hour report being discussed in detail each morning during the morning meeting.
- The following personnel attended the QAPI meeting: RN Supervisor, Medical Records, Director of Rehab, Director of Nursing, Financial Coordinator, Infection Control/Restorative, Housekeeping Supervisor, HR Corporate Director, Director of Operations, Administrator, Medical Director.
QAPI Committee Fails to Address Abuse Allegations
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to thoroughly review and address allegations of abuse that occurred on multiple occasions, specifically on 07/08/2023, 07/09/2023, 09/06/2023, and 05/10/2024. These incidents involved several residents and were not adequately analyzed to identify causal factors or to implement corrective actions to prevent future occurrences. The QAPI committee did not ensure that the facility's abuse policy was fully implemented, which includes identifying, stopping, and reporting abuse, as well as conducting thorough investigations. Interviews with facility staff, including the Director of Nursing (DON) and the Administrator, revealed that the QAPI meetings did not include discussions about the specific incidents of abuse. The DON admitted that the incidents involving certain residents were not discussed in any QAPI meetings, and the Administrator confirmed that while the number of abuse incidents was recorded, they were not reviewed or discussed in detail. This lack of discussion and analysis prevented the facility from addressing the culture and behavior of staff that led to the abuse. The Director of Operations, who was responsible for day-to-day operations, also acknowledged that she had not participated in QAPI meetings and expected them to occur monthly. She agreed that allegations of abuse should be discussed during these meetings to conduct root cause analysis. The failure to review and discuss these incidents in QAPI meetings resulted in the facility's noncompliance with regulatory requirements, which was determined to have caused or was likely to cause serious harm to residents.
Removal Plan
- Administrator resigned and the new administrator hired.
- Director of Clinical Services trained the Director of Operations on the abuse policy and how to conduct a thorough investigation, how to identify contributing factors and take corrective action to prevent further abuse.
- The Director of Operations in-serviced the new administrator on QAPI program and all the elements related to abuse including screening, training, prevention, identification, investigation, protection, reporting/response, and QAPI.
- The administrator trained following employees who attended QAPI committee meeting include RN supervisor, medical records, director of rehab, director of nursing, infection preventionist/restorative nurse, environmental services, director of operations, and corporate human resources director on QAPI program and all the elements related to abuse including screening, training, prevention, identification, investigation, protection, reporting/response, and QAPI.
- All abuse investigations were reviewed by the Administrator to ensure all allegations were identified by staff, residents were immediately protected, allegation reports per policy, investigations were completed appropriately, had appropriate witness statements collected, all causal factors were identified, and appropriate corrective action was taken.
- Employees who failed to report are no longer employed with the company and the residents are not in the facility at this time.
- The Director of Operations provided 1-on-1 in-service to Administrator and DON regarding conducting QAPI meeting.
- Monthly QAPI meetings were reviewed to ensure no other residents were affected. Reviewed to make sure nothing was missed in QAPI.
- The Ad Hoc QAPI meeting was completed. QAPI committee was informed and the plan was made that one member of the corporate team will be included in all meetings to ensure allegations of abuse and monthly QAPI meeting to ensure all causal factors are addressed.
- The causal factors will be identified through the root cause analysis using the five Why's method. QAPI team will need to be educated on conducting root cause analysis.
- QAPI meeting held to develop and implement a process to ensure all substantiated allegations of abuse are reviewed and analyzed to ensure the appropriate corrective actions is taken to address all contributing factors of abuse.
- The administrator will be responsible for bringing all allegations of abuse to the QAPI meeting utilizing root cause analysis and the five why's method to ensure all casual factors have been addressed.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse by staff and other residents, resulting in multiple incidents of verbal, physical, and mental abuse. One incident involved a Certified Nursing Assistant (CNA) verbally abusing a resident by cursing and slamming a bathroom door, causing the resident to cry. Another incident involved the same CNA withholding a lunch tray from a resident, leading to feelings of humiliation and dehumanization. Witnesses, including other CNAs and a Dietary Manager, failed to intervene or report the abuse immediately. In another case, a resident was physically and mentally abused by a CNA who hit the resident with a package of wipes, restrained the resident's arm, and threatened to break it. A witness to this abuse did not intervene or report it until the following day. Additionally, a resident was roughly handled by a CNA who jerked and pulled the resident in a wheelchair, causing the resident to become tearful and upset. This incident was witnessed by a Dietary Aid who reported the behavior. Further incidents included a resident being slapped by another resident in a dining area, and a CNA yelling at a resident to dress themselves despite the resident's care plan requiring assistance. These actions were witnessed by staff who either failed to intervene or report the incidents promptly. The facility's policy on abuse prevention was not effectively implemented, leading to these deficiencies.
Removal Plan
- Verbal abuse was submitted to the state. The allegation was that CNA #8 verbally abused RI #5. C.N.A #8 was placed on administrative leave and terminated. RI #5 had a skin evaluation. RI #5 was assessed with no indication of emotional distress.
- Verbal abuse was submitted to the state. The allegation was that CNA #8 verbally and mentally abused RI #98. C.N.A #8 was placed on administrative leave and terminated. No documentation of any assessment or notifications. RI #98 expired.
- Physical and mental abuse submitted to state. The allegation was CNA #8 physically and mentally abusing RI #99. The incident was witnessed by CNA #22. C.N.A #9 was terminated. Skin evaluation performed, DON entered a progress note concerning the event. Medical Director was notified.
- Physical and mental abuse submitted to state. CNA #24 was placed on administrative leave and terminated. Skin evaluation performed, Medical Director, family and police department was notified.
- Performed an audit by asking every resident with a BIMS of 8 or higher if they had been a victim of abuse or witnessed suspected abuse that has not been reported and/or investigated to ensure no other residents were affected by the deficient practice. Responsible parties were contacted for all residents with a BIMS' of 7 or less. Forty-three residents reviewed. Zero were found to be affected.
- Director of Clinical Services trained the Director of Operations on the abuse policy and how to conduct a thorough investigation, how to identify contributing factors and take corrective action to prevent further abuse.
- Director of Operations trained the Administrator, DON and RN Supervisor ensuring facility's abuse policies are implemented on how to conduct a thorough investigation, identifying contributing factors and take corrective action to prevent further abuse. Ensure during investigations all witness statements are collected, and the Administrator is the abuse coordinator and is responsible for all reporting of allegations and ensuring completion of the investigation.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its policies and protocols to immediately intervene and protect residents from abuse, as well as to report the abuse promptly. On one occasion, two CNAs witnessed another CNA intentionally withholding a meal tray from a resident for disciplinary reasons. Despite witnessing this act, the CNAs did not intervene to protect the resident or report the abuse immediately to the administration. The abuse was not reported until the following day, allowing the abusive CNA to continue working in the facility. In another incident, a CNA witnessed a colleague physically and verbally abusing a resident by hitting them with a package of wipes and threatening to break their arm. The witnessing CNA failed to intervene or report the abuse immediately, allowing the abusive CNA to continue working and having access to residents. The abuse was only reported the next day, and the resident was later found to have a bruise on their wrist. The facility's investigative files lacked documentation of witness statements or any information about the failure of staff to stop the abuse, protect the residents, and report the abuse immediately. Interviews with the former administrator and DON revealed confusion and inadequate training regarding the investigation and reporting of abuse incidents. The facility's noncompliance with abuse prevention policies was determined to have caused or was likely to cause serious harm to residents.
Removal Plan
- Verbal abuse was submitted to the state. C.N.A #8 was placed on administrative leave and terminated.
- Physical and mental abuse submitted to state. C.N.A#9 was terminated. Skin evaluation performed, DON entered a progress note concerning the event. The Medical Director was notified.
- All abuse investigations were reviewed by the Administrator to ensure all allegations were identified by staff, residents were immediately protected, allegation reports per policy, investigations were completed appropriately, had appropriate witness statements collected, all causal factors were identified, and appropriate corrective action was taken.
- The Administrator was in-serviced conducting a thorough investigation.
- Director of Clinical Services trained the Director of Operations on the abuse policy and how to conduct a thorough investigation, how to identify contributing factors, and take corrective action to prevent further abuse.
- Director of Operations trained the Administrator and DON.
- Director of Operations trained the Administrator, DON and RN Supervisor ensuring facility's abuse policies are implemented on how to conduct a thorough investigation, identifying contributing factors and take corrective action to prevent further abuse. Ensure during investigations all witness statements are collected, and the Administrator is the abuse coordinator and is responsible for all reporting of allegations and ensuring completion of the investigation.
- Abuse in-services were held by the DON, by the Administrator, and by RN Supervisor. All staff in all departments including nursing, therapy department, dietary, environmental services, management. 75 employees were in-serviced.
- Staff were educated on what constituted abuse including depriving goods/services for disciplinary reasons, when abuse is witnessed or suspected you are to PROTECT THE RESIDENT!!!, what should be reported (ANY suspected abuse), when to report, and to whom to report. Also, training included how to safely provide care for residents who may be agitated or resistive to care and that the facility has zero tolerance for abuse.
- Director of Clinical Services trained the Director of Operations the abuse policy and how to conduct a thorough investigation, how to identify contributing factors and take corrective action to prevent further abuse. If any staff do not attend the in-service for whatever reason, the Administrator and DON will train department heads to complete the in-service with the employees prior to returning to their next scheduled shift.
- Ad hoc QAPI meeting was attended by the RN Supervisor, Medical Records, Director of Rehab, Director of Nursing, Financial Coordinator, Infection Control/Restorative, Housekeeping Supervisor, HR Corporate Director, Director of Operations, Administrator, Medical Director to discuss abuse recognition, reporting, and prevention. Also to ensure the Administrator understands responsibility to ensure all facility policies are implemented.
- Corporate will sign off on facility reportable for compliance, and on facility abuse policy/QAPI policy are implemented/conducted according to the policy on abuse.
- The abuse policy was updated to include the use of root cause analysis, to identify, evaluate, monitor, and improve facility systems and processes that support the delivery of caring services. The updated policy was approved by the governing body.
Failure to Investigate and Report Abuse in LTC Facility
Penalty
Summary
The facility failed to conduct thorough investigations into multiple incidents of abuse involving residents and staff members. On one occasion, a Certified Nursing Assistant (CNA) verbally and mentally abused a resident by yelling and cursing at them, and another resident was denied a lunch tray, causing distress. Witnesses to these incidents, including other staff members, failed to intervene or report the abuse immediately. The facility's investigation did not include obtaining statements from all witnesses or identifying contributing factors to prevent further abuse. In another incident, a CNA physically and mentally abused a resident by hitting them with a package of wipes and threatening to break their arm. A staff member witnessed the abuse but did not intervene or report it. The facility's investigation lacked a comprehensive review, including interviews with other residents who might have had knowledge of unreported abuse. Additionally, a resident was physically abused by a CNA who handled them roughly in a wheelchair, causing the resident to become tearful and upset. The facility did not conduct interviews with other residents to determine if there were additional instances of abuse. The investigations were incomplete, lacking necessary documentation, witness statements, and timely reporting to the appropriate authorities.
Removal Plan
- CNA #8 was placed on administrative leave and terminated.
- CNA #9 was terminated.
- CNA #24 was terminated.
- Director of Clinical Services reviewed all abuse investigations.
- New administrator hired.
- Director of Operations provided an in-service to new administrator and DON regarding abuse policy implemented and including conducting thorough investigations, collecting and retaining witness statements to determine a clear time of occurrence of events to ensure all staff respond appropriately per the policy, preserving evidence such as videos of the incidents as applicable, identifying all causal factors, and implementing the appropriate corrective action(s).
- Administrator reviewed all incidents of abuse, neglect, and misappropriation reported to the state agency.
- QAPI meeting was attended by: RN Supervisor, Medical Records, Director of Rehab, Director of Nursing, Financial Coordinator, Infection Control/Restorative, Housekeeping Supervisor, HR Director, Director of Operations, Administrator and Medical Director to discuss the abuse prevention policy.
- Director of Operations completed QAPI meeting with the Administrator on understanding administrator's responsibility regarding policy being implemented and followed and expectations for conducting a thorough investigation including identification of all causal factors and implementing corrective action(s).
- Director of Operations will sign off on reportable investigations to ensure compliance with abuse/ and QAPI policy.
- Administrator will email the DO the allegation when reported and email the completed investigation summary.
- Administrator, DON and DO and Director of Clinical Services will do a conference call before submitting the five-day summary to state.
Delayed Reporting of Abuse Incidents
Penalty
Summary
The facility failed to ensure that staff reported abuse immediately to the Administrator, which resulted in a delay in reporting allegations of abuse to the State Agency within the required two-hour timeframe. In one instance, a resident was verbally and mentally abused by a CNA, witnessed by other staff members, but the incident was not reported to the Administrator until the following day. This delay in reporting prevented timely intervention and protection for the resident. In another case, a resident was verbally and physically abused by a CNA, with the incident being witnessed by another CNA who failed to report it until the next day. This delay in reporting also hindered the facility's ability to take immediate corrective actions to protect the resident from further potential abuse. The facility's noncompliance with reporting requirements was determined to have caused, or was likely to cause, serious harm to residents. The facility's policy on abuse prevention required immediate notification of the Administrator or designee of any allegations or suspicions of abuse, and completion of abuse reporting to the State Agency within two hours. However, in both cases, the facility did not adhere to this policy, resulting in a citation for Immediate Jeopardy due to the potential for serious injury, harm, impairment, or death to residents.
Removal Plan
- Verbal abuse involving CNA #8 was submitted to the state. CNA #8 was placed on administrative leave and terminated.
- Physical and mental abuse submitted to the state involving CNA #9 as perpetrator. CNA #9 was terminated.
- An audit was performed by asking every resident with a BIMS of 8 or higher if they had been a victim of abuse or witnessed suspected abuse that has not been reported and/or investigated. Forty-three residents reviewed. Zero was found to be affected.
- Director of Clinical Services trained the Director of Operations on the abuse policy and how to conduct a thorough investigation, identify contributing factors, and take corrective action to prevent further abuse.
- Abuse in-services were held for all staff in all departments including nursing, therapy department, dietary, environmental services, and management. 75 employees were in-serviced.
- Licensed nurses and CNAs will document any unusual observations in the 24-hour report book located at the nurse's desk and call the Administrator immediately if abuse is suspected or witnessed.
- Actions taken by the QAPI committee include the 24-hour report book and 24-hour report being discussed in detail each morning during the morning meeting.
- A QAPI meeting was held to discuss the abuse prevention policy and above-mentioned cases with personnel including RN Supervisor, Medical Records, Director of Rehab, Director of Nursing, Financial Coordinator, Infection Control/Restorative, Housekeeping Supervisor, HR Corporate Director, Director of Operations, Administrator, and Medical Director.
Deficiencies in Dishwashing and Temperature Recording Procedures
Penalty
Summary
The facility failed to adhere to its policy on cleaning dishes and dish machines, leading to wet nesting of plate domes and trays. Observations revealed that clean trays and domes were stacked on top of each other immediately after coming out of the dishwasher, without allowing them to air dry as required by the facility's policy. This resulted in several trays and domes having water in them, which was confirmed by a dietary aide who admitted to not knowing the policy on wet nesting and not having received training on the matter. The dietary manager acknowledged the lack of training and the importance of ensuring that domes and trays are dry to prevent bacterial growth. Additionally, the facility did not comply with its policy on taking and recording food temperatures. During a lunch meal service, a cook/dietary aide took temperatures of various food items but failed to document them as required. The aide admitted to not remembering the temperatures and not writing them down immediately, as well as not knowing the facility's policy on recording food temperatures. The dietary manager confirmed that all food items on the tray line should have their temperatures taken and recorded immediately.
Improper Insulin Administration by CMAs
Penalty
Summary
The facility failed to ensure that Certified Medication Aides (CMAs) did not administer subcutaneous insulin injections to residents, which is outside their scope of practice. This deficiency affected seven of the sixteen sampled residents receiving medications, with insulin being administered by four of the five Medication Assistants, Certified (MACs) involved. The facility's job responsibilities for CMAs clearly state that they are not permitted to administer injectable medications, except for specific exceptions like premeasured auto-injectable medications for anaphylaxis, vaccines, and opioid-related drug overdoses. Despite this, insulin was administered multiple times to several residents by MACs #10, #11, #12, and #13 from May 2023 through October 2023. Interviews with the MACs and nursing staff revealed that the MACs were instructed to administer insulin, although it was not within their scope of practice. MAC #13 admitted to administering insulin until October 2023, while MAC #18 refused to do so and reported the issue to the Director of Nursing (DON). The RN Supervisor and the current DON confirmed that MACs were not trained to recognize signs of hypoglycemia or hyperglycemia and that insulin administration was not part of their training or scope of practice. The former DON stated that the practice was already in place when she was hired, and it was instructed by the corporate nurse at the time. The current DON, upon discovering the issue, contacted the Alabama Board of Nursing, which confirmed that MACs should not administer insulin, leading to the cessation of this practice.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for several residents, as observed during a survey. Specifically, the facility did not ensure that window screens were present on the windows of multiple residents' rooms, including those of Resident Identifiers (RI) #8, #10, #11, #12, #19, and #44. Additionally, there were holes in the glass windowpanes in the rooms of RI #10, #11, and #44, and paint was observed peeling off the ceiling in these rooms. The shared bathroom for these residents had a stained floor, and the call light wires were intertwined with plumbing under the sink, which was not in line with the facility's policy for a homelike environment. Observations revealed that the windows in the affected rooms had missing or broken screens, and some windowpanes had holes, allowing cold air to enter the rooms. This was corroborated by residents' complaints of feeling cold, as noted by RI #44 and RI #10. The Maintenance Director (MTD) acknowledged these issues, stating that the absence of window screens and the presence of holes in the windowpanes posed risks such as bugs entering the building and potential harm to residents. The MTD also noted that the peeling paint and missing baseboards did not contribute to a homelike environment. Interviews with the MTD and the current Administrator (ADM) #1 confirmed that the facility was aware of these deficiencies. The MTD admitted to being responsible for the upkeep of the windows and acknowledged that the facility should be a clean, homelike environment. ADM #1 stated that repairs should be timely to ensure a homelike environment, indicating an awareness of the need for improvements. However, the report does not mention any corrective actions taken to address these deficiencies.
Failure to Post Accurate Daily Staffing Information
Penalty
Summary
The facility failed to ensure that the required data was included on the staff posting form, specifically the census and the number of staff working along with the actual hours worked for all nursing staff on four out of five days during the survey. The facility's policy, titled 'Posting Direct Care Daily Staffing Numbers,' required that within two hours of the beginning of each shift, the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care be posted. The policy also required that the staffing information include the facility name, date, resident census, shift schedule, and actual hours worked for each category and type of nursing staff. During the survey, it was observed that the staffing sheets posted at the nurses' station lacked documentation of the census and total hours worked for the first and second shifts on multiple days. Interviews with the Director of Nurses (DON) revealed that the facility did not follow its policy, as the staffing sheets were not posted within the required timeframe, and essential information such as the census and total hours worked was missing. The DON acknowledged the importance of having an accurate staff count for emergency situations and confirmed that the policy was not adhered to, resulting in a lack of accurate staffing information.
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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