Monroe Manor Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Monroeville, Alabama.
- Location
- 236 West Claiborne Street, Monroeville, Alabama 36460
- CMS Provider Number
- 015398
- Inspections on file
- 14
- Latest survey
- April 13, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Monroe Manor Health & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Address Abuse and Resident Boundaries: The DON and Administrator did not identify or act on repeated abuse concerns involving multiple residents. Staff reported one resident’s inappropriate sexual touching and boundary violations with other residents, including a cognitively intact resident who had set limits and a protected resident who could not consent under state law, yet the facility assessed and care planned the protected resident as able to consent. Two other residents were also involved in physical abuse, and the Former DON stated concerns were raised repeatedly with leadership and the owner.
The facility failed to protect residents from abuse by other residents. A cognitively intact resident verbally abused another resident by making a sexually explicit statement, while a severely cognitively impaired resident was care planned for sexual expression without a capacity-to-consent assessment. The facility also allowed a resident assessed as unable to consent to have repeated kissing and touching with another resident, including contact to the chest and inner thighs, with staff giving inconsistent accounts of whether the residents could be alone together or needed visual supervision. The report also describes physical altercations between other residents, including one resident striking another in the face and another incident involving residents hitting each other during a room altercation.
Abuse Policy and Capacity-to-Consent Failures: The facility failed to follow its abuse policy and did not ensure its sexual abuse definition and consent procedures met regulatory requirements. One severely cognitively impaired resident had a care plan for sexual expression but no available capacity-to-consent assessment, while another resident with dementia and court-appointed guardianship was assessed as unable to consent after the SSD completed the assessment and then created a sexual expression care plan. Staff observed kissing and intimate touching between residents, and the MD and FNP gave conflicting views about the resident’s ability to consent.
A resident with DM and MS had repeated blood glucose readings in the 30s and 40s across multiple shifts, including a reading of 32 mg/dL, but staff did not immediately notify the physician. The chart showed no BG parameters or notify orders, and an RN and LPN confirmed they did not contact the physician despite the resident’s ongoing low BG and poor intake; the physician was contacted only after the resident’s condition declined and the resident was sent to the ER.
Failure to provide NOMNC notification and notify responsible parties affected two residents with significant cognitive impairment. One resident had Alzheimer’s disease and severe cognitive impairment, and another had cerebral infarction with moderately impaired decision-making and memory problems. Both signed SNF ABN forms, but there was no documented evidence that the family/representative was properly informed, and the Bookkeeper stated conversations were not documented and no hard copies were mailed.
An LPN failed to promptly assess a resident who showed signs of aspiration, including vomiting, low O2 saturation, and abnormal vital signs, and the resident was later hospitalized with aspiration pneumonia. The RN stated the LPN should have listened to breath sounds to help confirm possible aspiration. The facility also continued a wander guard on a resident with no documented wandering or exit-seeking behavior, despite assessments and care plan conference notes stating the device should be removed, and staff were unclear who was responsible for discontinuing it.
Missing Physician Order for Dialysis Care: A resident with ESRD and severe cognitive impairment was documented as receiving hemodialysis, but the EMR contained no current physician order for dialysis treatment. Staff interviews confirmed dialysis residents should have an order directing access-site care, monitoring of the thrill and bruit, and documentation on the MAR, and the facility's hemodialysis policy required physician orders to include dialysis center visits and access-site care.
The facility failed to document alternative measures, risk-benefit discussion, and informed consent before side rail use for two residents. One resident with ESRD and severe cognitive impairment and another resident with dementia and intellectual disabilities were observed with side rails raised in bed, but records showed no current order for side rails and no documented evidence that alternatives were explored or that risks and benefits were reviewed with the resident or RP.
The SSD failed to properly assess residents’ capacity to consent to sexual contact and failed to provide psychosocial follow-up after a companionship ended. Two residents with severe cognitive impairment were involved in sexual relationship care planning, including one resident with a guardian and another whose decision maker was not informed or supportive. A cognitively intact resident reported that a relationship ended after an unwanted sexual comment, leaving the resident upset and crying for days, but the SSD did not ask about the resident’s distress or the reason the relationship ended.
A resident with type 2 DM and MS had ordered glimepiride and BG checks, but staff administered the medication despite BG readings in the 40s and poor oral intake. An LPN gave glimepiride after a low BG was reported, another LPN later gave the same medication again, and hospital records showed the resident was admitted to the ED for hypoglycemia and treated with IV dextrose.
An LPN did not wear a gown while administering medication via a resident’s G-tube even though the resident was on EBP and signage in the room identified gowns and gloves as required. The resident had a G-tube and severe cognitive impairment, and the care plan and physician order directed staff to use gown and gloves during high-contact care. The IP confirmed staff were expected to use appropriate PPE for direct care involving indwelling devices, and training records did not show the LPN attended the PPE in-service.
A resident with Alzheimer's disease, dementia, and mild neurocognitive disorder was given the COVID-19 vaccine after the ADON/IP documented resident consent, even though a court had appointed a guardian and conservator for medical decision-making. The resident's sponsor later reported the vaccine had been given when it should not have been, and the facility's policy required documentation of education and consent from the resident or representative.
Failure to Address Abuse and Resident Boundaries
Penalty
Summary
The facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently because the Administrator and DON did not identify and/or act on known failures related to abuse and the implementation of the abuse policy. The deficiency affected four of 29 sampled residents reviewed for abuse: one cognitively intact resident who had set relationship boundaries with another resident but was subjected to verbal sexual abuse when those boundaries were crossed; one resident who had been adjudicated incapacitated by a judge and was therefore a protected person under Alabama law, yet was assessed and care planned as if able to consent to sexual contact; and two residents who engaged in physical abuse. The Former DON stated that staff had repeatedly reported concerns about one resident’s behavior with other residents, including initiating relationships with new residents and touching residents in sexual ways, such as hugging, kissing on the mouth, and touching a resident’s breast and inner thighs. The Former DON stated these concerns were brought up more than once in morning meetings and were also reported to corporate leadership and the owner in the presence of the Administrator. She further stated she wanted to report sexual abuse but was directed not to by the Administrator and corporate superiors, and that corporate leadership advised the facility to care plan the residents to be able to engage in sexual touching. The Administrator stated his expectation was that all code requirements were met.
Failure to Protect Residents From Abuse by Other Residents
Penalty
Summary
The facility failed to ensure residents were free from abuse by other residents, including verbal abuse, sexual abuse, and physical abuse. The report states that R41, a resident with diagnoses including Alzheimer's disease and dementia, was involved in repeated inappropriate sexual behavior with other residents. R41 was documented as cognitively intact on a quarterly MDS with a BIMS score of 15, yet the care plan addressed sexual expression with other residents and staff interviews showed inconsistent understanding of what behavior was allowed and what level of supervision was required. R86, who also had Alzheimer's disease and major depressive disorder and was assessed as cognitively intact with a BIMS of 15, reported that R41 put both hands on R86's face cheeks and said, "I want to f*** you so bad." R86 stated this made him/her feel dirty and upset and that he/she had told R41 he/she did not want any sexual relationship or sexual language. R86 also reported that staff did not ask what was wrong after the incident. The facility had a capacity-to-consent assessment for R86 indicating capacity to consent to sexual contact limited to holding hands and kissing, and the care plan included privacy and sexual expression interventions. R87, who had Alzheimer's disease and dementia and was severely cognitively impaired with a BIMS of 2, was also care planned for sexual expression with another resident. The report states the facility did not assess R87's capacity to consent before developing that care plan. R87's decision maker stated he/she was not involved in or approving of the care plan and reported that R87 had said R41 asked him/her to have sex, that R87 was scared to return to the facility because of R41, and that staff had reported hugging, holding hands, kissing, and touching. The SSD stated that R41 was to be banned from R87's hall, but the care plan still reflected sexual expression interventions without a documented capacity assessment before planning. The facility also failed to ensure R44 was free from sexual abuse. R44 had Alzheimer's disease, dementia, mild neurocognitive disorder, and repeated MDS scores showing severe cognitive impairment, including BIMS scores of 6, 7, 6, 3, and 3. A facility assessment questionnaire indicated R44 did not have the capacity to consent, yet multiple staff reported observing R41 and R44 kissing and touching, including touching of the chest/breast area and inner thighs. Staff also reported R41 was in R44's room unsupervised, while other staff said the residents only needed to be in staffed areas or under visual supervision. The Administrator stated R41 was supposed to stay in staffed areas, but staff interviews showed inconsistent knowledge of the supervision required, and the former DON reported repeated concerns about the relationship and that corporate leadership advised care planning the residents to engage in sexual touching.
Abuse Policy and Capacity-to-Consent Failures
Penalty
Summary
The facility failed to implement its abuse policies to ensure residents were free from all forms of abuse and failed to ensure its policy met minimum federal requirements related to sexual abuse and residents’ capacity to consent to sexual activity. The report states the facility’s abuse policy did not include procedures to protect residents from sexual abuse or protocols for determining capacity to consent, and its definition of sexual abuse did not reflect the current regulatory language. The policy also did not include any process for residents adjudicated by a court to be incapacitated. For one resident, the facility did not have a capacity-to-consent assessment available when interviewed by surveyors, despite the resident being severely cognitively impaired with BIMS scores of 2 out of 15 on MDS assessments and having diagnoses including Alzheimer’s disease and dementia. The resident’s care plan addressed a desire to engage in sexual expression with another resident and included an approach to assess capacity to consent annually and with significant change, but the Social Services Director stated she did not have a copy of a capacity assessment. For another resident, the record showed the resident had dementia, severe cognitive impairment with BIMS scores of 6 out of 15 and later 3 out of 15, and court documents establishing temporary guardianship and then guardianship/conservatorship because the resident was an incapacitated person. The facility’s assessment for capacity to consent indicated that because the resident had been declared incompetent by a judge, the resident was assessed to not have the capacity to consent. The Social Services Director stated she completed the assessment and then developed a care plan for sexual expression. Staff statements described kissing and touching between this resident and another resident, including touching on the lips, thighs, chest/breast area, and inner thighs. The Medical Director stated the resident had the capacity to consent emotionally in a social relationship, while the FNP stated it would be surprising for the resident, given the cognitive impairment and dementia, to have the capacity to consent to sexual contact.
Failure to Notify Physician of Repeated Severe Hypoglycemia
Penalty
Summary
The facility failed to ensure the attending physician was immediately notified of significant low blood glucose readings for one resident with type 2 diabetes mellitus and multiple sclerosis. The resident’s record showed repeated blood glucose values in the 30s and 40s, including readings of 44 mg/dL, 42 mg/dL, 43 mg/dL, and 38 mg/dL across multiple shifts, and staff documented a blood glucose of 32 mg/dL with interventions provided. The resident was cognitively intact with a BIMS score of 15 out of 15, and the care plan identified risk for blood sugar fluctuation and hypoglycemia with an approach to notify the MD as needed of complications. The EMR contained no physician orders specifying blood glucose parameters or when to notify the physician, and there was no documentation that the physician was notified of the low readings. During interviews, an LPN stated the resident had low blood glucose during the night shift and continued poor intake during the day shift, but she did not notify the physician. An RN stated she did not notify the physician because she was not concerned, while the RNUM and former DON stated blood glucose levels in the 30s or 40s were significant and should have been reported to the physician or on-call provider. The physician was ultimately contacted only after the resident’s condition declined and the resident was transferred to the emergency room.
Failure to Notify Responsible Parties of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure Notice of Medicare Non-Coverage (NOMNC) notification was provided and that the responsible party was notified for two residents reviewed for beneficiary notification. For one resident with Alzheimer’s disease and dementia, the quarterly MDS showed a BIMS score of 3 out of 15, indicating severe cognitive impairment. The resident’s SNF ABN form showed the Medicare Part A skilled services start date and last covered day, and the resident signed the form on an illegible date despite being severely cognitively impaired. For another resident admitted with cerebral infarction, the quarterly MDS showed the BIMS could not be completed, with short- and long-term memory problems and moderately impaired decision-making requiring cues/supervision. The resident’s SNF ABN form showed the skilled services start date and last covered day, and the resident signed the form on 03/31/2026. There was no evidence that the family was notified of the information. During interview, the family member for the first resident stated they were responsible for decisions because the resident could not make informed decisions, and said they had not been made aware of the therapy services or the decision to appeal. The Bookkeeper stated she spoke with both residents’ representatives but did not document those conversations and did not mail a hard copy to them.
Delayed Aspiration Assessment and Unjustified Continued Wander Guard Use
Penalty
Summary
The facility failed to identify and intervene for a change in condition and ensure prompt assessment and emergency care for one resident who later was hospitalized with aspiration pneumonia. The resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction, COPD, and GERD. The record showed an enema was administered at 10:17 AM, and the first documented assessment of a change in condition was not completed until 11:20 AM, when the resident was found lying in bed hard to arouse with vomit on the shirt, O2 saturation of 85% on room air, pulse 109, respirations 22, and blood pressure 106/61. At that 11:20 AM assessment, the LPN documented oxygen was started at 2 L/min, Zofran was given, and the resident’s oxygen saturation improved. The note also documented hypoactive bowel sounds, a PRN enema, liquid stool, and that the resident later followed commands and oxygen saturation improved to 95% on room air. A later note at 12:21 PM documented that the sponsor requested hospital evaluation and an order was obtained to send the resident to the hospital, with transport at 12:19 PM. A subsequent RN assessment documented the resident was minimally responsive, had snoring-like respirations, diminished breath sounds bilaterally, O2 saturation of 86% on 2 L/min, pulse 109, and blood pressure 104/47, and the RN stated the LPN should have listened to the resident’s breath sounds to rule out or confirm possible aspiration. The facility also failed to ensure a resident was appropriately screened and had documentation to support the continued use of a wander guard. The resident had Alzheimer’s disease, a BIMS score of 3, and was care planned for risk of elopement with an intervention to place a wander guard. However, the annual MDS and elopement risk assessment documented no wandering behavior and indicated the resident was not at risk for elopement, and the care plan conference notes stated the resident was no longer at risk and the elopement bracelet would be removed. Despite this, observations on three separate occasions showed the resident still wearing a wander guard on the right ankle. Interviews showed staff were unclear about who was responsible for discontinuing the code alert/wander guard, and the restorative nurse stated the bracelet was not removed because the team decided to reassess the resident, but there was nothing documented about that. The social services director stated the resident had been assessed as a wander risk when first admitted, that the team discussed discontinuing the wander guard, and that it should have been documented if the device was continued or removed. The DON stated residents were assessed for elopement risk based on criteria such as statements about leaving or elopement history, and that if an assessment indicated a resident was not at risk, staff may want to continue to monitor.
Missing Physician Order for Dialysis Care
Penalty
Summary
The facility failed to ensure there was a current physician's order for dialysis treatment for one resident with end stage renal disease who was receiving hemodialysis. The resident's face sheet identified end stage renal disease, and the admission MDS showed a BIMS score of 3 out of 15, indicating severe cognitive impairment, with documentation that the resident was receiving hemodialysis. The care plan, dated 02/24/2026, also identified the resident as having end stage renal disease and receiving dialysis. Review of the physician orders dated 04/10/2026 revealed no current order for dialysis treatment. During interviews, an LPN stated there should always be a physician's order for dialysis and that nursing staff should check the access site, thrill and bruit, and document care on the MAR. Another LPN stated dialysis residents normally have an order directing care of the access site and monitoring for bleeding, infection, and drainage, and said having an order was very important. An RN confirmed the dialysis order should have been entered when the resident was admitted, while the DON stated she would not provide treatment without a physician's order. The facility's Hemodialysis Care policy stated physician's orders for hemodialysis residents should include information regarding visits to a dialysis center and care of the access site.
Failure to Document Alternatives, Risk-Benefit Discussion, and Informed Consent for Side Rail Use
Penalty
Summary
The facility failed to ensure that alternative measures were tried before side rails were used, and failed to document discussion of risks versus benefits and obtain informed consent for side rail use for two residents. The report states that these issues were identified for R3 and R6 during observation, interview, record review, and policy review. The deficiency involved side rail use without a current physician order and without the required documentation in the residents’ records. R3 was admitted with end stage renal disease and had a BIMS score of 3, indicating severe cognitive impairment. R3’s care plan listed upper side rails for mobility, and during observation R3 was resting in bed with the head of bed upright and side rails up on both sides. The side rail/entrapment evaluation for R3 showed no documentation that alternatives were explored before bed rail use, and there was no documentation of risks versus benefits or informed consent. The RNN stated the facility did not try alternatives before bedrail use for R3, did not discuss risks and benefits, and had nothing for the resident to sign for informed consent. R6 was admitted with mild intellectual disabilities and dementia and also had a BIMS score of 3. R6’s care plan included side rails up while in bed to aid in bed mobility and transfers, and during observation R6 was lying in bed with the head of bed elevated and bilateral half side rails raised. The side rail evaluation completed after the surveyor identified concern showed side rails were used, but the record contained no documented evidence of what alternatives were explored before implementation and no documented evidence that risks versus benefits were explained to the responsible party or that informed consent was obtained. The facility policy stated bedrails could be considered a form of physical restraint and that the need for bedrails should be identified in the resident assessment and plan of care.
Failure to Assess Sexual Consent Capacity and Provide Psychosocial Follow-Up
Penalty
Summary
The facility failed to provide medically related social services to assess residents’ capacity to consent to sexual contact and to follow up with psychosocial support after a companionship ended. The Social Services Director’s job description stated the role included planning, organizing, developing, and directing social services to meet residents’ emotional and social needs, as well as assisting with resident assessments and care plans. Survey findings identified deficiencies involving three residents: one resident with severe cognitive impairment and a court-appointed guardian, another resident with severe cognitive impairment, and a third resident who was cognitively intact. For one resident, the record showed diagnoses including Alzheimer’s disease, dementia, and mild neurocognitive disorder, along with a BIMS score of 6 indicating severe cognitive impairment and a court order appointing a guardian. The SSD completed an assessment for capacity to consent to sexual relations and marked that the resident had been declared incompetent by a judge, which indicated the resident did not have capacity to consent; however, the SSD continued the assessment and documented that the resident had some memory deficits but stated clear understanding of consent for sexual activity. The SSD also initiated a care plan that included educating the resident on safe sexual practices and supporting the resident’s decision to engage in sexual expression. Staff and family interviews showed the SSD told others the residents had rights and could have a sexual relationship if they chose. For another resident, the record showed Alzheimer’s disease and dementia with a BIMS score of 2 indicating severe cognitive impairment, and the care plan included education on safe sexual practices and providing a privacy sign. The resident’s decision maker stated they were never made aware of, and would not have supported, care planning for any kind of sexual activity. For the cognitively intact resident, the record showed a BIMS score of 15 and the resident reported a friendship that became a companionship with another resident, then ended after the other resident made a sexual comment that made the resident feel dirty and upset for days. The resident stated no staff asked what was wrong, and the SSD acknowledged knowing the relationship had ended and that the resident was upset, but did not talk to the resident about why the resident was upset.
Unnecessary Drug Administration With Hypoglycemia
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs when nursing staff administered glimepiride despite documented low blood glucose levels and poor oral intake. The resident had diagnoses including type 2 diabetes mellitus and multiple sclerosis, and was cognitively intact with a BIMS score of 15 out of 15. Physician orders included blood glucose monitoring twice daily and glimepiride 1 mg by mouth twice daily, but there were no orders for blood glucose parameters or physician notification. On 03/29/2025, the resident had a blood glucose of 44 mg/dL at 6:00 AM and 42 mg/dL at 6:00 PM, and staff documented that the resident had low blood sugar during the night shift and continued poor oral intake. Despite this, an LPN administered glimepiride at 9:00 AM and another LPN administered glimepiride at 5:00 PM. Hospital records showed the resident was admitted to the emergency department for hypoglycemia after receiving glimepiride with a blood glucose level of 42 mg/dL and was treated with intravenous dextrose before discharge.
Failure to Use Required PPE During EBP G-Tube Care
Penalty
Summary
The facility failed to ensure staff used appropriate PPE in accordance with Enhanced Barrier Precautions during high-contact care for a resident with a gastrostomy tube. The resident was admitted with diagnoses including cerebral infarction and presence of a G-tube, and the quarterly MDS indicated the resident was severely cognitively impaired. The active physician order and comprehensive care plan both identified EBP related to the G-tube, with directions for staff to don a gown and gloves during high-contact care activities, maintain EBP for the duration of need, and perform hand hygiene after PPE removal. During an observation and concurrent interview, EBP signage was posted outside the resident’s room and PPE supplies were available inside the room. An LPN performed hand hygiene and donned gloves before administering medication via the G-tube, but did not don a gown. After the task, the LPN removed gloves and performed hand hygiene. In interview, the LPN confirmed the resident was on EBP due to the G-tube and acknowledged after reviewing the signage that a gown was also required. The Infection Preventionist stated staff were expected to perform hand hygiene and wear appropriate PPE during direct care activities, including care involving indwelling devices. Staff development records for PPE in-service training did not include the LPN’s attendance, and the facility policy and CDC guidance both identified gowns and gloves as required for applicable EBP care activities.
COVID-19 Vaccine Given Without Guardian Consent
Penalty
Summary
The facility failed to ensure the resident's guardian gave consent before administering the COVID-19 vaccine to one resident, R44. R44's face sheet showed diagnoses including Alzheimer's disease, dementia, and mild neurocognitive disorder. A court order dated 01/15/2025 found R44 to be an incapacitated person and appointed a guardian and conservator because the resident was unable to manage personal medical needs, assets, or financial matters. The resident's progress notes showed the Assistant Director of Nursing/Infection Preventionist documented that R44 consented to the 2024-2025 COVID vaccine and that the vaccine was explained to the resident. Another note documented that the resident's sponsor called and stated the facility had already given the resident a COVID shot that he/she was not supposed to have. During interview, the sponsor stated the facility had called to offer the vaccine, but the decision had already been made to decline it because of the resident's dementia diagnosis. The ADON/IP stated he/she obtained the resident's consent, later informed the sponsor that the vaccine had been given, and then learned from the face sheet that the sponsor was the resident's decision maker. The facility policy required documentation that the resident or representative received education and that the resident or representative consented to the vaccine.
Latest citations in Alabama
Failure to Address Abuse and Resident Boundaries: The DON and Administrator did not identify or act on repeated abuse concerns involving multiple residents. Staff reported one resident’s inappropriate sexual touching and boundary violations with other residents, including a cognitively intact resident who had set limits and a protected resident who could not consent under state law, yet the facility assessed and care planned the protected resident as able to consent. Two other residents were also involved in physical abuse, and the Former DON stated concerns were raised repeatedly with leadership and the owner.
The facility failed to protect residents from abuse by other residents. A cognitively intact resident verbally abused another resident by making a sexually explicit statement, while a severely cognitively impaired resident was care planned for sexual expression without a capacity-to-consent assessment. The facility also allowed a resident assessed as unable to consent to have repeated kissing and touching with another resident, including contact to the chest and inner thighs, with staff giving inconsistent accounts of whether the residents could be alone together or needed visual supervision. The report also describes physical altercations between other residents, including one resident striking another in the face and another incident involving residents hitting each other during a room altercation.
Abuse Policy and Capacity-to-Consent Failures: The facility failed to follow its abuse policy and did not ensure its sexual abuse definition and consent procedures met regulatory requirements. One severely cognitively impaired resident had a care plan for sexual expression but no available capacity-to-consent assessment, while another resident with dementia and court-appointed guardianship was assessed as unable to consent after the SSD completed the assessment and then created a sexual expression care plan. Staff observed kissing and intimate touching between residents, and the MD and FNP gave conflicting views about the resident’s ability to consent.
A resident with DM and MS had repeated blood glucose readings in the 30s and 40s across multiple shifts, including a reading of 32 mg/dL, but staff did not immediately notify the physician. The chart showed no BG parameters or notify orders, and an RN and LPN confirmed they did not contact the physician despite the resident’s ongoing low BG and poor intake; the physician was contacted only after the resident’s condition declined and the resident was sent to the ER.
Failure to provide NOMNC notification and notify responsible parties affected two residents with significant cognitive impairment. One resident had Alzheimer’s disease and severe cognitive impairment, and another had cerebral infarction with moderately impaired decision-making and memory problems. Both signed SNF ABN forms, but there was no documented evidence that the family/representative was properly informed, and the Bookkeeper stated conversations were not documented and no hard copies were mailed.
An LPN failed to promptly assess a resident who showed signs of aspiration, including vomiting, low O2 saturation, and abnormal vital signs, and the resident was later hospitalized with aspiration pneumonia. The RN stated the LPN should have listened to breath sounds to help confirm possible aspiration. The facility also continued a wander guard on a resident with no documented wandering or exit-seeking behavior, despite assessments and care plan conference notes stating the device should be removed, and staff were unclear who was responsible for discontinuing it.
Missing Physician Order for Dialysis Care: A resident with ESRD and severe cognitive impairment was documented as receiving hemodialysis, but the EMR contained no current physician order for dialysis treatment. Staff interviews confirmed dialysis residents should have an order directing access-site care, monitoring of the thrill and bruit, and documentation on the MAR, and the facility's hemodialysis policy required physician orders to include dialysis center visits and access-site care.
The facility failed to document alternative measures, risk-benefit discussion, and informed consent before side rail use for two residents. One resident with ESRD and severe cognitive impairment and another resident with dementia and intellectual disabilities were observed with side rails raised in bed, but records showed no current order for side rails and no documented evidence that alternatives were explored or that risks and benefits were reviewed with the resident or RP.
The SSD failed to properly assess residents’ capacity to consent to sexual contact and failed to provide psychosocial follow-up after a companionship ended. Two residents with severe cognitive impairment were involved in sexual relationship care planning, including one resident with a guardian and another whose decision maker was not informed or supportive. A cognitively intact resident reported that a relationship ended after an unwanted sexual comment, leaving the resident upset and crying for days, but the SSD did not ask about the resident’s distress or the reason the relationship ended.
A resident with type 2 DM and MS had ordered glimepiride and BG checks, but staff administered the medication despite BG readings in the 40s and poor oral intake. An LPN gave glimepiride after a low BG was reported, another LPN later gave the same medication again, and hospital records showed the resident was admitted to the ED for hypoglycemia and treated with IV dextrose.
Failure to Address Abuse and Resident Boundaries
Penalty
Summary
The facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently because the Administrator and DON did not identify and/or act on known failures related to abuse and the implementation of the abuse policy. The deficiency affected four of 29 sampled residents reviewed for abuse: one cognitively intact resident who had set relationship boundaries with another resident but was subjected to verbal sexual abuse when those boundaries were crossed; one resident who had been adjudicated incapacitated by a judge and was therefore a protected person under Alabama law, yet was assessed and care planned as if able to consent to sexual contact; and two residents who engaged in physical abuse. The Former DON stated that staff had repeatedly reported concerns about one resident’s behavior with other residents, including initiating relationships with new residents and touching residents in sexual ways, such as hugging, kissing on the mouth, and touching a resident’s breast and inner thighs. The Former DON stated these concerns were brought up more than once in morning meetings and were also reported to corporate leadership and the owner in the presence of the Administrator. She further stated she wanted to report sexual abuse but was directed not to by the Administrator and corporate superiors, and that corporate leadership advised the facility to care plan the residents to be able to engage in sexual touching. The Administrator stated his expectation was that all code requirements were met.
Failure to Protect Residents From Abuse by Other Residents
Penalty
Summary
The facility failed to ensure residents were free from abuse by other residents, including verbal abuse, sexual abuse, and physical abuse. The report states that R41, a resident with diagnoses including Alzheimer's disease and dementia, was involved in repeated inappropriate sexual behavior with other residents. R41 was documented as cognitively intact on a quarterly MDS with a BIMS score of 15, yet the care plan addressed sexual expression with other residents and staff interviews showed inconsistent understanding of what behavior was allowed and what level of supervision was required. R86, who also had Alzheimer's disease and major depressive disorder and was assessed as cognitively intact with a BIMS of 15, reported that R41 put both hands on R86's face cheeks and said, "I want to f*** you so bad." R86 stated this made him/her feel dirty and upset and that he/she had told R41 he/she did not want any sexual relationship or sexual language. R86 also reported that staff did not ask what was wrong after the incident. The facility had a capacity-to-consent assessment for R86 indicating capacity to consent to sexual contact limited to holding hands and kissing, and the care plan included privacy and sexual expression interventions. R87, who had Alzheimer's disease and dementia and was severely cognitively impaired with a BIMS of 2, was also care planned for sexual expression with another resident. The report states the facility did not assess R87's capacity to consent before developing that care plan. R87's decision maker stated he/she was not involved in or approving of the care plan and reported that R87 had said R41 asked him/her to have sex, that R87 was scared to return to the facility because of R41, and that staff had reported hugging, holding hands, kissing, and touching. The SSD stated that R41 was to be banned from R87's hall, but the care plan still reflected sexual expression interventions without a documented capacity assessment before planning. The facility also failed to ensure R44 was free from sexual abuse. R44 had Alzheimer's disease, dementia, mild neurocognitive disorder, and repeated MDS scores showing severe cognitive impairment, including BIMS scores of 6, 7, 6, 3, and 3. A facility assessment questionnaire indicated R44 did not have the capacity to consent, yet multiple staff reported observing R41 and R44 kissing and touching, including touching of the chest/breast area and inner thighs. Staff also reported R41 was in R44's room unsupervised, while other staff said the residents only needed to be in staffed areas or under visual supervision. The Administrator stated R41 was supposed to stay in staffed areas, but staff interviews showed inconsistent knowledge of the supervision required, and the former DON reported repeated concerns about the relationship and that corporate leadership advised care planning the residents to engage in sexual touching.
Abuse Policy and Capacity-to-Consent Failures
Penalty
Summary
The facility failed to implement its abuse policies to ensure residents were free from all forms of abuse and failed to ensure its policy met minimum federal requirements related to sexual abuse and residents’ capacity to consent to sexual activity. The report states the facility’s abuse policy did not include procedures to protect residents from sexual abuse or protocols for determining capacity to consent, and its definition of sexual abuse did not reflect the current regulatory language. The policy also did not include any process for residents adjudicated by a court to be incapacitated. For one resident, the facility did not have a capacity-to-consent assessment available when interviewed by surveyors, despite the resident being severely cognitively impaired with BIMS scores of 2 out of 15 on MDS assessments and having diagnoses including Alzheimer’s disease and dementia. The resident’s care plan addressed a desire to engage in sexual expression with another resident and included an approach to assess capacity to consent annually and with significant change, but the Social Services Director stated she did not have a copy of a capacity assessment. For another resident, the record showed the resident had dementia, severe cognitive impairment with BIMS scores of 6 out of 15 and later 3 out of 15, and court documents establishing temporary guardianship and then guardianship/conservatorship because the resident was an incapacitated person. The facility’s assessment for capacity to consent indicated that because the resident had been declared incompetent by a judge, the resident was assessed to not have the capacity to consent. The Social Services Director stated she completed the assessment and then developed a care plan for sexual expression. Staff statements described kissing and touching between this resident and another resident, including touching on the lips, thighs, chest/breast area, and inner thighs. The Medical Director stated the resident had the capacity to consent emotionally in a social relationship, while the FNP stated it would be surprising for the resident, given the cognitive impairment and dementia, to have the capacity to consent to sexual contact.
Failure to Notify Physician of Repeated Severe Hypoglycemia
Penalty
Summary
The facility failed to ensure the attending physician was immediately notified of significant low blood glucose readings for one resident with type 2 diabetes mellitus and multiple sclerosis. The resident’s record showed repeated blood glucose values in the 30s and 40s, including readings of 44 mg/dL, 42 mg/dL, 43 mg/dL, and 38 mg/dL across multiple shifts, and staff documented a blood glucose of 32 mg/dL with interventions provided. The resident was cognitively intact with a BIMS score of 15 out of 15, and the care plan identified risk for blood sugar fluctuation and hypoglycemia with an approach to notify the MD as needed of complications. The EMR contained no physician orders specifying blood glucose parameters or when to notify the physician, and there was no documentation that the physician was notified of the low readings. During interviews, an LPN stated the resident had low blood glucose during the night shift and continued poor intake during the day shift, but she did not notify the physician. An RN stated she did not notify the physician because she was not concerned, while the RNUM and former DON stated blood glucose levels in the 30s or 40s were significant and should have been reported to the physician or on-call provider. The physician was ultimately contacted only after the resident’s condition declined and the resident was transferred to the emergency room.
Failure to Notify Responsible Parties of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure Notice of Medicare Non-Coverage (NOMNC) notification was provided and that the responsible party was notified for two residents reviewed for beneficiary notification. For one resident with Alzheimer’s disease and dementia, the quarterly MDS showed a BIMS score of 3 out of 15, indicating severe cognitive impairment. The resident’s SNF ABN form showed the Medicare Part A skilled services start date and last covered day, and the resident signed the form on an illegible date despite being severely cognitively impaired. For another resident admitted with cerebral infarction, the quarterly MDS showed the BIMS could not be completed, with short- and long-term memory problems and moderately impaired decision-making requiring cues/supervision. The resident’s SNF ABN form showed the skilled services start date and last covered day, and the resident signed the form on 03/31/2026. There was no evidence that the family was notified of the information. During interview, the family member for the first resident stated they were responsible for decisions because the resident could not make informed decisions, and said they had not been made aware of the therapy services or the decision to appeal. The Bookkeeper stated she spoke with both residents’ representatives but did not document those conversations and did not mail a hard copy to them.
Delayed Aspiration Assessment and Unjustified Continued Wander Guard Use
Penalty
Summary
The facility failed to identify and intervene for a change in condition and ensure prompt assessment and emergency care for one resident who later was hospitalized with aspiration pneumonia. The resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction, COPD, and GERD. The record showed an enema was administered at 10:17 AM, and the first documented assessment of a change in condition was not completed until 11:20 AM, when the resident was found lying in bed hard to arouse with vomit on the shirt, O2 saturation of 85% on room air, pulse 109, respirations 22, and blood pressure 106/61. At that 11:20 AM assessment, the LPN documented oxygen was started at 2 L/min, Zofran was given, and the resident’s oxygen saturation improved. The note also documented hypoactive bowel sounds, a PRN enema, liquid stool, and that the resident later followed commands and oxygen saturation improved to 95% on room air. A later note at 12:21 PM documented that the sponsor requested hospital evaluation and an order was obtained to send the resident to the hospital, with transport at 12:19 PM. A subsequent RN assessment documented the resident was minimally responsive, had snoring-like respirations, diminished breath sounds bilaterally, O2 saturation of 86% on 2 L/min, pulse 109, and blood pressure 104/47, and the RN stated the LPN should have listened to the resident’s breath sounds to rule out or confirm possible aspiration. The facility also failed to ensure a resident was appropriately screened and had documentation to support the continued use of a wander guard. The resident had Alzheimer’s disease, a BIMS score of 3, and was care planned for risk of elopement with an intervention to place a wander guard. However, the annual MDS and elopement risk assessment documented no wandering behavior and indicated the resident was not at risk for elopement, and the care plan conference notes stated the resident was no longer at risk and the elopement bracelet would be removed. Despite this, observations on three separate occasions showed the resident still wearing a wander guard on the right ankle. Interviews showed staff were unclear about who was responsible for discontinuing the code alert/wander guard, and the restorative nurse stated the bracelet was not removed because the team decided to reassess the resident, but there was nothing documented about that. The social services director stated the resident had been assessed as a wander risk when first admitted, that the team discussed discontinuing the wander guard, and that it should have been documented if the device was continued or removed. The DON stated residents were assessed for elopement risk based on criteria such as statements about leaving or elopement history, and that if an assessment indicated a resident was not at risk, staff may want to continue to monitor.
Missing Physician Order for Dialysis Care
Penalty
Summary
The facility failed to ensure there was a current physician's order for dialysis treatment for one resident with end stage renal disease who was receiving hemodialysis. The resident's face sheet identified end stage renal disease, and the admission MDS showed a BIMS score of 3 out of 15, indicating severe cognitive impairment, with documentation that the resident was receiving hemodialysis. The care plan, dated 02/24/2026, also identified the resident as having end stage renal disease and receiving dialysis. Review of the physician orders dated 04/10/2026 revealed no current order for dialysis treatment. During interviews, an LPN stated there should always be a physician's order for dialysis and that nursing staff should check the access site, thrill and bruit, and document care on the MAR. Another LPN stated dialysis residents normally have an order directing care of the access site and monitoring for bleeding, infection, and drainage, and said having an order was very important. An RN confirmed the dialysis order should have been entered when the resident was admitted, while the DON stated she would not provide treatment without a physician's order. The facility's Hemodialysis Care policy stated physician's orders for hemodialysis residents should include information regarding visits to a dialysis center and care of the access site.
Failure to Document Alternatives, Risk-Benefit Discussion, and Informed Consent for Side Rail Use
Penalty
Summary
The facility failed to ensure that alternative measures were tried before side rails were used, and failed to document discussion of risks versus benefits and obtain informed consent for side rail use for two residents. The report states that these issues were identified for R3 and R6 during observation, interview, record review, and policy review. The deficiency involved side rail use without a current physician order and without the required documentation in the residents’ records. R3 was admitted with end stage renal disease and had a BIMS score of 3, indicating severe cognitive impairment. R3’s care plan listed upper side rails for mobility, and during observation R3 was resting in bed with the head of bed upright and side rails up on both sides. The side rail/entrapment evaluation for R3 showed no documentation that alternatives were explored before bed rail use, and there was no documentation of risks versus benefits or informed consent. The RNN stated the facility did not try alternatives before bedrail use for R3, did not discuss risks and benefits, and had nothing for the resident to sign for informed consent. R6 was admitted with mild intellectual disabilities and dementia and also had a BIMS score of 3. R6’s care plan included side rails up while in bed to aid in bed mobility and transfers, and during observation R6 was lying in bed with the head of bed elevated and bilateral half side rails raised. The side rail evaluation completed after the surveyor identified concern showed side rails were used, but the record contained no documented evidence of what alternatives were explored before implementation and no documented evidence that risks versus benefits were explained to the responsible party or that informed consent was obtained. The facility policy stated bedrails could be considered a form of physical restraint and that the need for bedrails should be identified in the resident assessment and plan of care.
Failure to Assess Sexual Consent Capacity and Provide Psychosocial Follow-Up
Penalty
Summary
The facility failed to provide medically related social services to assess residents’ capacity to consent to sexual contact and to follow up with psychosocial support after a companionship ended. The Social Services Director’s job description stated the role included planning, organizing, developing, and directing social services to meet residents’ emotional and social needs, as well as assisting with resident assessments and care plans. Survey findings identified deficiencies involving three residents: one resident with severe cognitive impairment and a court-appointed guardian, another resident with severe cognitive impairment, and a third resident who was cognitively intact. For one resident, the record showed diagnoses including Alzheimer’s disease, dementia, and mild neurocognitive disorder, along with a BIMS score of 6 indicating severe cognitive impairment and a court order appointing a guardian. The SSD completed an assessment for capacity to consent to sexual relations and marked that the resident had been declared incompetent by a judge, which indicated the resident did not have capacity to consent; however, the SSD continued the assessment and documented that the resident had some memory deficits but stated clear understanding of consent for sexual activity. The SSD also initiated a care plan that included educating the resident on safe sexual practices and supporting the resident’s decision to engage in sexual expression. Staff and family interviews showed the SSD told others the residents had rights and could have a sexual relationship if they chose. For another resident, the record showed Alzheimer’s disease and dementia with a BIMS score of 2 indicating severe cognitive impairment, and the care plan included education on safe sexual practices and providing a privacy sign. The resident’s decision maker stated they were never made aware of, and would not have supported, care planning for any kind of sexual activity. For the cognitively intact resident, the record showed a BIMS score of 15 and the resident reported a friendship that became a companionship with another resident, then ended after the other resident made a sexual comment that made the resident feel dirty and upset for days. The resident stated no staff asked what was wrong, and the SSD acknowledged knowing the relationship had ended and that the resident was upset, but did not talk to the resident about why the resident was upset.
Unnecessary Drug Administration With Hypoglycemia
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs when nursing staff administered glimepiride despite documented low blood glucose levels and poor oral intake. The resident had diagnoses including type 2 diabetes mellitus and multiple sclerosis, and was cognitively intact with a BIMS score of 15 out of 15. Physician orders included blood glucose monitoring twice daily and glimepiride 1 mg by mouth twice daily, but there were no orders for blood glucose parameters or physician notification. On 03/29/2025, the resident had a blood glucose of 44 mg/dL at 6:00 AM and 42 mg/dL at 6:00 PM, and staff documented that the resident had low blood sugar during the night shift and continued poor oral intake. Despite this, an LPN administered glimepiride at 9:00 AM and another LPN administered glimepiride at 5:00 PM. Hospital records showed the resident was admitted to the emergency department for hypoglycemia after receiving glimepiride with a blood glucose level of 42 mg/dL and was treated with intravenous dextrose before discharge.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
