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)
Latest citations in Alabama
A resident with documented elopement risk, a guardian, and a Wander Guard was not physically checked when staff realized the resident was missing, and the resident was later found by police lying in a road with seizures and altered mental status after leaving the facility unnoticed. Another resident with wandering and cognitive concerns was observed near a busy roadway after leaving unsupervised, with incomplete sign-out documentation and no elopement reassessment. The facility also failed to control smoking safety for a resident with a history of arson and fire-setting and for another resident who smoked in a room with a blind roommate, despite policies requiring supervised smoking and secure control of smoking materials.
Failure to Manage Unsafe Behaviors and Behavioral Health Needs: A resident with dementia, schizophrenia, and a history of fire-setting repeatedly smoked in undesignated areas and in the building, while another resident with mood disorder, nicotine dependence, and TBI repeatedly smoked in the room and bathroom and kept smoking paraphernalia in the room. The facility also failed to monitor residents with elopement risk, allowing one resident to wander unsupervised and elope, another to leave the building unsupervised multiple times and nearly be struck by a vehicle, and a third resident with a history of aggression to physically assault other residents.
A resident with moderate cognitive impairment and a care plan addressing refusals of care was forcibly held down by an RN and CNA after refusing incontinent care multiple times. During the interaction, the resident became physically aggressive, but staff continued the care, with witness statements describing the RN directing that the resident had to be changed. The resident later reported being held down, having arms grabbed, clothing ripped off, and being washed with a cold rag; bruising, wrist redness, hand discoloration, soreness, and emotional distress were documented.
Failure to Assess and Treat Worsening Pressure Injuries: Two residents with high pressure injury risk had new skin breakdown that was not promptly assessed or treated by the treatment nurse. One resident’s buttocks/sacral excoriation progressed to an unstageable wound with foul odor, drainage, and necrotic tissue, while another resident’s buttocks and sacral open areas were not evaluated or placed on treatment until they later became unstageable and then stage III/IV pressure injuries. Staff interviews confirmed the wounds should have been documented, measured, and monitored earlier.
Staff did not follow the posted lunch menu for a puree entree and fruit side. A Dietary Manager used a #12 scoop for Puree Beef Stroganoff and stated the puree version did not include noodles, even though the recipe called for the dish to be served over rice or noodles and the diet guide listed a 6 oz portion. Staff also used a #16 scoop for Sliced Strawberries instead of the 1/2 cup portion listed on the diet guide. The RD confirmed the menu was not being followed and that the portions served were incorrect.
Failure to Protect Residents from Resident-on-Resident Physical Abuse: A resident with documented aggressive behavior repeatedly assaulted other residents after wheelchair contact in the dining room and hallway. The resident yelled, cursed, grabbed hair and clothing, hit residents in the face and head, and pulled one resident from a wheelchair, causing scratches, discoloration, and other minor injuries. Facility records described a pattern of monthly physical altercations, but no effective supervision or behavior-management approaches were included in the care plan.
Failure to Supervise Elopement Risks and Enforce Smoking Safety
Penalty
Summary
The facility failed to ensure residents at risk for elopement were supervised so their whereabouts were known and they remained free from accident hazards. RI #106 had diagnoses including encephalopathy, schizoaffective disorder, expressive language disorder, adjustment disorder with mixed anxiety and depressed mood, mood disorder due to a known physiological condition with manic features, and other speech disturbances. The resident also had a court-appointed guardian, an elopement evaluation that identified elopement risk, a care plan with interventions for exit-seeking behavior, and an order for a Wander Guard device to be secured to the ankle and checked every shift. On the morning of the incident, staff found the resident was not in the room, the window was raised, and the resident was not in the building. Staff interviews showed the resident had last been seen around 2:00 AM, but when the resident was not found around 4:00 AM, staff did not physically check the resident or determine the resident’s whereabouts. The nurse later acknowledged she documented the Wander Guard as checked even though she had not actually verified it. RI #106 was later found by police lying in the middle of a road near an intersection adjacent to an interstate and U.S. highway, nearly struck by a patrol car. EMS documented seizures while the resident was being evaluated, and the resident was transported to the hospital and later transferred to an acute care psychiatric facility. Hospital records documented altered mental status, expressive aphasia, right hemiplegia, encephalopathy, seizures, and inability to provide identifying information. The facility investigation also noted the window screen appeared cut, the window was pushed up, and nail clippers were found on the bed. The maintenance director stated the door alarm system had not been functioning properly and that the alarm sensitivity and volume had been lowered. The facility also failed to ensure RI #121 was supervised in a manner that kept the resident’s whereabouts known. RI #121 had diagnoses including end stage renal disease, dependence on renal dialysis, hypertensive heart disease, cognitive communication deficit, difficulty walking, and other abnormalities of gait and mobility. The resident had a prior elopement evaluation that found minimal risk and no care plan, despite documentation of wandering and behavioral concerns. Records showed the resident signed out of the facility on one occasion with incomplete documentation, and staff later observed the resident unsupervised on the front porch and then near a busy roadway. Staff reported the resident was nearly struck by employees’ vehicles and was found standing near the road wearing earphones and unable to hear staff calling out. Interviews confirmed no elopement reassessment was completed after the resident left the facility unsupervised. The facility further failed to monitor smoking safety for RI #33 and RI #109. RI #33 had diagnoses including dementia with mood disorder and paranoid schizophrenia, a behavior plan for noncompliance with smoking and setting fires, and a documented history of arson and attempted fire-setting. Despite this history, the resident was observed with cigarettes and lighters and was later seen burning an orange juice container in the smoking area. RI #109 was the subject of an anonymous complaint that the resident smoked in a room with a blind roommate, and the investigation determined the resident was noncompliant with the facility smoking policy and procedures. The report states these deficiencies were cited as immediate jeopardy and substandard quality of care under F689, and also includes separate actual-harm findings related to unsafe mechanical lift transfers involving RI #103 and RI #74.
Failure to Manage Unsafe Behaviors and Provide Behavioral Health Services
Penalty
Summary
The facility failed to ensure behavioral health care and services were provided for residents with known unsafe behaviors, including unsafe smoking, wandering, elopement risk, and physical aggression toward other residents. The report states the facility did not implement a behavior management process to identify, evaluate, and address behaviors affecting resident safety, and did not recognize the need for adequate supervision and monitoring of residents with unsafe behaviors. The Immediate Jeopardy was cited under F740 Behavioral Health Services and was identified as beginning on 03/30/2024. Resident #33 had diagnoses including Dementia with Moderate Mood Disturbance, Insomnia due to other mental disorders, Mental Disorder NOS, and Paranoid Schizophrenia, and had a BIMS score of 15 of 15. The resident’s behavior management care plan addressed noncompliance with smoking and setting fires, with interventions including 1:1 supervision, re-education on smoking policy, observation and documentation of target behaviors, diversional activities, and behavior medications as ordered. Progress notes and staff interviews documented repeated unsafe smoking-related behaviors, including smoking in undesignated areas, smoking in the building, possession of cigarettes and lighters, and a history of starting fires. Staff described that when cigarettes or lighters were found, they were taken away, and the medical director stated she was aware of the smoking and aggression but not that the resident was a fire starter. Resident #109 had diagnoses including Mood Disorder due to Psychological Condition with Depressive Features, Paraplegia, Nicotine Dependence, and Personal History of Traumatic Brain Injury, and also had a BIMS score of 15 of 15. The resident was care planned for verbal behavioral symptoms, nicotine addiction, and smoking outside designated areas, with an approach to observe for need for 1:1 smoking supervision. Progress notes documented repeated smoking in the room and bathroom, strong cigarette odor, cigarette butts and smoking paraphernalia in the room, and marijuana odor in the room. Staff interviews confirmed that the resident continued to smoke in the room and that no new interventions were put in place beyond education on the smoking policy. Resident #106, who had a history of elopement risk, wandered the facility unsupervised during the day and at night and eloped on 04/14/2026 without the facility being aware. Resident #121, who had a history of elopement risk, noncompliance with care/treatment, and confusion, left the building unsupervised on 04/05/2026 and 04/10/2026, and eloped again on 04/11/2026, nearly being struck by an employee’s vehicle. The facility was aware of the earlier instances because the resident was allowed to leave unsupervised. The report also states the facility failed to manage Resident #116’s pattern of abusive behavior toward other residents, including swinging at, hitting, and pulling other residents to the floor when wheelchairs bumped into each other. Investigative files documented physically abusive incidents involving multiple residents on several dates, and the deficiency affected five sampled residents.
Physical restraint during refused care
Penalty
Summary
Freedom from physical restraint was not maintained when staff forcibly held a resident down after repeated refusals of incontinent care. The resident had diagnoses including myopathy and essential hypertension, and a recent MDS documented a BIMS score of 11 out of 15, indicating moderate cognitive impairment. The care plan noted behavioral symptoms such as refusing care, becoming combative during care, and frequent refusal of incontinent and hygiene care, with interventions directing staff to allow choices, avoid arguing, approach later if combative, and provide peri-care as the resident would allow. On the day of the incident, the resident refused care on multiple occasions. CNA #64 reported that she attempted to check the resident’s brief, was refused, and returned twice more with the same result before informing RN #63. RN #63 then directed CNA #64 to gather supplies and return to assist with care. During the attempt to provide care, the resident became physically aggressive, and staff continued with the interaction rather than stopping after the refusals. Witness statements described RN #63 directing continued care and stating the resident had to be changed, while CNA #64 stated she followed RN #63’s instructions and believed the resident could no longer refuse care. The resident reported that RN #63 and CNA #64 came into the room, held him/her down, grabbed his/her arms, ripped off clothing, and washed him/her with a cold rag. The resident’s daughter reported being told that staff held the resident down, and a police report documented visible fresh bruising to the wrists and hands. A clinical assessment found bilateral bruising and redness to the wrist area, discoloration to both hands, soreness to touch, and emotional distress with tearfulness when recalling the event. RN #63 denied restraining the resident and stated she was guarding herself and CNA #64 from the resident’s aggressive actions, but the investigation substantiated the incident as physical abuse.
Failure to Assess and Treat Worsening Pressure Injuries
Penalty
Summary
The facility failed to provide ongoing skin assessments and timely wound evaluation for two residents with identified skin breakdown, resulting in pressure injuries being recognized only after they had progressed to advanced, unstageable wounds. The deficiency was cited under F686, Treatment/Services to Prevent/Heal Pressure Ulcers, and was associated with Immediate Jeopardy findings involving Resident Identifier #108 and Resident Identifier #51. The report states that the facility did not identify or reassess worsening skin conditions early enough, and that treatment changes were not initiated when new open areas or excoriation were first observed. For Resident Identifier #108, staff noted excoriation and redness to the buttocks/sacral area, but the area was not fully assessed with measurements, drainage, or odor documentation at that time. An order was obtained to clean and cover the area three times weekly, yet the area was not reassessed or changed until it was later documented as an unstageable wound measuring 5 cm by 4.5 cm with 1 cm depth, seropurulent drainage, foul odor, and necrotic tissue. The resident had diagnoses including Parkinsonism, contracture, autistic disorder, muscle weakness, and aphasia, and was identified as high risk for pressure injuries on Braden Scale and MDS review. Interviews with nursing staff and the CRNP indicated the wound had progressed from a skin shear/excoriation to a much larger, deeper wound over time, and staff acknowledged that the wound should have been documented and treated earlier. For Resident Identifier #51, staff documented two small open abrasions and several red areas on the lower right buttocks, but the treatment nurse did not assess the area and preventive treatment was not initiated at that time. The wound was later identified as an unstageable pressure ulcer with slough and drainage, measuring 5 cm by 4 cm, and was subsequently documented as stage IV. The resident also had several open areas on the coccyx/sacrum after readmission from the hospital, but the treatment nurse did not document an initial assessment or start treatment until the areas were later identified as a pressure ulcer, then unstageable, and later stage III. The resident’s diagnoses included osteomyelitis, type 2 diabetes with diabetic neuropathy, and pressure ulcer of unspecified buttocks, and the record showed the resident was at risk for pressure ulcers. Interviews with nursing staff and the CRNP confirmed that newly identified open areas should have been assessed, measured, documented, and treated promptly, but that did not occur in these instances.
Menu Portions Not Followed for Puree Entree and Fruit Side
Penalty
Summary
The facility failed to follow the Spring/Summer 2026 Week 3 menu for Wednesday lunch by not providing the portion sizes listed for Puree Beef Stroganoff and Sliced Strawberries. The facility’s policies stated that menus should meet residents’ nutritional needs, be prepared in advance, be followed, and include portions stated in ounces or measurements. The Puree Foods policy also stated that pureed food items should be the same as those served on the regular menu, and the Food Preparation Guidelines required menu items to be prepared according to written menus and recipes. During the lunch trayline observation, the Dietary Manager was acting as the AM dietary lead. Puree Beef Stroganoff was portioned using a #12 scoop, which measured 2 2/3 oz, and a normal puree plate was observed containing one #12 scoop of Puree Beef Stroganoff, one #8 scoop of Puree beans, and one #12 scoop of Puree bread. The facility’s Beef Stroganoff recipe directed that the dish be served over rice or noodles, but the Dietary Manager stated the puree Beef Stroganoff was only the beef and gravy and did not include noodles. The Production Sheet used by staff did not include puree diet portion information. Sliced Strawberries were also portioned incorrectly. The diet guide specified 1/2 cup for the regular menu, but staff used a #16 scoop, which measured 2 oz, to serve the strawberries. The AM Dietary Aide said she used the diet guide and had not referred to the scoop chart, and she did not know the scoop size until it was pointed out. The Regional Dietary Consultant, a Registered Dietitian, stated that the correct serving for puree Beef Stroganoff should have been 6 oz of meat and gravy mixed with pasta using a #5 scoop, and that a #8 scoop should have been used for the 1/2 cup strawberries. The consultant stated the menu was not being followed and that four residents were receiving a puree diet and 75 residents were eligible to receive the strawberries.
Failure to Protect Residents from Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by a resident with a documented pattern of aggressive behavior toward others when wheelchairs bumped together. Resident #116 had diagnoses including Peripheral Vascular Disease, Mood Disorder, and Intellectual Disabilities, and a quarterly MDS documented a BIMS score of 15, indicating intact cognition. The resident’s care plan identified that the resident was aggressive with other residents and had a history of hitting and fighting, but it did not include approaches to guide staff in supervising or de-escalating the resident to prevent abuse of others. On 12/24/2024, during an activity in the dining room, Resident #115 accidentally bumped into Resident #116’s wheelchair while backing out after getting a soda. Resident #116 yelled and cursed, then the two residents hit each other in the face. The facility’s investigation documented pink discoloration to Resident #115’s left cheek and a small cut to the bridge of Resident #116’s nose, and the investigator concluded that resident-to-resident physical abuse was confirmed. The investigative file also noted there were no staff members who witnessed how the physical abuse started. On 08/09/2025, Resident #81 accidentally bumped Resident #116’s wheelchair near the dining room entrance, after which Resident #116 swung at Resident #81, grabbed the resident’s shirt, and the two residents struck each other. Resident #81 had a small discoloration under the right eye and redness to the left side of the neck. On 10/08/2025, Resident #115 again accidentally bumped Resident #116’s wheelchair, and Resident #116 grabbed Resident #115’s hair, pulled the resident out of the wheelchair, and would not let go as both residents fell to the floor and hit each other. Resident #115 had scratches to a finger and forehead, and Resident #116 had a red eye, surrounding discoloration, and a raised area to the forehead. On 10/27/2025, Resident #116 bumped into Resident #21’s wheelchair, tried to grab the resident’s hair, and then hit the resident in the side of the head with a fist. The facility’s records and interviews described Resident #116 as having combative behavior and monthly physical altercations, but the report states there were no recommendations for supervision or monitoring to prevent further abuse of residents.
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Compliance trends in Alabama
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 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: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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 May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 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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