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.
The facility failed to disinfect a shared glucometer between resident uses, with an LPN using the same meter for two residents without proper cleaning and disinfection. It also failed to use enteric precautions for a resident with suspected and later confirmed C. difficile while stool testing was pending, and staff did not consistently perform hand hygiene, glove changes, or gown use during personal care and transfers for residents on EBP, including a resident with a catheter and another receiving a bed bath.
A facility failed to protect two residents with severe cognitive impairment from sexual abuse by not completing a comprehensive assessment of each resident’s capacity to consent after repeated sexual encounters were discovered. Staff found the residents together in bed or in the bathroom, often unclothed, and allowed privacy based on their behavior without documenting a structured consent assessment. The facility also did not fully investigate unexplained bruising and reported vaginal bleeding for one resident in the setting of the known relationship, and the MD was not notified of the incidents or injuries.
A resident with dementia, cleft palate, and dysphagia was ordered an IDDSI Level 6 soft and bite-sized diet, but marshmallows were left in the room and later eaten, leading to a choking episode with cyanosis, pulselessness, apnea, and hospitalization. Staff also served a meal tray with a whole Salisbury steak patty and other foods not prepared into bite-sized pieces, and interviews showed staff were not consistently educated on the resident’s diet restrictions or IDDSI requirements.
Failure to Notify MD of Worsening Wound: A resident with multiple comorbidities and a pressure injury had a right gluteal abrasion that progressively worsened from an open wound to a stage IV ulcer with drainage, odor, slough, and exposed tissue. Staff documented the decline in skin assessments and notes, but there was no reproducible evidence that the MD was notified when the wound first deteriorated. The wound later became infected and required hospital transfer for surgical debridement.
Failure to supervise a resident during bathing, address fall risks, and use wheelchair foot pedals. A resident who needed help with bathing was left alone in an unlocked shower room after a CNA assisted with shaving; he slipped, struck his chin, later developed nausea and vomiting, and was diagnosed with an SDH, required a ventilator, returned on hospice, and died in the facility. The facility also did not identify fall causes or add fall-prevention interventions for one resident after a fall, and staff were observed pushing another resident in a wheelchair without foot pedals.
Failure to supervise a cognitively impaired resident at high risk for wandering led to an elopement from an unsecured smoking area. While a CNA was assisting another resident, the resident walked out of the parking lot smoking area, passed the front entrance, and was not recognized as missing until lunch tray pickup. Staff later found him about 0.8 miles away after he had crossed busy streets and railroad tracks; he returned without injury.
Infection Control Failures With Shared Glucometer Use, C. difficile Precautions, and Personal Care Practices
Penalty
Summary
The facility failed to clean and disinfect shared blood glucose monitoring equipment between resident uses. During observation, an LPN checked blood glucose for a resident with DM II and HIV, placed the contaminated glucometer into a red tote without disinfecting it, and then brought the same tote into another resident’s room to perform another blood glucose check without cleaning or disinfecting the meter first. The LPN initially stated she would use an alcohol wipe from the tote, then acknowledged that this had not been done between residents and that alcohol wipes were not effective against blood borne pathogens. The meter was later cleaned with a disinfecting wipe that was effective against hepatitis B, hepatitis C, and HIV. The facility’s infection preventionist, DON, and MD all stated shared glucometers were expected to be disinfected between uses, and the meter’s user manual required cleaning and disinfection between each patient. The facility also failed to implement transmission-based precautions for a resident with ongoing diarrhea and abdominal pain who was later confirmed to have C. difficile. The resident had stool testing ordered, but the record lacked documented results for a specimen reportedly collected earlier and lacked evidence that a second specimen had been collected as ordered. While testing was pending, there was no enteric precautions sign on the door and no PPE outside the room. The resident reported multiple episodes of diarrhea and feeling unwell, and staff later confirmed the resident tested positive for C. difficile and had been placed on contact precautions after the positive result. The TBP sign on the door indicated contact precautions rather than enteric precautions. The facility further failed to maintain hand hygiene and glove hygiene during personal care and failed to use appropriate barrier precautions during care for residents on enhanced barrier precautions. During a bed bath, nursing assistants changed gloves without performing hand hygiene, moved from dirty to clean tasks without changing gloves, and handled clean washcloths and towels with contaminated gloves. During transfers, staff did not wear gowns for residents who were on EBP. For another resident with a catheter and EBP, nursing assistants transferred the resident without gowns and handled the catheter bag during the transfer. The report also states the facility failed to properly disinfect a blood glucose monitor after use with one resident before placing it on a shelf at the nursing station for shared use.
Failure to Assess Consent and Investigate Injury With Resident Sexual Activity
Penalty
Summary
The facility failed to protect two cognitively impaired residents from sexual abuse by not completing a comprehensive assessment of each resident’s capacity to consent to sexual activity after becoming aware that they were engaging in sexual contact. One resident had diagnoses including Alzheimer’s disease, neurocognitive disorder with Lewy bodies, dementia, and anxiety, with documentation showing severe cognitive impairment, wandering, hallucinations, confusion, and inability to consistently orient to time or place. The other resident also had diagnoses including Alzheimer’s disease and dementia with psychotic disturbance, with repeated BIMS scores showing severe cognitive impairment and care plan documentation noting cognitive loss and a history of wandering and checking doors. The record showed repeated incidents in which the two residents were found together in bed or in the bathroom, often unclothed, and staff documented that they appeared calm or did not show obvious distress. Staff notes and interviews showed that the residents were allowed privacy and continued access to each other without documentation of a formal assessment of whether either resident understood the nature of the relationship or could knowingly and voluntarily consent. Staff interviews also reflected that they relied on the residents’ behavior, such as whether they pushed away or said no, rather than documenting a structured assessment of capacity after each incident. The facility also failed to investigate unexplained bruising and reported vaginal bleeding for one resident in the context of the known sexual activity. The record documented bruises on the forearms and thigh in various stages of healing, along with a report of bloody vaginal discharge, but there was no evidence of a physical assessment or investigation to determine whether the findings were related to abuse, coercion, trauma, or another cause. Interviews with the RN, LPN, DON, MD, and family showed that the physician had not been notified of the sexual incidents, the bruising, or the vaginal bleeding, and that staff had not documented a formal assessment after the incidents.
Choking Episode After Inappropriate Foods Were Left and Served to a Resident on a Soft and Bite-Sized Diet
Penalty
Summary
The facility failed to provide appropriate supervision for a resident with an ordered mechanically altered diet when snack items not consistent with that diet were left in the resident’s room. The resident had diagnoses including dementia, cleft palate, and dysphagia, and speech therapy had recommended an IDDSI Level 6 soft and bite-sized diet. The care plan identified the resident as being at risk for aspiration and choking and specified mechanically altered consistency, Level 6 soft and bite-sized. On the day of the incident, staff found the resident after a loud thump and observed him face down on the floor with blood present and his color purple from the head to the upper limbs. A nurse documented that marshmallows were coming out of the resident’s mouth and nose and that suctioning was performed. The resident’s record and hospital documentation stated he had been eating marshmallows when he became pulseless, apneic, and cyanotic, and he was admitted after a choking-related event with aspiration pneumonia and oxygen needs. The facility investigation stated the resident had been snacking on a bag of marshmallows that had been brought in by his sister and left on his over-the-bed table. The investigation and interviews showed staff did not ensure foods served or available to the resident matched the ordered diet. Administrative nurses stated the marshmallows were not bite-sized and that staff were not really educated on mechanically altered diets and IDDSI levels. The CNA involved stated the nurse was in charge of knowing what the resident could or could not have. During a later meal observation, a CNA delivered a tray to the resident that included a whole Salisbury steak patty and baked apples cut into approximately 1-inch pieces, and the CNA left without cutting the meat into bite-sized pieces. The dietary supervisor stated kitchen staff did not cut food into bite-sized pieces before meals left the kitchen, and the dietician and speech language pathologist confirmed that marshmallows were not appropriate and that meat patties should be cut into bite-sized pieces for this diet.
Failure to Notify Physician of Worsening Pressure Ulcer
Penalty
Summary
The facility failed to notify the physician when a resident’s right gluteal wound deteriorated. The resident was admitted with diagnoses including major depressive disorder, atrial fibrillation, obesity, osteoarthritis, and a pressure ulcer of the left heel, and was cognitively intact with a BIMS score of 15. The resident required substantial to maximal assistance with bed mobility and was dependent on staff for transfers. The care plan and MDS documented pressure injury risk, pressure-reducing devices, turning and repositioning, weekly skin assessments, and reporting abnormal findings to the PCP. The resident’s right gluteal abrasion was first identified after a hospital return and was treated with ordered wound care. The wound then worsened over time, with skin issue reports documenting deterioration, increasing size, non-healing tissue, pain, drainage, odor, slough, and exposed adipose tissue. A nurse note on 3/23 documented increased drainage, slough, foul odor, exposed adipose tissue, and that the resident needed to see a doctor and may need antibiotics, but the facility could not provide reproducible evidence that the physician was notified or what the physician ordered in response. Staff statements reflected that notes were placed for the physician to see, but documentation of actual notification was not available. The wound continued to decline after the 3/23 note, with later reports showing worsening odor, purulent drainage, bleeding, and rapid enlargement. The wound nurse practitioner later documented that the wound had significantly deteriorated and required debridement, and the resident was ultimately hospitalized for surgical debridement. Hospital records documented a stage IV pressure ulcer with infection and sepsis/shock, and the wound culture grew multiple organisms. The survey findings also included staff and physician interviews indicating that the physician had no documentation of notification during the period when the wound was worsening and that earlier notification could have allowed more aggressive treatment.
Failure to Supervise During Bathing, Address Fall Risks, and Use Wheelchair Foot Pedals
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who required assistance with bathing. On 04/27/2026 at about 8:00 PM, the resident self-propelled into an unlocked shower room, came out, and waved down a CNA to request help with shaving. The CNA assisted with shaving and then left the resident alone in the shower to complete his own shower. While staff were out of the shower room, the resident slipped and hit his chin on the shower bar. About two hours later, he became nauseous, vomited, reported a headache, and asked to go to the hospital. The resident went to the emergency department and was diagnosed with a subdural hematoma. He was subsequently placed on a ventilator. The resident returned to the facility on hospice and died in the facility on 05/06/2026. The report states this placed the resident in immediate jeopardy. The facility also failed to identify causative factors for falls and develop and implement interventions to prevent further falls for another resident, and failed to ensure a safe environment when staff propelled a resident in a wheelchair without foot pedals. One resident had diagnoses including difficulty walking, weakness, abnormal posture, lack of coordination, and anxiety, and was documented as moderate to high fall risk, with a care plan that did not address fall risk or fall-prevention interventions. After a fall in the hall that sent the resident to the hospital for shoulder pain, there was no post-fall intervention documented. Another resident, who had diagnoses including pneumonia, sepsis, altered mental status, neuropathy, neuralgia, anxiety, and hypertension, was observed being pushed in a wheelchair without foot pedals, with his legs bent and feet positioned just above the floor. Staff acknowledged that the wheelchair should not have been used that way, and nursing staff stated foot pedals should be used whenever pushing a resident in a wheelchair.
Failure to Supervise High-Risk Resident During Smoking Break
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement for a cognitively impaired resident who was identified as high risk for wandering. The resident had diagnoses including hallucinations, bipolar disorder, schizophrenia, major depressive disorder, and anxiety. His MDS documented a BIMS score of 8, indicating moderate cognitive impairment, and his care plan identified him as an elopement risk/wanderer due to a history of attempts to leave the facility unattended. He also had a WanderGuard applied to his wrist and was known to ambulate without his wheelchair despite staff encouragement to use it. On the day of the incident, the resident was taken to the unsecured smoking area in the facility parking lot with staff and other residents. While CNA M was assisting another resident, the resident walked away from the smoking area, continued through the parking lot, and exited past the front door. Camera review later showed him leaving the unsecured area and heading west toward the church parking lot. Staff did not realize he was missing until dietary staff went to his room to pick up his lunch tray and found that he was not there and had not eaten lunch. After the resident was identified as missing, staff began searching the building and grounds and later located him approximately 0.8 miles from the facility. The resident had to cross multiple busy streets and railroad tracks to reach the area where he was found. He was returned to the facility without injuries. The report also states that the resident was later observed pushing on an exit door leading to the patio/gazebo smoking area and that staff redirected him back inside to wait for a supervised smoke break.
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