Citations in Alabama
Comprehensive analysis of citations, statistics, 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
The facility failed to prevent multiple forms of abuse and exploitation. A cognitively impaired, wandering resident was not adequately supervised and entered the room of another cognitively impaired resident with a documented history of sexually inappropriate behavior; a CNA later observed that resident fondling the wandering resident’s genitalia, despite prior documentation of repeated sexualized behaviors and no clear supervision directions in the care plan. In a separate event, a staff member posted a photo on social media of a cognitively intact but physically disabled resident soiled with feces, with a derogatory caption, contrary to written policies prohibiting unauthorized resident images and protecting privacy and confidentiality; the resident reported feeling angry and embarrassed. Additionally, a resident with a known history of verbal and physical aggression struck another resident on the arm in the dining room, causing pain, demonstrating inadequate supervision and interventions to prevent resident-to-resident physical abuse.
The facility failed to implement its abuse, neglect, and exploitation policy to prevent and investigate resident‑on‑resident sexual abuse involving two cognitively impaired residents, one with Alzheimer’s disease who wandered into others’ rooms and one with intellectual disability and a documented history of sexually inappropriate behavior. Over several months, staff documented repeated sexually inappropriate acts and aggressive behaviors by the latter resident, yet the resident remained on a memory care unit populated by wandering residents. One evening, a CNA observed this resident with a hand inside another resident’s brief, fondling the genital area. The CNA removed the resident and notified an LPN, but no body audit was performed, and staff reported they had not been instructed on specific supervision of wandering residents. The facility’s investigation was limited to two staff statements, did not include comprehensive interviews or assessments, and concluded the allegation was not substantiated despite acknowledgment that both residents lacked capacity to consent. Leadership, including the abuse coordinator and administrator, could not identify the cause of the incident or effective preventive measures, and surveyors cited Immediate Jeopardy under F607 for failure to establish a safe environment, implement effective protocols, and conduct a thorough abuse investigation.
The facility failed to implement an effective QAPI process after a resident-to-resident sexual abuse incident involving a resident with a known history of sexually inappropriate behavior and another cognitively impaired, wandering resident. Although policies required QAA review of sexual abuse cases to ensure thorough investigation, resident protection, analysis of why the event occurred, and identification of systemic actions, the QAPI Committee did not verify a complete investigation, did not classify the event as abuse, and did not analyze risk factors such as unsupervised wandering and access to other residents’ rooms. The ADM acknowledged that not all aspects of the investigation were documented, did not recall reviewing the investigation before submission to the State Agency, and reported that QAPI did not identify a need for systemic changes, relying instead on separating the residents. The lack of documented QAPI review and failure to identify and address causal and contributing factors resulted in unsafe conditions persisting and led to an Immediate Jeopardy citation at F867.
The facility failed to follow its abuse policy requiring notification of law enforcement for alleged abuse when a staff member observed two residents in a situation documented as sexual abuse, with one resident’s hand inside another resident’s brief. The incident was entered into the state’s online reporting system as sexual abuse, but the report indicated that law enforcement was not notified. In a later interview, the SSD/Abuse Coordinator confirmed that law enforcement should have been contacted for such an allegation and acknowledged that the policy was not followed, affecting two residents reviewed in the abuse sample.
The facility did not provide two residents and their representatives with written transfer notices containing all required information during emergent hospital transfers. Instead of specifying the actual medical reasons for transfer, the notices used a generic statement, and there was no documentation in the EMR that written notices were given, only that representatives were notified by phone.
A resident with severe mental illness and behavioral disturbances physically struck two other residents on separate occasions in the dining room. Despite a history of unpredictable and aggressive behaviors, the care plans lacked specific supervision interventions, and no assessment was conducted to determine the necessary level of supervision after the first incident. Multiple staff were present but did not witness the abuse until after it occurred, and the facility did not adequately analyze or address the causes to prevent recurrence.
A resident with severe mental illness and dementia, known for unpredictable and aggressive behaviors, was not adequately supervised or provided with individualized behavioral interventions. This lack of supervision led to two incidents where the resident physically struck other residents, with staff and witness interviews confirming the actions were linked to delusional thinking. Facility records and care plans did not reflect ongoing supervision or updated interventions despite the resident's history and repeated incidents.
Staff did not follow the care plan and facility policy requiring a mechanical lift with two-person assistance for a resident with severe mobility and cognitive impairments. Instead, a staff member performed a lift alone in the morning, and later, two staff members completed a manual transfer without the lift. These actions resulted in the resident sustaining a large bruise and experiencing significant pain, necessitating pain medication.
A resident with severe cognitive impairment was subjected to physical and mental abuse when an LPN placed a hand over the resident's mouth and pinched the nose to force medication administration, despite the resident's right to refuse treatment. The incident was witnessed by a CNA, and subsequent staff interviews confirmed that such actions were improper and could be considered abuse. Facility policies clearly state residents' rights to refuse care, but the LPN admitted to the coercive act, and the facility failed to provide adequate oversight upon the LPN's return to work.
A resident with severe cognitive impairment was physically and mentally abused by an LPN during medication administration, when the LPN covered the resident's mouth and pinched their nose to force medication intake. A CNA witnessed the incident but failed to intervene or report it immediately, and the LPN continued working without supervision. Facility administration did not initially identify the event as abuse, allowing the LPN to return to work and administer medications to other vulnerable residents without monitoring.
Failure to Prevent Resident-to-Resident Abuse and Staff Social Media Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, neglect, and exploitation, including sexual abuse between residents, physical abuse between residents, and mental abuse/exploitation by staff through social media. One resident with Alzheimer’s disease and severe cognitive impairment, who wandered frequently and intruded into other residents’ rooms, was not adequately supervised despite documented wandering episodes and a care plan noting exit-seeking and room entry behaviors. Another resident with myocardial infarction, intellectual disabilities, mood disorder, mild cognitive impairment, and a documented history of sexually inappropriate behavior toward staff and possible other residents was also not care planned with specific directions for supervision. Progress notes over several months documented repeated sexually inappropriate touching and comments toward staff, combative behavior, and the need for two staff for care, yet the care plan did not specify how or when this resident should be supervised. On one evening, a CNA observed the cognitively impaired, wandering resident sitting on the bed of the resident with sexually inappropriate behaviors, and saw the latter with a hand inside the other resident’s brief, fondling the resident’s genitalia. Staff interviews confirmed that both residents lacked the ability to consent to sexual activity and that the contact was non-consensual sexual contact. The CNA who witnessed the event reported having no specific instruction on how to supervise wandering residents beyond photos at the nurses’ station. The unit manager and DON acknowledged that the wandering resident entered other residents’ rooms frequently, that staff were expected to round every two hours or more often, and that more frequent monitoring could have prevented the incident. The administrator stated that the resident with sexually inappropriate behaviors could remain on the memory care unit after allegations of sexual touching because he did not feel the resident posed a threat to others. The facility also failed to protect another resident from mental abuse and exploitation when a former CNA posted a photograph of the resident in a vulnerable, soiled condition on Snapchat with a derogatory caption. The resident, who had anoxic brain damage and spastic quadriplegic cerebral palsy but intact cognition, later reported feeling angry and embarrassed after being informed of the incident. Facility policies on social media use, cell phones, and confidentiality explicitly prohibited taking, keeping, or distributing unauthorized photographs of residents and described such actions as violations of privacy and confidentiality that could degrade or embarrass residents. A nurse aide witness reported seeing the image on social media, recognized the resident by the room items, and described the picture as showing the resident’s body from armpit to ankle covered in feces, with no face or genitalia visible. Staff interviews confirmed that posting such an image would be considered abuse and a violation of policy and resident privacy. In a separate incident, the facility failed to protect a resident from physical abuse by another resident with a known history of aggressive behaviors, including verbal and physical aggression. A CNA witnessed the aggressive resident hitting another resident on the arm in the dining room. The victim reported that his/her arm hurt after being hit. The aggressive resident’s history of physical aggression was known, but the facility did not provide adequate supervision and interventions to prevent this resident from abusing others. These failures occurred despite facility policies that required screening of residents for behavioral risks, assessment and care planning for behaviors that might lead to conflict or neglect, training staff on behavioral symptoms that increase risk of abuse, and implementing policies and procedures to prevent all types of abuse, including sexual, physical, and mental abuse facilitated by technology.
Failure to Implement Abuse Policy and Prevent Resident‑on‑Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy to prevent, identify, and investigate an allegation of sexual abuse involving two cognitively impaired residents. One resident with Alzheimer’s disease had a care plan for wandering, exit seeking, and entering other residents’ rooms, with interventions focused on redirection and a secure care monitor to prevent elopement. Another resident with hemiplegia, unspecified intellectual disabilities, and mild cognitive impairment had a comprehensive care plan identifying a history of attention‑seeking behaviors, combative behavior, verbal abuse, and sexually inappropriate behavior toward staff and possibly other residents, with interventions including administration of medications per MD order and use of two staff for care due to sexually inappropriate episodes. Despite these identified risks and documented behaviors, the facility did not establish or implement effective protocols to prevent sexual abuse between these residents. From December 2024 through February 2025, multiple progress notes documented escalating sexually inappropriate behaviors by the resident with intellectual disability toward staff, including touching female staff inappropriately, grabbing breasts and buttocks, and other aggressive behaviors such as yelling out, throwing items, and being verbally and physically abusive. The Memory Care Unit, where this resident was housed at the time, was described by staff as a unit with wandering residents who had decreased cognition. The wandering resident with Alzheimer’s disease was known to enter other residents’ rooms. On the evening of 02/11/2025, a CNA making rounds observed the wandering resident sitting on the side of the sexually inappropriate resident’s bed, with the latter’s hand inside the wandering resident’s brief, fondling the genital area. The CNA immediately removed the wandering resident from the room and reported the incident to an LPN. The LPN did not perform a body audit on either resident, and the CNA reported she had not been instructed on how to supervise wandering residents beyond recognizing their photos at the nurses’ station. The facility’s investigation did not follow its own written procedures for abuse investigations. The investigative file contained only two staff statements (from the CNA and the LPN) and did not include interviews with all potentially involved or knowledgeable staff, nor did it document a body assessment of either resident. The Abuse Coordinator’s closing report concluded the incident was “not substantiated” sexual abuse, citing insufficient evidence regarding which resident initiated the contact and the absence of observed distress, despite acknowledging that neither resident had the ability to consent. In subsequent interviews, the Abuse Coordinator stated they had no identified cause for the incident because neither resident could explain what happened and acknowledged that staff did not observe the wandering resident entering the room because they were in other residents’ rooms providing care. The Abuse Coordinator also stated that, given both residents lacked capacity to consent, there was nonconsensual sexual contact on 02/11/2025. The Administrator reported he did not recall reviewing the investigation findings before submission to the State Agency and could not identify what could have been done to prevent the abuse. The surveyors determined that the facility failed to establish a safe environment, failed to implement protocols to prevent sexual abuse among residents with known wandering and sexually inappropriate behaviors, and failed to conduct a thorough investigation to accurately determine that abuse occurred and the cause of the incident, resulting in Immediate Jeopardy under F607. Additional documentation after the incident showed that the resident with sexually inappropriate behaviors continued to exhibit similar behaviors toward staff throughout 2025, including inappropriate touching and aggressive actions, with periodic notes indicating that such behaviors had increased in frequency. Interviews with the Memory Care Unit manager confirmed awareness of the resident’s ongoing sexually inappropriate behaviors and refusal of medications, and acknowledged that when the resident was later returned to the Memory Care Unit, that unit continued to house more wandering, confused residents than other units. The manager also confirmed there was no staff specifically assigned to monitor wandering residents, and that the primary intervention was general redirection. Staff interviews, including with an RN who characterized the 02/11/2025 event as abuse, further supported that the facility did not implement targeted supervision or environmental controls to prevent recurrence of sexual abuse between residents with known risk factors, despite the facility’s written policy requiring identification, ongoing assessment, care planning, monitoring, and establishment of a safe environment with protocols for preventing sexual abuse.
Failure of QAPI Oversight After Resident-to-Resident Sexual Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective Quality Assurance and Performance Improvement (QAPI) program in relation to a resident-to-resident sexual abuse incident. The facility’s QAPI plan and abuse policy required that cases of physical or sexual abuse be reviewed by the Quality Assurance and Assessment (QAA) Committee to ensure a thorough investigation, protection of residents, analysis of why the situation occurred, identification of contributing risk factors, and determination of whether systemic actions were needed. Despite these written policies, the QAPI Committee did not review the sexual abuse incident in a manner that verified a thorough investigation, did not classify the incident as abuse, and did not analyze why it occurred. The report states that the incident involved a resident with a documented history of sexually inappropriate behavior toward staff and another resident who wandered without supervision. The facility failed to analyze contributing risk factors, including the presence of wandering, cognitively impaired residents on the same unit as a resident with known sexually inappropriate behaviors. The QAPI Committee did not identify or address the lack of supervision that allowed wandering residents to enter other residents’ rooms without supervision. The Administrator later stated that the incident was discussed in QAPI, including who was involved, what happened, and how the facility would do things differently, but acknowledged that not all aspects of the investigation were in the documentation. The Administrator reported that QAPI did not determine that systemic changes were needed, explaining that the mental capacity of both residents led the team to believe that separation of the residents was sufficient. The Administrator also indicated he did not recall reviewing the investigation before it was submitted to the State Agency and was unsure what could have been done to prevent the abuse. The facility did not provide documentation showing that the allegation of resident-on-resident abuse was reviewed to ensure the investigation identified contributing or causal factors to be corrected and prevent recurrence. These failures in QAPI oversight and follow-through allowed unsafe conditions to persist and placed residents at risk for serious harm, leading surveyors to cite Immediate Jeopardy at F867 for QAPI/QAA improvement activities.
Failure to Report Alleged Sexual Abuse to Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse to local law enforcement as required by its own abuse policy. According to the facility’s written policy on Abuse, Neglect and Exploitation, revised 01/01/2024, sexual abuse is defined as non-consensual sexual contact of any type with a resident, and the policy requires reporting all alleged violations to the administrator, state agency, adult protective services, and other required agencies, including law enforcement when applicable, within specified timeframes. On 02/11/2025 at approximately 7:30 PM, a staff member observed one resident standing over another resident’s bed with the second resident’s hand down the first resident’s brief, and this was documented in the Online Incident Reporting System as an incident of sexual abuse. The Online Incident Reporting System entry for this event indicated that the incident type was “Abuse – Sexual” and that the incident was not reported to any law enforcement agency. During an interview on 01/18/2026 at 4:47 PM, the Social Service Director, who also served as the Abuse Coordinator, stated that law enforcement should be notified when abuse is alleged and acknowledged that law enforcement was not notified of the 02/11/2025 incident. The Social Service Director further stated that the facility’s abuse policy was not followed and expressed that the concern with not reporting the allegation to law enforcement was that vulnerable residents were at risk. This failure to report affected two of six residents sampled for abuse and was cited as a result of complaint investigation #471525.
Failure to Provide Required Written Transfer Notices with Specific Reasons
Penalty
Summary
The facility failed to provide residents and their representatives with written notices of transfer that included all required information during emergent transfers to the hospital. Specifically, for two residents who experienced acute medical events requiring hospital transfer, there was no documentation that written transfer notices were given to either the residents or their representatives at the time of transfer. In both cases, the facility's documentation only indicated that the representatives were notified by phone, and there was no evidence in the electronic medical record (EMR) that written notices were provided as required by facility policy. Additionally, the transfer notices that were completed did not specify the actual medical reasons for the transfers. Instead, the notices used a generic statement of "inability to meet resident's needs" rather than detailing the specific clinical circumstances, such as allergic skin reaction with difficulty breathing or symptoms like pallor, diaphoresis, lethargy, low blood pressure, and urinary issues. Interviews with facility staff, including the DON, confirmed the lack of documentation and the omission of specific reasons for transfer in the written notices.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision and Assessment
Penalty
Summary
The facility failed to protect residents from physical abuse perpetrated by another resident with a known history of severe mental illness and behavioral disturbances. One resident, who had diagnoses including Schizoaffective Disorder, Bipolar Disorder, Dementia with Behavioral Disturbance, and severely impaired cognition, was involved in two separate incidents where they physically struck other residents in the dining room. The first incident involved this resident approaching and hitting another resident on the right upper arm without provocation, and the second incident involved the same resident getting up from their chair and hitting a different resident on the left shoulder during a meal. Despite the resident's documented history of unpredictable and aggressive behaviors, including resistance to care, verbal aggression, and poor impulse control, the care plans did not include specific interventions or guidance for staff regarding the level of supervision required to prevent further abuse. Staff interviews confirmed that the resident's behaviors were unpredictable and that constant supervision would be necessary to prevent such incidents. However, after initial one-to-one supervision was discontinued following the first incident, no assessment was conducted to determine the ongoing level of supervision needed, and the resident was able to commit a second act of physical abuse. The facility's investigative files and staff interviews revealed that during both incidents, multiple staff members were present in the dining room, but most were unaware of the abusive acts until after they occurred. Only one staff member witnessed each event directly. The facility did not analyze or review the incidents in a manner that would determine the underlying causes or implement effective corrective actions to prevent recurrence, resulting in repeated abuse affecting multiple residents.
Failure to Supervise Resident with Psychosis Resulting in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide adequate supervision and appropriate behavioral health interventions for a resident with a known history of chronic delusions, psychosis, restlessness, agitation, and aggressive behaviors. This resident, who had diagnoses including Schizoaffective Disorder, Bipolar Disorder, and Dementia with Behavioral Disturbance, exhibited impaired cognition and was documented as resistant to care, wandering, and receiving antipsychotic medication. Despite these known risk factors and a history of unpredictable and aggressive behaviors, the facility did not consistently implement or document supervision or individualized interventions to prevent harm to other residents. Two separate incidents occurred in which the resident physically struck other residents on the shoulder. In both cases, the actions were linked to the resident's delusional thinking and psychosis, as evidenced by statements made during investigations and interviews with staff and witnesses. Staff interviews confirmed that the resident's behaviors were unpredictable and that effective prevention would require close or one-to-one supervision when the resident was in common areas with others. However, the facility's records and care plans did not reflect ongoing or routine supervision or specific interventions to address the risk of harm to others, despite the resident's established behavioral history and previous incidents. Facility policies on abuse prevention and behavior management required individualized assessment and intervention for residents with behaviors that could harm themselves or others. However, after the initial incident, there was no documented assessment to determine the appropriate level of supervision needed for the resident, and the care plan was not updated to reflect the physical aggression. The lack of consistent supervision and failure to update care plans or implement effective interventions resulted in repeated incidents of resident-to-resident abuse, as observed and reported by staff and documented in investigative files.
Failure to Follow Safe Transfer Procedures Results in Resident Injury
Penalty
Summary
Staff failed to follow established safe transfer procedures for a resident with significant mobility and cognitive impairments. The resident, who had diagnoses including heart failure, chronic pain, and cognitive communication deficit, was care planned for transfers using a full body mechanical lift with two-person assistance due to an inability to stand or assist with transfers. On the morning of the incident, a staff member transferred the resident from bed to chair using the mechanical lift but did so alone, without the required second staff member present. Later that same day, two staff members transferred the resident from a Broda chair back to bed without using the mechanical lift at all, instead performing a manual two-person lift. Both staff members admitted in interviews that they did not follow the care plan or facility policy, which required the use of a mechanical lift with two-person assistance for this resident. The staff could not provide a valid reason for not using the lift, with one stating she was following the other's lead and another citing being in a rush. As a result of these actions, the resident sustained a 10-centimeter bruise to the left lower leg, experienced pain rated up to seven out of ten, and required both Tylenol and Hydrocodone-Acetaminophen for pain management. The injury was discovered during routine rounds, and subsequent investigation by the facility determined that the bruise was most likely caused by the improper manual transfer. The failure to adhere to the resident's care plan and facility policy directly led to the resident's injury.
Resident Rights Violated During Medication Administration
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) administered medication to a resident with severe cognitive impairment and a history of acute respiratory failure, dementia, and cerebrovascular disease. During the medication administration, the LPN placed his hand over the resident's mouth and pinched the resident's nose to prevent the resident from spitting out the medication. This act was witnessed by a Certified Nursing Assistant (CNA), who observed the resident's face turning red and the resident struggling and moving their head from side to side in response to the force used by the LPN. The CNA considered the LPN's actions to be abusive and left the room to report the incident. Interviews with other staff members, including additional LPNs, the Unit Manager, the Social Worker, and the Director of Nursing (DON), confirmed that the resident had the right to refuse medication and that placing a hand over a resident's mouth to force medication was improper, could be considered abuse, and posed a risk of aspiration. The facility's own policies on medication administration and the Resident Bill of Rights explicitly state that residents have the right to refuse treatment and must not be subjected to coercion or force. Despite this, the LPN admitted to placing his hand over the resident's mouth to prevent the medication from being spit out, acknowledging that this was not appropriate and that the resident should have been allowed to refuse the medication. Following the incident, it was revealed that the LPN was suspended but returned to work without direct monitoring or oversight. There was no evidence that the facility took steps to ensure that the LPN did not repeat this behavior with other residents during medication administration. The lack of immediate and ongoing supervision after the incident, combined with the failure to protect the resident's right to refuse care, led to the citation of Immediate Jeopardy under F578 for violation of resident rights.
Abuse During Medication Administration and Failure to Protect Residents
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of acute respiratory failure, dementia, and cerebrovascular disease was subjected to physical and mental abuse by an LPN during medication administration. The LPN placed his hand and a paper towel over the resident's mouth and pinched the resident's nose to force the resident to swallow medication, while telling the resident to take the medication. This act was witnessed by a CNA, who observed the resident's face turning red and the resident struggling and moving their head from side to side. The CNA left the room, leaving the resident alone with the LPN, and did not immediately report the incident. The LPN continued to work his scheduled shift after the incident, as the facility administration did not immediately identify the event as abuse or take appropriate corrective action to protect residents. The LPN was only suspended after administration was made aware of the incident later in the day. Despite the seriousness of the event, the LPN was allowed to return to work after a brief suspension and was not monitored or supervised while administering medications to other vulnerable residents, including those with dementia, who could be at risk of similar abuse. Interviews with staff familiar with the resident confirmed that the LPN's actions were physically, emotionally, and psychologically abusive, and could have resulted in aspiration. The responsible party for the resident stated that having a hand placed over the resident's mouth would have caused significant fear. The facility's failure to recognize, report, and respond appropriately to the abuse, as well as the lack of monitoring of the LPN after the incident, resulted in a finding of immediate jeopardy due to the likelihood of serious injury, harm, impairment, or death to residents.
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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