Latest Serious Citations
Stay informed about the most recent serious citations (J-L severity) issued to long-term care facilities nationwide.
Latest high scope & severity citations
Every Immediate Jeopardy finding (J–L severity) issued nationwide in the last six months, summarized from the inspection reports.
Two residents were involved in a deficiency related to supervision and wander alert safety. One resident with severe cognitive impairment and known elopement risk exited the facility unnoticed through unsecured doors and was found miles away by police. A second resident’s wander alert bracelet failed to alarm during an elevator transfer, and staff later found the bracelet battery was dead. Leadership and nursing staff stated there was no policy for door checks or for the current wander alert system.
Failure to respond appropriately to an alleged sexual abuse incident: a resident with intact cognition alleged a CNA raped them during incontinence care, but the resident remained in the facility for hours without a documented medical or psychosocial assessment. The CNA said they provided care and applied ointment to the resident’s groin and vaginal area, while video showed the CNA in the room for 36 minutes. The resident was later tearful, fearful, and distrustful of staff, and the DON and admin did not report the allegation to DOH because the resident later described rough handling.
Failure to report alleged sexual abuse within required timeframe. A resident with intact cognition and significant ADL dependence alleged that a CNA raped them during incontinence care; the resident later described possible penetration and burning, while the CNA said they only provided brief care and applied ointment. The family member contacted law enforcement and requested hospital transfer, but facility leadership did not report the allegation to DOH within 2 hours, stating they believed the allegation had changed to rough handling and did not meet the reporting threshold.
Delayed reporting of resident-on-resident sexual abuse allowed continued nonconsensual sexual contact. A resident with schizophrenia and moderate cognitive impairment reported that his roommate kissed, touched, and sexually assaulted him without consent, while the roommate admitted to sexual contact. A nurse aide heard the allegation but did not report it right away, and the unit manager later confirmed the delay.
A resident with dementia and a history of aggression assaulted another resident in a hallway, pushing him from a chair onto the floor and then attempting to strike him with a chair while a third resident was nearby. Staff on constant observation and another observer did not intervene until after the resident had already been pushed down, despite the resident being on enhanced supervision for prior resident-to-resident altercations. Both residents had severe cognitive impairment, and interviews showed the assigned aide did not understand the urgency of the constant observation role.
Failure to Supervise Resident at Risk for Elopement: A resident with severe cognitive impairment and known exit-seeking behavior was not accurately assessed or care planned for elopement risk. Staff observed the resident in another resident’s room, then an exit alarm sounded; an LPN closed the door and reset the alarm without checking outside, and staff later could not locate the resident. The resident was found outside the secured unit in cold weather with injuries and confusion, while video showed the resident leaving the building and staff not stepping outside to verify whether anyone had eloped.
Failure to Prevent Elopement and Ensure Wander Alert Device Functionality
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices to prevent accidents for two residents. One resident had diagnoses including Alzheimer’s disease, alcohol abuse, and COPD, and was assessed as having severe cognitive impairment. The resident was identified on admission as having wandering, exit-seeking, and elopement risk, and the baseline care plan noted the resident wore a wander alert bracelet on the right wrist. On the morning of the incident, the resident was not found in the room during breakfast service, and staff initiated a search and notified leadership, the spouse, and law enforcement. The resident was later found by police approximately three miles from the facility and returned that evening. Video surveillance showed the resident walking alone through the third-floor west wing, past the nurses’ station, toward an emergency exit door, then continuing down the east wing hallway toward a stairwell door that led to the first-floor exit to the parking lot. The surveillance outside the building showed a laundry aide arriving and remaining in a vehicle while the resident exited the facility. The report also states that the stairwell door had a keypad and magnetic locking system, but the first-floor exit door near the parking lot had no alarm system, and the wander alert system did not cover the doors the resident used to leave the building. During interviews, maintenance staff stated that magnets on the magnetic-locked doors had previously slipped and disengaged the locking mechanisms, and the administrator stated the facility did not have a policy regarding door checks. A second resident had diagnoses including hypertension, diabetes mellitus, and depression. The resident was listed on the facility’s wander alert list as a wanderer, but the resident’s assessment documented independence with transfers and wheelchair mobility and no wandering behaviors. During observation, a unit clerk wheeled the resident to the elevator, and the wander alert device did not alarm when the resident entered the elevator. When the assistant director of nursing replaced the bracelet with a new one and tested it, the system sounded. The assistant director of nursing stated the old bracelet’s battery was no good and did not know how long it had been dead. Staff and leadership stated they did not have a policy for the current wander alert system, and the director of nursing stated routine checks had been stopped when the new system was implemented.
Failure to Respond to Alleged Sexual Abuse and Assess Resident Distress
Penalty
Summary
The facility failed to protect a resident from abuse, psychosocial harm, and to respond appropriately after an allegation of staff-to-resident sexual abuse. The resident had diagnoses including obstructive and reflux uropathy and hemiplegia and hemiparesis following cerebral infarction. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and the care plan included psychosocial well-being interventions such as orienting the resident to the environment, introducing compatible peers, and addressing concerns. During incontinence care, the resident alleged that a CNA raped them. The incident report documented that the resident told an LPN they were raped, and the LPN notified a supervisor. The supervisor assessed the resident and noted redness in the perineal area. A nursing progress note later documented that the resident complained of burning in the sacral and vaginal area after incontinence care and that the DON was aware. Video review showed the CNA in the resident’s room for 36 minutes. The CNA stated they provided incontinence care, applied A and D ointment to the resident’s pubis, groin crease, and vagina, and remained in the room because the resident had multiple bowel movements, although the bowel record did not document multiple bowel movements. The resident remained in the facility for about five and a half hours after the allegation without documentation of a medical or psychosocial assessment. Family members reported the resident was hysterically crying, contacted law enforcement, and requested hospital transfer. The resident later stated they felt something enter their anus and vagina, that they told the CNA to stop, and that they became distressed, tearful, fearful, and distrustful of facility staff. The facility concluded abuse did not occur because of conflicting statements, and the DON and administrator stated the allegation was not reported to the state because the resident later described rough handling. The PCP stated the facility should have called law enforcement and the Department of Health if the allegation was rape, and stated a psychosocial assessment should have been completed. The social worker stated they were aware of the incident after it occurred and did not know what interventions should be put in place.
Failure to Report Alleged Sexual Abuse Within Required Timeframe
Penalty
Summary
The facility failed to ensure that an alleged incident of abuse was reported to the New York State Department of Health and local law enforcement within two hours of the allegation. The deficiency involved one resident who had diagnoses including obstructive and reflux uropathy, hemiplegia, and hemiparesis following cerebral infarction. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and the care plan showed the resident required assistance with ADLs, including two staff members for transfers and toileting and extensive assistance for dressing, bathing, grooming, and bed mobility. According to the facility’s incident report, the resident told an LPN that they had been raped by a CNA while receiving care. The resident later described that the CNA entered the room to change a wet brief, applied cream to the hip and then to the anus and vaginal area, and that they felt something enter the anus and vagina while asking the CNA to stop. The CNA stated they provided incontinence care and applied A and D ointment to the perianal area, and the video review showed the CNA entered the room at 4:43 AM and exited at 5:19 AM. The resident’s family member reported that the resident called them, said to come immediately, and later stated that a staff member had raped them. The family member contacted law enforcement and requested hospital transfer. Facility leadership acknowledged awareness of the allegation but did not report the alleged rape to the Department of Health, stating they believed the allegation changed to rough handling and did not meet the reporting threshold. The DON, Administrator, and Social Worker each described differing understandings of the allegation and reporting status, and the report states there was no documented evidence that the allegation was reported to local law enforcement or the Department of Health within two hours as required.
Delayed Reporting of Resident-on-Resident Sexual Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from abuse when continued nonconsensual sexual contact occurred between two roommates. Resident 1 had diagnoses including schizophrenia and a BIMS score of 9, indicating moderate cognitive impairment. Resident 2 had a BIMS score of 15, indicating normal cognitive function. According to the resident’s statement, Resident 2 kissed his body and engaged in sexual contact that Resident 1 did not consent to, including manual genital manipulation, kissing and licking of his body, and anal penetration. A nurse aide heard Resident 1 say that Resident 2 liked to kiss his body and later questioned him about whether Resident 2 asked him to do things he did not want to do. Resident 1 responded that Resident 2 “jerks me off” and said it happened often. The nurse aide stated that he or she was unsure what to do and did not feel comfortable talking to anyone except the unit manager. The unit manager’s statement indicated that the nurse aide reported the allegation four days after the initial disclosure. Resident 2 also acknowledged sexual contact, stating that he had kissed Resident 1 all over his body and touched his private area, and said the last contact occurred two nights before the interview. The resident was evaluated in the ED for sexual assault, and the facility later substantiated sexual abuse based on the delayed reporting by the nurse aide. The report identified that the delay in reporting allowed further nonconsensual sexual contact to occur before the allegation was acted upon.
Failure to Prevent Resident-to-Resident Abuse During Constant Observation
Penalty
Summary
The facility failed to protect a resident from abuse when a resident with severe cognitive impairment and a history of aggressive behavior assaulted another resident in the hallway. Resident #1 had diagnoses including unspecified dementia with behavioral disturbance, COPD, muscle weakness, and major depressive disorder, and his MDS coded him with a BIMS score of 3 out of 15. Resident #2 also had severe cognitive impairment, with diagnoses including Alzheimer’s disease with early onset, unspecified dementia without behavioral disturbance, hypertension, and muscle wasting and atrophy, and his MDS also coded a BIMS score of 3 out of 15. During the incident, staff heard a chair flip over and a thud, then found Resident #2 on the floor. A video reviewed by the facility showed Resident #1 standing in front of Resident #2 and pushing him out of a chair and onto the floor. The video also showed Resident #1 picking up a chair and attempting to strike Resident #2 with it while Resident #3 was in close proximity. An OSM sitting nearby observed the incident and did not intervene until after Resident #2 had been pushed to the floor, and the chair was only stopped when the OSM placed a hand on it. The record and interviews showed that Resident #1 had been on constant supervision because of prior aggressive behavior and resident-to-resident altercations. The care plan documented behaviors related to aggression during care and a history of pushing another resident. Staff interviews indicated that the Activities Aide assigned to constant observation was watching the incident but did not intervene quickly, and the aide stated she did not think the situation would become physical and did not know what the constant observation was for. The facility’s policy required staff on constant observation to remain within close proximity to intervene immediately if necessary, but that did not occur during the altercation.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility did not ensure adequate supervision to prevent accidents for a resident with dementia and a known pattern of exit seeking. The resident had diagnoses including unspecified dementia, Alzheimer’s disease, Major Depressive Disorder, COPD, and insomnia, and her MDS showed severely impaired cognition with a BIMS score of 3 out of 15. Her comprehensive care plan noted periodic exit seeking, but it did not contain interventions or goals related to that behavior. The resident’s elopement risk assessment was also incomplete and inaccurate, with missing answers and no score, and facility leadership acknowledged that the assessment should have been accurate and complete. On the evening of the incident, staff observed the resident in another resident’s room, and later an emergency exit alarm sounded. An LPN reported that she looked at the door, saw it open, did not see footprints or snow disturbance, closed the door, and turned off the alarm. The LPN and a CNA then searched inside the building but could not find the resident. The CNA later stated she initialed the 15-minute check sheet without actually checking on the resident because she was told the resident had been seen by the LPN. The 15-minute check sheet showed observations continuing until 8:45 PM even though staff reported they were unable to locate the resident. The resident was later found outside the facility after exiting the secured memory care wing. Facility records, police documentation, EMS, and the ER report described that she had wandered into cold weather, was confused and disoriented, had abrasions and injuries, and had a low body temperature. Video footage showed the resident leaving the building at 8:27:56 PM, walking across the parking lot, and continuing onto the street while staff did not step outside to check the area. The facility’s misconduct report stated that two agency staff on the wing did not respond for over two minutes when the emergency exit alarm sounded and did not look outside to ensure no residents had eloped.
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