Citations in Alabama
Statistics, citations and compliance trends for long-term care facilities in Alabama.
Statistics for Alabama (Last 12 Months)
Financial Impact (Last 12 Months)
Compliance trends in Alabama
Data through Mar 2026Comparisons below measure the most recent period Apr 2025 – Mar 2026 against the prior period Apr 2024 – Mar 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
No tags meet the emerging criteria for this period — nothing rare is spiking right now.
Latest Citations in Alabama
Failure to Address Abuse and Resident Boundaries: The DON and Administrator did not identify or act on repeated abuse concerns involving multiple residents. Staff reported one resident’s inappropriate sexual touching and boundary violations with other residents, including a cognitively intact resident who had set limits and a protected resident who could not consent under state law, yet the facility assessed and care planned the protected resident as able to consent. Two other residents were also involved in physical abuse, and the Former DON stated concerns were raised repeatedly with leadership and the owner.
The facility failed to protect residents from abuse by other residents. A cognitively intact resident verbally abused another resident by making a sexually explicit statement, while a severely cognitively impaired resident was care planned for sexual expression without a capacity-to-consent assessment. The facility also allowed a resident assessed as unable to consent to have repeated kissing and touching with another resident, including contact to the chest and inner thighs, with staff giving inconsistent accounts of whether the residents could be alone together or needed visual supervision. The report also describes physical altercations between other residents, including one resident striking another in the face and another incident involving residents hitting each other during a room altercation.
Abuse Policy and Capacity-to-Consent Failures: The facility failed to follow its abuse policy and did not ensure its sexual abuse definition and consent procedures met regulatory requirements. One severely cognitively impaired resident had a care plan for sexual expression but no available capacity-to-consent assessment, while another resident with dementia and court-appointed guardianship was assessed as unable to consent after the SSD completed the assessment and then created a sexual expression care plan. Staff observed kissing and intimate touching between residents, and the MD and FNP gave conflicting views about the resident’s ability to consent.
A resident with DM and MS had repeated blood glucose readings in the 30s and 40s across multiple shifts, including a reading of 32 mg/dL, but staff did not immediately notify the physician. The chart showed no BG parameters or notify orders, and an RN and LPN confirmed they did not contact the physician despite the resident’s ongoing low BG and poor intake; the physician was contacted only after the resident’s condition declined and the resident was sent to the ER.
Failure to provide NOMNC notification and notify responsible parties affected two residents with significant cognitive impairment. One resident had Alzheimer’s disease and severe cognitive impairment, and another had cerebral infarction with moderately impaired decision-making and memory problems. Both signed SNF ABN forms, but there was no documented evidence that the family/representative was properly informed, and the Bookkeeper stated conversations were not documented and no hard copies were mailed.
An LPN failed to promptly assess a resident who showed signs of aspiration, including vomiting, low O2 saturation, and abnormal vital signs, and the resident was later hospitalized with aspiration pneumonia. The RN stated the LPN should have listened to breath sounds to help confirm possible aspiration. The facility also continued a wander guard on a resident with no documented wandering or exit-seeking behavior, despite assessments and care plan conference notes stating the device should be removed, and staff were unclear who was responsible for discontinuing it.
Missing Physician Order for Dialysis Care: A resident with ESRD and severe cognitive impairment was documented as receiving hemodialysis, but the EMR contained no current physician order for dialysis treatment. Staff interviews confirmed dialysis residents should have an order directing access-site care, monitoring of the thrill and bruit, and documentation on the MAR, and the facility's hemodialysis policy required physician orders to include dialysis center visits and access-site care.
The facility failed to document alternative measures, risk-benefit discussion, and informed consent before side rail use for two residents. One resident with ESRD and severe cognitive impairment and another resident with dementia and intellectual disabilities were observed with side rails raised in bed, but records showed no current order for side rails and no documented evidence that alternatives were explored or that risks and benefits were reviewed with the resident or RP.
The SSD failed to properly assess residents’ capacity to consent to sexual contact and failed to provide psychosocial follow-up after a companionship ended. Two residents with severe cognitive impairment were involved in sexual relationship care planning, including one resident with a guardian and another whose decision maker was not informed or supportive. A cognitively intact resident reported that a relationship ended after an unwanted sexual comment, leaving the resident upset and crying for days, but the SSD did not ask about the resident’s distress or the reason the relationship ended.
A resident with type 2 DM and MS had ordered glimepiride and BG checks, but staff administered the medication despite BG readings in the 40s and poor oral intake. An LPN gave glimepiride after a low BG was reported, another LPN later gave the same medication again, and hospital records showed the resident was admitted to the ED for hypoglycemia and treated with IV dextrose.
Failure to Address Abuse and Resident Boundaries
Penalty
Summary
The facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently because the Administrator and DON did not identify and/or act on known failures related to abuse and the implementation of the abuse policy. The deficiency affected four of 29 sampled residents reviewed for abuse: one cognitively intact resident who had set relationship boundaries with another resident but was subjected to verbal sexual abuse when those boundaries were crossed; one resident who had been adjudicated incapacitated by a judge and was therefore a protected person under Alabama law, yet was assessed and care planned as if able to consent to sexual contact; and two residents who engaged in physical abuse. The Former DON stated that staff had repeatedly reported concerns about one resident’s behavior with other residents, including initiating relationships with new residents and touching residents in sexual ways, such as hugging, kissing on the mouth, and touching a resident’s breast and inner thighs. The Former DON stated these concerns were brought up more than once in morning meetings and were also reported to corporate leadership and the owner in the presence of the Administrator. She further stated she wanted to report sexual abuse but was directed not to by the Administrator and corporate superiors, and that corporate leadership advised the facility to care plan the residents to be able to engage in sexual touching. The Administrator stated his expectation was that all code requirements were met.
Failure to Protect Residents From Abuse by Other Residents
Penalty
Summary
The facility failed to ensure residents were free from abuse by other residents, including verbal abuse, sexual abuse, and physical abuse. The report states that R41, a resident with diagnoses including Alzheimer's disease and dementia, was involved in repeated inappropriate sexual behavior with other residents. R41 was documented as cognitively intact on a quarterly MDS with a BIMS score of 15, yet the care plan addressed sexual expression with other residents and staff interviews showed inconsistent understanding of what behavior was allowed and what level of supervision was required. R86, who also had Alzheimer's disease and major depressive disorder and was assessed as cognitively intact with a BIMS of 15, reported that R41 put both hands on R86's face cheeks and said, "I want to f*** you so bad." R86 stated this made him/her feel dirty and upset and that he/she had told R41 he/she did not want any sexual relationship or sexual language. R86 also reported that staff did not ask what was wrong after the incident. The facility had a capacity-to-consent assessment for R86 indicating capacity to consent to sexual contact limited to holding hands and kissing, and the care plan included privacy and sexual expression interventions. R87, who had Alzheimer's disease and dementia and was severely cognitively impaired with a BIMS of 2, was also care planned for sexual expression with another resident. The report states the facility did not assess R87's capacity to consent before developing that care plan. R87's decision maker stated he/she was not involved in or approving of the care plan and reported that R87 had said R41 asked him/her to have sex, that R87 was scared to return to the facility because of R41, and that staff had reported hugging, holding hands, kissing, and touching. The SSD stated that R41 was to be banned from R87's hall, but the care plan still reflected sexual expression interventions without a documented capacity assessment before planning. The facility also failed to ensure R44 was free from sexual abuse. R44 had Alzheimer's disease, dementia, mild neurocognitive disorder, and repeated MDS scores showing severe cognitive impairment, including BIMS scores of 6, 7, 6, 3, and 3. A facility assessment questionnaire indicated R44 did not have the capacity to consent, yet multiple staff reported observing R41 and R44 kissing and touching, including touching of the chest/breast area and inner thighs. Staff also reported R41 was in R44's room unsupervised, while other staff said the residents only needed to be in staffed areas or under visual supervision. The Administrator stated R41 was supposed to stay in staffed areas, but staff interviews showed inconsistent knowledge of the supervision required, and the former DON reported repeated concerns about the relationship and that corporate leadership advised care planning the residents to engage in sexual touching.
Abuse Policy and Capacity-to-Consent Failures
Penalty
Summary
The facility failed to implement its abuse policies to ensure residents were free from all forms of abuse and failed to ensure its policy met minimum federal requirements related to sexual abuse and residents’ capacity to consent to sexual activity. The report states the facility’s abuse policy did not include procedures to protect residents from sexual abuse or protocols for determining capacity to consent, and its definition of sexual abuse did not reflect the current regulatory language. The policy also did not include any process for residents adjudicated by a court to be incapacitated. For one resident, the facility did not have a capacity-to-consent assessment available when interviewed by surveyors, despite the resident being severely cognitively impaired with BIMS scores of 2 out of 15 on MDS assessments and having diagnoses including Alzheimer’s disease and dementia. The resident’s care plan addressed a desire to engage in sexual expression with another resident and included an approach to assess capacity to consent annually and with significant change, but the Social Services Director stated she did not have a copy of a capacity assessment. For another resident, the record showed the resident had dementia, severe cognitive impairment with BIMS scores of 6 out of 15 and later 3 out of 15, and court documents establishing temporary guardianship and then guardianship/conservatorship because the resident was an incapacitated person. The facility’s assessment for capacity to consent indicated that because the resident had been declared incompetent by a judge, the resident was assessed to not have the capacity to consent. The Social Services Director stated she completed the assessment and then developed a care plan for sexual expression. Staff statements described kissing and touching between this resident and another resident, including touching on the lips, thighs, chest/breast area, and inner thighs. The Medical Director stated the resident had the capacity to consent emotionally in a social relationship, while the FNP stated it would be surprising for the resident, given the cognitive impairment and dementia, to have the capacity to consent to sexual contact.
Failure to Notify Physician of Repeated Severe Hypoglycemia
Penalty
Summary
The facility failed to ensure the attending physician was immediately notified of significant low blood glucose readings for one resident with type 2 diabetes mellitus and multiple sclerosis. The resident’s record showed repeated blood glucose values in the 30s and 40s, including readings of 44 mg/dL, 42 mg/dL, 43 mg/dL, and 38 mg/dL across multiple shifts, and staff documented a blood glucose of 32 mg/dL with interventions provided. The resident was cognitively intact with a BIMS score of 15 out of 15, and the care plan identified risk for blood sugar fluctuation and hypoglycemia with an approach to notify the MD as needed of complications. The EMR contained no physician orders specifying blood glucose parameters or when to notify the physician, and there was no documentation that the physician was notified of the low readings. During interviews, an LPN stated the resident had low blood glucose during the night shift and continued poor intake during the day shift, but she did not notify the physician. An RN stated she did not notify the physician because she was not concerned, while the RNUM and former DON stated blood glucose levels in the 30s or 40s were significant and should have been reported to the physician or on-call provider. The physician was ultimately contacted only after the resident’s condition declined and the resident was transferred to the emergency room.
Failure to Notify Responsible Parties of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure Notice of Medicare Non-Coverage (NOMNC) notification was provided and that the responsible party was notified for two residents reviewed for beneficiary notification. For one resident with Alzheimer’s disease and dementia, the quarterly MDS showed a BIMS score of 3 out of 15, indicating severe cognitive impairment. The resident’s SNF ABN form showed the Medicare Part A skilled services start date and last covered day, and the resident signed the form on an illegible date despite being severely cognitively impaired. For another resident admitted with cerebral infarction, the quarterly MDS showed the BIMS could not be completed, with short- and long-term memory problems and moderately impaired decision-making requiring cues/supervision. The resident’s SNF ABN form showed the skilled services start date and last covered day, and the resident signed the form on 03/31/2026. There was no evidence that the family was notified of the information. During interview, the family member for the first resident stated they were responsible for decisions because the resident could not make informed decisions, and said they had not been made aware of the therapy services or the decision to appeal. The Bookkeeper stated she spoke with both residents’ representatives but did not document those conversations and did not mail a hard copy to them.
Delayed Aspiration Assessment and Unjustified Continued Wander Guard Use
Penalty
Summary
The facility failed to identify and intervene for a change in condition and ensure prompt assessment and emergency care for one resident who later was hospitalized with aspiration pneumonia. The resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction, COPD, and GERD. The record showed an enema was administered at 10:17 AM, and the first documented assessment of a change in condition was not completed until 11:20 AM, when the resident was found lying in bed hard to arouse with vomit on the shirt, O2 saturation of 85% on room air, pulse 109, respirations 22, and blood pressure 106/61. At that 11:20 AM assessment, the LPN documented oxygen was started at 2 L/min, Zofran was given, and the resident’s oxygen saturation improved. The note also documented hypoactive bowel sounds, a PRN enema, liquid stool, and that the resident later followed commands and oxygen saturation improved to 95% on room air. A later note at 12:21 PM documented that the sponsor requested hospital evaluation and an order was obtained to send the resident to the hospital, with transport at 12:19 PM. A subsequent RN assessment documented the resident was minimally responsive, had snoring-like respirations, diminished breath sounds bilaterally, O2 saturation of 86% on 2 L/min, pulse 109, and blood pressure 104/47, and the RN stated the LPN should have listened to the resident’s breath sounds to rule out or confirm possible aspiration. The facility also failed to ensure a resident was appropriately screened and had documentation to support the continued use of a wander guard. The resident had Alzheimer’s disease, a BIMS score of 3, and was care planned for risk of elopement with an intervention to place a wander guard. However, the annual MDS and elopement risk assessment documented no wandering behavior and indicated the resident was not at risk for elopement, and the care plan conference notes stated the resident was no longer at risk and the elopement bracelet would be removed. Despite this, observations on three separate occasions showed the resident still wearing a wander guard on the right ankle. Interviews showed staff were unclear about who was responsible for discontinuing the code alert/wander guard, and the restorative nurse stated the bracelet was not removed because the team decided to reassess the resident, but there was nothing documented about that. The social services director stated the resident had been assessed as a wander risk when first admitted, that the team discussed discontinuing the wander guard, and that it should have been documented if the device was continued or removed. The DON stated residents were assessed for elopement risk based on criteria such as statements about leaving or elopement history, and that if an assessment indicated a resident was not at risk, staff may want to continue to monitor.
Missing Physician Order for Dialysis Care
Penalty
Summary
The facility failed to ensure there was a current physician's order for dialysis treatment for one resident with end stage renal disease who was receiving hemodialysis. The resident's face sheet identified end stage renal disease, and the admission MDS showed a BIMS score of 3 out of 15, indicating severe cognitive impairment, with documentation that the resident was receiving hemodialysis. The care plan, dated 02/24/2026, also identified the resident as having end stage renal disease and receiving dialysis. Review of the physician orders dated 04/10/2026 revealed no current order for dialysis treatment. During interviews, an LPN stated there should always be a physician's order for dialysis and that nursing staff should check the access site, thrill and bruit, and document care on the MAR. Another LPN stated dialysis residents normally have an order directing care of the access site and monitoring for bleeding, infection, and drainage, and said having an order was very important. An RN confirmed the dialysis order should have been entered when the resident was admitted, while the DON stated she would not provide treatment without a physician's order. The facility's Hemodialysis Care policy stated physician's orders for hemodialysis residents should include information regarding visits to a dialysis center and care of the access site.
Failure to Document Alternatives, Risk-Benefit Discussion, and Informed Consent for Side Rail Use
Penalty
Summary
The facility failed to ensure that alternative measures were tried before side rails were used, and failed to document discussion of risks versus benefits and obtain informed consent for side rail use for two residents. The report states that these issues were identified for R3 and R6 during observation, interview, record review, and policy review. The deficiency involved side rail use without a current physician order and without the required documentation in the residents’ records. R3 was admitted with end stage renal disease and had a BIMS score of 3, indicating severe cognitive impairment. R3’s care plan listed upper side rails for mobility, and during observation R3 was resting in bed with the head of bed upright and side rails up on both sides. The side rail/entrapment evaluation for R3 showed no documentation that alternatives were explored before bed rail use, and there was no documentation of risks versus benefits or informed consent. The RNN stated the facility did not try alternatives before bedrail use for R3, did not discuss risks and benefits, and had nothing for the resident to sign for informed consent. R6 was admitted with mild intellectual disabilities and dementia and also had a BIMS score of 3. R6’s care plan included side rails up while in bed to aid in bed mobility and transfers, and during observation R6 was lying in bed with the head of bed elevated and bilateral half side rails raised. The side rail evaluation completed after the surveyor identified concern showed side rails were used, but the record contained no documented evidence of what alternatives were explored before implementation and no documented evidence that risks versus benefits were explained to the responsible party or that informed consent was obtained. The facility policy stated bedrails could be considered a form of physical restraint and that the need for bedrails should be identified in the resident assessment and plan of care.
Failure to Assess Sexual Consent Capacity and Provide Psychosocial Follow-Up
Penalty
Summary
The facility failed to provide medically related social services to assess residents’ capacity to consent to sexual contact and to follow up with psychosocial support after a companionship ended. The Social Services Director’s job description stated the role included planning, organizing, developing, and directing social services to meet residents’ emotional and social needs, as well as assisting with resident assessments and care plans. Survey findings identified deficiencies involving three residents: one resident with severe cognitive impairment and a court-appointed guardian, another resident with severe cognitive impairment, and a third resident who was cognitively intact. For one resident, the record showed diagnoses including Alzheimer’s disease, dementia, and mild neurocognitive disorder, along with a BIMS score of 6 indicating severe cognitive impairment and a court order appointing a guardian. The SSD completed an assessment for capacity to consent to sexual relations and marked that the resident had been declared incompetent by a judge, which indicated the resident did not have capacity to consent; however, the SSD continued the assessment and documented that the resident had some memory deficits but stated clear understanding of consent for sexual activity. The SSD also initiated a care plan that included educating the resident on safe sexual practices and supporting the resident’s decision to engage in sexual expression. Staff and family interviews showed the SSD told others the residents had rights and could have a sexual relationship if they chose. For another resident, the record showed Alzheimer’s disease and dementia with a BIMS score of 2 indicating severe cognitive impairment, and the care plan included education on safe sexual practices and providing a privacy sign. The resident’s decision maker stated they were never made aware of, and would not have supported, care planning for any kind of sexual activity. For the cognitively intact resident, the record showed a BIMS score of 15 and the resident reported a friendship that became a companionship with another resident, then ended after the other resident made a sexual comment that made the resident feel dirty and upset for days. The resident stated no staff asked what was wrong, and the SSD acknowledged knowing the relationship had ended and that the resident was upset, but did not talk to the resident about why the resident was upset.
Unnecessary Drug Administration With Hypoglycemia
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs when nursing staff administered glimepiride despite documented low blood glucose levels and poor oral intake. The resident had diagnoses including type 2 diabetes mellitus and multiple sclerosis, and was cognitively intact with a BIMS score of 15 out of 15. Physician orders included blood glucose monitoring twice daily and glimepiride 1 mg by mouth twice daily, but there were no orders for blood glucose parameters or physician notification. On 03/29/2025, the resident had a blood glucose of 44 mg/dL at 6:00 AM and 42 mg/dL at 6:00 PM, and staff documented that the resident had low blood sugar during the night shift and continued poor oral intake. Despite this, an LPN administered glimepiride at 9:00 AM and another LPN administered glimepiride at 5:00 PM. Hospital records showed the resident was admitted to the emergency department for hypoglycemia after receiving glimepiride with a blood glucose level of 42 mg/dL and was treated with intravenous dextrose before discharge.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Some of the Latest Corrective Actions taken by Facilities in Alabama
- Implemented monthly printing of the Medication Administration Record (MAR) to ensure availability during internet outages, with responsibility assigned to the Director of Nursing, Assistant Director of Nursing, or Unit Manager (L - F0760 - AL) (L - F0580 - AL) .
- Conducted in-service training for all LPNs and RNs to ensure they know the location of the paper MAR and update it promptly with any new admissions or physician order changes (L - F0760 - AL) (L - F0580 - AL) .
- Educated all nursing and administrative staff on the policy titled Policy on Computer or Internet Downtime and EHR, including the importance of documenting medication administration at the time of administration (L - F0760 - AL) (L - F0580 - AL) .
- Established a monthly MAR printout schedule to ensure clarity and preparedness for potential internet downtimes (L - F0760 - AL) (L - F0580 - AL) .
- Conducted mock drills for nursing personnel to practice procedures during internet outages (L - F0760 - AL) (L - F0580 - AL) .
- Replaced the facility's router to improve internet reliability and reduce the likelihood of future outages (L - F0760 - AL) (L - F0580 - AL) .
- Held an ad-hoc Quality Assurance meeting to discuss the deficient practice and plan of correction, ensuring continuous improvement and oversight (L - F0760 - AL) (L - F0580 - AL) .
Medication Administration Failure During Internet Outage
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors during a forecasted snowstorm when the internet connection was lost, preventing access to the Electronic Health Record (EHR) and Electronic Medication Administration Record (eMAR). This resulted in the failure to administer critical medications, including insulin and other significant medications, to residents from the evening of one day until the following evening. The deficiency was identified as Immediate Jeopardy, indicating that the non-compliance was likely to cause serious harm or death. Resident Identifier #12, who had Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Hyperglycemia, did not receive their prescribed insulin doses and blood glucose monitoring during this period. Similarly, Resident Identifier #15, with diagnoses including Type 2 Diabetes Mellitus and Hypertension, missed doses of insulin, blood pressure, and seizure medications. Resident Identifier #30, with conditions such as Type 2 Diabetes Mellitus and Chronic Heart Failure, also missed critical medications, including insulin and anticoagulants, and did not have their blood glucose monitored. Resident Identifier #308, who had epilepsy, did not receive their anticonvulsant medications, increasing the risk of seizure recurrence. Interviews with nursing staff revealed that the lack of access to the eMAR due to the internet outage was a significant barrier to medication administration. Some staff were unable to administer medications or monitor blood glucose levels because they did not have access to the necessary records. The facility's policy required medications to be administered in a timely manner and in accordance with prescriber orders, but the outage led to a failure in adhering to these protocols, affecting the care of the residents involved.
Removal Plan
- The medication administration Record (MAR) will be printed monthly by the Director of Nursing Assistant Director of Nursing or Unit Manager.
- The paper MAR will be updated at the time the order is received or confirmed for all current resident and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes including all new orders for new admits.
- The updated MAR will be located by the nursing stations.
- All LPNs and RNs were in-serviced to ensure they know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR.
- The Director of Nursing and Assistant Director of Nursing educated all nurses, physical therapy staff, and administrative staff on the policy titled Policy on Computer or Internet Downtime and EHR.
- In-service included the standard of practice to administer medication, monitor blood glucose, implement the prescribing physicians' orders, and the importance of documenting medication administration at the time of administration.
- In-service included calling the physician as well as notifying the Director of Nursing or Designee if staff are unable to carry out a physician's order.
- In-service included how it led to neglect and the facility's Abuse Policy.
- A printed MAR will be ready and a copy will be kept at each nurses' station for use during downtime.
- RNs and LPNs who receive an order or confirm a new order for any medication changes including all new orders for new admits will update the paper medication administration records at the time the order is received or confirmed.
- The Administrator educated the Director of Nursing and the Assistant Director of Nursing that both are responsible to print the paper MAR to be ready and will be placed by each of the nurse's station.
- A monthly MAR print out schedule was created for clarity.
- The DON and the ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm or other reason to expect downtime.
- A mock drill was conducted for the nursing personnel on shift.
- The facility replaced the router through its internet provider.
- The entire Medical Record Administration was reprinted in the event of outage and nurses were all educated that any medication changes or new admissions will need to be updated in the paper medical administration records.
- All residents that had the potential of being affected by this deficient practice were assessed by the medical director.
- An ad-hoc Quality Assurance meeting was conducted to discuss the deficient practice and plan of correction.
- The nurses responsible were immediately educated about the improper practice and on the Policy on Computer or Internet Downtime and EHR access.
Neglect and Verbal Abuse During Internet Outage
Penalty
Summary
The facility failed to protect residents from neglect during a forecasted winter storm that caused an internet outage, preventing access to the Electronic Health Record (EHR) system. This outage occurred on January 21 and 22, 2025, and the facility did not have systems in place to ensure continuity of care. As a result, pre-printed paper documentation forms such as physician orders and Medication Administration Records (MARs) were not available for the licensed nursing staff to use for resident care, treatment, and medication administration. Consequently, residents on the second and third floors did not receive their medications as ordered by the physician during this period. The nursing staff, including the nurse supervisor on duty, failed to ensure that residents received their medications and treatments as ordered. They also did not notify management staff or the residents' physicians of their inability to safely administer medications. This lack of communication and failure to implement a backup plan for medication administration during the internet outage led to a situation where residents did not receive necessary medications, including insulin and other significant medications, for more than 24 hours. Additionally, the facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA). The CNA, who was reportedly tired and frustrated from working a double shift, verbally abused the resident by using derogatory language. The resident reported feeling shocked and stunned by the CNA's behavior. The facility's investigation substantiated the allegation of verbal abuse, and the CNA was subsequently terminated.
Removal Plan
- The medication administration Record (MAR) will be printed monthly by the Director of Nursing Assistant Director of Nursing or Unit Manager.
- The paper MAR will be updated at the time the order is received or confirmed for all current resident and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes including all new orders for new admits.
- The updated MAR will be located by the nursing stations.
- All LPNs and RNs were in-serviced to ensure nurses know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR.
- The Director of Nursing and Assistant Director of Nursing began to educate all nurses, all physical therapy staff and administrative staff and provided the education with 1:1 in-service to specific staff.
- The in-services included the policy titled Policy on Computer or Internet Downtime and EHR, the standard of practice to administer medication, monitor blood glucose, the implementation of the prescribing physicians' orders, the importance of documenting medication administration at the time of administration.
- Inservice included calling the physician as well as notify the Director of Nursing or Designee if staff including nurses are unable to carry out a physician's order.
- Inservice included how it led to neglect and the facility's Abuse Policy titled Abuse Policy.
- The in-service was completed for all nurses, PT staff, and administrative staff.
- The nursing staff were all educated by the Director of Nursing or Assistant Director of Nursing and 1:1 in-service to specific staff.
- The in-service included that a printed MAR will be ready for each month.
- A copy of the paper MAR will be kept at each nurses' station for use during downtime.
- Education included that RNs and LPNs who receive an order or confirm a new order for any medication changes including all new orders for new admits will update the paper medication administration records at the time the order is received or confirmed for all current resident and new admits.
- The Administrator educated the Director of Nursing and the Assistant Director of Nursing that both of them are responsible to print the paper MAR to be ready for each month and will be placed by each of the nurse's station.
- A monthly MAR print out schedule was created for clarity.
- The education included that the DON and the ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm or other reason to expect downtime.
- A mock drill was conducted for the nursing personnel on shift.
- The facility replaced the router through its internet provider.
- The entire Medical Record Administration was reprinted in the event of outage and nurses were all educated that any medication changes or new admissions will need to be updated in the paper medical administration records.
- A report was generated from the electronic medical records to see which residents could have been affected.
- All residents that had the potential of being affected by this deficient practice were assessed by the medical director.
- An ad-hoc Quality Assurance meeting which included the entire IDT team was conducted to discuss the deficient practice and plan of correction.
- The nurses that were responsible were immediately educated about the improper practice and on the Policy on Computer or Internet Downtime and EHR access.
- The QA team discussed the needed in services/education for specific staff.
Failure to Notify Physician of Medication Administration Issues During Internet Outage
Penalty
Summary
The facility failed to ensure that the physician was notified when residents on the second and third floors did not receive their medications and treatments as ordered due to an internet outage. This outage occurred on January 21 and 22, 2025, and prevented access to the Electronic Health Record (EHR) system. As a result, nurses did not have access to pre-printed paper documentation forms such as physician orders and Medication Administration Records (MARs) to administer medications during this period. The facility staff did not notify the Director of Nursing (DON), residents, or resident representatives about the residents not receiving their ordered medications and treatments. Interviews revealed that the Licensed Practical Nurse (LPN) who was a supervisor during the snowstorm was unsure if the residents received their medications and did not inform the DON or Administrator (ADM) about the system being down. The DON was not at the facility during the outage and was not informed about the issue until March 20, 2025. Similarly, the ADM was unaware that residents did not receive their medications until informed by the survey team. The Physician/Medical Director was also not informed about the facility's computer system being down and the residents not receiving their medications. The physician expressed that he would have liked to have been informed of this situation, as missing medications could lead to various health issues for the residents. The facility's non-compliance with the requirement to notify the physician and other relevant parties was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death, leading to an Immediate Jeopardy citation.
Removal Plan
- The medication administration Record (MAR) will be printed monthly by the Director of Nursing, Assistant Director of Nursing, or Unit Manager.
- The paper MAR will be updated at the time the order is received or confirmed for all current residents and new admits by the RN/LPN who receives the order or confirms the new order for any medication changes.
- The updated MAR will be located by the nursing stations.
- All LPNs and RNs were in-serviced to ensure they know where the paper MAR is located and to update it as soon as a new admission or whenever the physician changes an order in the MAR.
- In-services were conducted to educate all nurses, physical therapy staff, and administrative staff on the policy titled Policy on Computer or Internet Downtime and EHR, standard practices for administering medication, monitoring blood glucose, implementing physician orders, and documenting medication administration.
- In-service included calling the physician and notifying the Director of Nursing or Designee if staff are unable to carry out a physician's order.
- In-service included how the situation led to neglect and the facility's Abuse Policy.
- The Administrator educated the Director of Nursing and the Assistant Director of Nursing that they are responsible for printing the paper MAR and placing it by each nurse's station.
- A monthly MAR printout schedule was created for clarity.
- The DON and ADON will confirm that an accurate MAR for all residents is printed and available for use in the event of a forecasted severe storm or other reason to expect downtime.
- A mock drill was conducted for the nursing personnel on shift.
- The facility replaced the router through its internet provider.
- The entire Medical Record Administration was reprinted in the event of an outage, and nurses were educated that any medication changes or new admissions will need to be updated in the paper medical administration records.
- All residents that had the potential of being affected by this deficient practice were assessed by the medical director, and no adverse effects were identified.
- An ad-hoc Quality Assurance meeting was conducted to discuss the deficient practice and plan of correction.
- The nurses responsible were immediately educated about the improper practice and on the Policy on Computer or Internet Downtime and EHR access.
Failure to Monitor Vital Signs in Newly Admitted Resident
Penalty
Summary
The facility failed to ensure that a system was in place to assess the vital signs of newly admitted residents at a frequency expected by the physician or CRNP. Specifically, a resident admitted after hospitalization for Atrial Fibrillation with Rapid Ventricular Response had orders for vital signs to be checked only once a month, contrary to the physician's expectation of daily assessments for new admissions. This oversight led to a situation where the resident's heart rate was significantly elevated, reaching 142 bpm, without timely intervention. The deficiency was further compounded by the lack of established parameters for when the physician should be notified of abnormal vital sign values. On one occasion, the resident's heart rate was recorded at 120 bpm, but no action was taken until the resident experienced chest pain and shortness of breath, prompting a request for hospital transfer. Interviews with facility staff, including the DON and CRNP, revealed a discrepancy between the expected and actual practices for monitoring vital signs in newly admitted residents. The facility's non-compliance with the requirements of participation was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death, resulting in an Immediate Jeopardy citation. The deficiency was identified during the investigation of a complaint, highlighting the need for a systematic approach to vital sign monitoring and physician notification for newly admitted residents.
Removal Plan
- The facility failed to ensure a system was in place to ensure newly admitted residents' vital signs were assessed at a frequency expected by the physician/CRNP.
- Resident specific vital sign parameters were established including when the physician should be notified of abnormal values.
- The Director of Nursing contacted the Medical Director for guidance on updating vital sign thresholds for notification.
- The Medical Director was contacted by the DON on his expectations on vital sign monitoring.
- An updated New Admit/Readmit Checklist was implemented to ensure vital sign frequency and parameters are established at the time of admission.
- The vital sign monitoring policy was updated by the RDHS to require at least daily vital signs for all newly admitted or readmitted residents for 2 weeks.
- The Director of Nursing contacted the Medical Director for guidance on updating vital sign thresholds for notification.
- The Medical Director was contacted by the DON on his expectations on vital sign frequency.
- Vital sign parameter thresholds and frequency were updated for all newly admitted or readmitted residents over the last 30 days, vital sign orders by the RDHS and DON.
- The Daily Clinical Meeting form was revised by RDHS to include review of vital signs outside physician ordered parameters with follow up documentation.
- The DON and Staff Development Coordinator provided education for licensed staff on the updated VS Monitoring Policy, monitoring residents' vital signs at least daily for 2 weeks following an admission or re-admission and vital signs thresholds that require physician notification, and process to document vitals, notification, and physician recommendations.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident identified as RI #497. On January 4, 2025, the resident experienced an elevated heart rate of 142 beats per minute at 1:24 PM, which was not communicated to the physician. Later that day, at 9:22 PM, the resident's heart rate remained elevated at 120 beats per minute, yet again, the physician was not informed. This lack of communication resulted in no additional treatment or interventions being implemented, leading to a delay in necessary medical care. The resident, who had a history of Chronic Obstructive Pulmonary Disease and Atrial Fibrillation, continued to experience elevated heart rates and eventually complained of chest pain and difficulty breathing. Despite these symptoms, the resident was not transferred to the hospital until the early hours of January 5, 2025. Upon arrival at the hospital, the resident was admitted to the Intensive Care Unit for treatment of Atrial Fibrillation with Rapid Ventricular Response. Interviews with facility staff revealed that there was a failure to follow the facility's policy on notifying physicians of changes in a resident's condition. The Registered Nurse and Licensed Practical Nurse involved did not notify the physician or follow up on instructions given by the Certified Nurse Practitioner. This oversight was identified as a deficiency under Resident Rights, specifically regarding the notification of changes in a resident's condition.
Removal Plan
- The Director of Nursing (DON) provided 1:1 in-service with the licensed nurse who failed to notify the physician on physician notification when resident experiences change in condition and notification parameters on vital signs.
- All residents in house most recent vital signs were reviewed by the DON, Regional Director of Health Services and Regional Assessment Coordinator for any change of condition as well as vital signs outside parameters that were set forth by the Medical Director.
- Any resident with a change of condition or vital signs outside the parameters, the provider was notified by DON, Unit Manager or Charge nurse for any additional orders or treatment.
- All licensed nurses, which are 31 in total, were educated on notification to the provider for change in condition, to include vital signs outside the parameters given by the DON and Staff Development Coordinator. Any licensed nurse who did not receive the in-service will not be allowed to work until the in-service has been provided. There is 1 LPN pending (on medical leave) and the DON is responsible to ensure they are educated before working.
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