Lack of Governing Body Engagement in QAPI Program
Summary
The facility failed to ensure the governing body was actively engaged and involved in the oversight of the Quality Assurance Performance Improvement (QAPI) program, affecting all 50 residents. The facility had not conducted any QAPI meetings since before their last annual survey, which was completed on 11/17/22. This lack of engagement was confirmed through interviews with the facility's Administrator and the Medical Director, who both acknowledged the absence of QAPI meetings and the lack of a functioning QAPI program. The Medical Director was not informed about the absence of the QAPI program since his hiring, and the Administrator admitted to the lack of evidence for any QAPI meetings since the last annual survey. The governing body was responsible for reviewing QAPI information quarterly and ensuring compliance with the QA committee, but there was no evidence of their involvement or attendance at any QA meetings since the last annual survey. The facility's policies outlined the governing board's responsibility for the management and operation of the facility, including the establishment and implementation of a QAPI program. However, the governing body failed to fulfill these responsibilities, as confirmed by the President of Clinical Operations, who verified the absence of a QAPI program and the governing body's lack of attendance at QA meetings.
Penalty
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Surveyors found that multiple residents with orders for low air loss mattresses (LALM) for PU/PI prevention and wound healing were using these specialty beds without any facility policy or procedure in place to guide their use. The DON confirmed there was no written P&P for LALM, including no direction on linen use, and that staff relied on manufacturer guidelines, which did not address linen. The administrator acknowledged that a P&P for LALM should exist to guide care for the many residents using these mattresses, despite job descriptions assigning responsibility for developing and implementing such policies.
Surveyors found that the facility lacked a formally appointed, properly licensed Administrator (ADM) serving as the NHA and did not have consistent on-site administrative oversight. Staff reported that the prior ADM had left, the Department Head Directory did not list an ADM, and a regional ADM only visited a few hours several times per week without a formal appointment letter. The receptionist also noted that this temporary ADM had been absent for several days due to a corporate conference, leaving the DON identified only as the Abuse Coordinator and no clearly designated ADM present to manage operations.
The facility lacked a policy and procedure governing the use of USB drives for transmitting PHI, leading to an incident in which a resident’s complete medical record was saved to an unencrypted, non–password-protected USB drive and mailed to the resident’s authorized representative. After email transmission failed due to large file size, the MRD used a USB drive containing the resident’s medical records, medical record number, insurance details, residency dates, and share of cost, and sent it by certified mail. The envelope was later returned torn open with the USB drive missing. The ADM acknowledged that existing PHI policies were outdated and did not address USB drives or current technology.
The facility operated for several months without a DON, leaving an ADON who is an LPN to manage nursing needs and contributing to poor communication between nursing and therapy. The Administrator acknowledged ongoing communication problems, including no defined process for sharing therapy recommendations and no nursing access to therapy documentation. In this context, a resident’s G-tube was pulled out, enteral feeding orders were discontinued, and only site care was provided, yet speech therapy records continued to reflect that a feeding tube was in place with recommendations for puree diet and therapeutic feedings with the SLP only. The SLP later reported believing the tube remained in place and not being informed of its removal, illustrating the communication breakdown surrounding the resident’s G-tube management.
The governing body failed to oversee a contracted behavioral health vendor’s documentation and interventions for two residents in a Medicaid behaviorally complex care program. Behavior tracking sheets contained multiple entries initialed by an unidentifiable individual, and one resident’s records listed numerous unapproved interventions such as detention, seclusion, suspension, and corporal punishment that were not part of the care plan and were not used by facility staff. Facility leadership reported that only contracted behavioral health staff completed these behavior sheets and submitted them to Medicaid, while a vendor supervisor later determined that a single employee had used an AI tool to generate interventions and had signed using other initials instead of obtaining real-time intervention information from facility staff as required.
The governing body failed to establish and implement effective management and operational policies and did not maintain consistent, effective administrative leadership, resulting in widespread regulatory noncompliance. Surveyors cited numerous deficiencies, including repeat citations for failure to maintain a safe, clean, homelike environment, to develop and revise comprehensive care plans, and to provide or document required influenza and pneumococcal immunizations. Additional deficiencies involved resident dignity, notification of providers and representatives about condition changes, protection from abuse and neglect, reporting and investigating injuries and allegations, discharge/transfer documentation, activities programming, and ensuring that clinical and respiratory services met professional standards. The facility’s QAPI policy described a structured program with feedback, data systems, and Performance Improvement Projects, but the document provided was incomplete, and the Administrator reported not recalling any PIPs being conducted. Interviews indicated that the Administrator was infrequently present on-site, residents viewed the Assistant Administrator as the de facto administrator, and a newly arrived DON believed the facility needed revamping while a local administrator was being sought. Further citations included insufficient and incompetent staffing, inadequate pharmaceutical and dietary services, failure to maintain equipment safely, inaccurate staffing data submission to CMS, and inadequate staff and nurse aide training, including missing mandatory QAPI training.
Lack of Policies and Procedures for Low Air Loss Mattress Use
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement policies and procedures for the use of low air loss mattresses (LALM) for all 12 sampled residents who were using these specialty beds for pressure ulcer/injury (PU/PI) prevention and treatment. Record review of the facility’s Order Listing Report showed that each of the 12 residents had active physician orders for LALM, with start dates ranging from the prior year to the current month. During observation, all 12 residents were confirmed to be on LALM, and the treatment nurse stated that the mattresses were being used to prevent pressure ulcers and promote wound healing for residents with existing pressure ulcers. In interviews, the DON acknowledged that the facility did not have any written policy or procedure governing LALM use, including guidance on linen use with the mattresses, and stated that the facility followed the manufacturer’s guidelines. However, the manufacturer’s guidelines provided did not address linen use with LALM. The administrator also stated that the facility should have a policy and procedure for LALM use to guide management of residents on these mattresses and noted that many residents were using them. Review of the DON and administrator job descriptions showed that both positions were responsible for developing, maintaining, and ensuring implementation of facility policies and procedures, including nursing policies that conform to current standards and regulations.
Lack of Formally Appointed and Consistently Present Administrator
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed Administrator (ADM) was formally appointed and serving in the capacity of a Nursing Home Administrator (NHA), and that an ADM was present for sufficient hours to provide adequate oversight and management of operations. During observation and interview, the DON’s license was posted in the lobby identifying the DON as the Abuse Coordinator, but there was no indication of an appointed ADM. The facility’s Department Head Directory did not list an ADM, and staff interviews confirmed that the previous ADM had left on January 10, 2026. Staff reported that since the prior ADM’s departure, an interim or regional ADM had been coming to the facility only approximately three times per week for a few hours per visit, either in the morning or afternoon. The receptionist stated that the temporary ADM had been absent from the facility for the past three days due to attending a corporate conference. The DON confirmed that the regional ADM providing oversight did not have a formal appointment letter designating them as the Administrator and had been assigned by the corporate office. As a result, the facility was operating without a consistently present, formally appointed, and properly licensed ADM responsible for managing and overseeing facility operations.
Loss of Unencrypted PHI on USB Drive Due to Lack of Policy
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a policy and procedure governing the use of USB drives for transmitting Protected Health Information (PHI). The governing body was responsible for establishing and implementing policies for managing and operating the facility and for appointing an administrator to manage the facility. The Medical Records Director (MRD) received an email request from a resident’s authorized representative for copies of the resident’s complete medical record. The MRD initially attempted to send the requested records via email, but the files were too large to transmit. The MRD then saved all requested medical record documents onto a USB flash drive and mailed it via certified mail to the address provided by the authorized representative. The USB drive contained the resident’s medical records, medical record number, payor/insurance provider and eligibility information, residency dates at the facility, and share of cost. The facility later received the envelope back marked “Return to Sender; Attempted – Not Known Unable to Forward,” and the envelope was torn open with the USB drive missing. The MRD stated the USB drive was not password protected and confirmed there was no policy or procedure addressing the use of USB drives to send PHI. The Administrator reported that, after learning of the lost unencrypted USB drive, he reviewed the facility’s PHI-related policies and found they were outdated and did not address the use of USB drives or current technology, and acknowledged that if USB drives were being used to send PHI, there should have been a policy requiring password protection.
Lack of DON Oversight and Poor Nursing–Therapy Communication on G-Tube Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure the nursing department was directed by a qualified Director of Nursing (DON), resulting in a lack of direction and communication within nursing and therapy regarding resident care needs. The Administrator reported that the facility had been without a DON for several months and acknowledged communication issues between departments, including the absence of a defined process for communicating therapy recommendations and the lack of nursing staff access to therapy documentation. The Assistant Director of Nursing, an LPN, stated that the former DON had left approximately eight months earlier and that the position had not been replaced, leaving her to manage nursing needs to the best of her ability. For one resident reviewed for G-tube management, speech therapy documentation over a period of time recorded that the resident had a feeding tube in place and recommended puree consistencies with therapeutic feedings only with the Speech Language Pathologist (SLP). However, nursing progress notes documented that the resident had pulled out her G-tube, that enteral feeding orders were discontinued by a nurse practitioner, and that G-tube site care was initiated. The SLP later stated that at the time of the resident’s discharge from therapy, the SLP believed the feeding tube was still in place and had not been informed that the G-tube had been removed and not replaced, demonstrating a breakdown in communication about the resident’s G-tube status and care needs.
Failure to Oversee Contracted Behavioral Health Documentation and Interventions
Penalty
Summary
The governing body failed to oversee services performed by a contracted behavioral health vendor, including the accuracy of behavior documentation for two residents enrolled in the Medicaid Behaviorally Complex Care Program. The facility used a multi-page Behavior Frequency Documentation Data Sheet to track behaviors and interventions, but review of these sheets for two sampled residents showed entries with initials that could not be linked to any identifiable staff member. For one resident with schizophrenia, dementia, major depressive disorder, and generalized anxiety disorder, behavior sheets for two consecutive months contained multiple entries initialed as "AB" by an unverified staff member; a similar pattern of unverified initials appeared on another resident’s behavior sheets over two months. The behavior documentation for one of these residents included numerous interventions that were not part of the resident’s care plan and were not used by facility staff. These interventions were described as effective, successful, failed, or ineffective and included terms such as loss of privileges, time-out, detention, parent-teacher conferences, suspension, student-teacher conferences, expulsion, seclusion, calm-down corner, and corporal punishment. The Unit Manager stated that facility staff did not have access to the behavior data sheets, did not document on them, and had never used the listed interventions when addressing resident behaviors. The Administrator similarly reported that contracted behavioral health staff were solely responsible for completing the behavior documentation and submitting all related documents to Medicaid. Interviews with facility leadership and contracted vendor staff further showed that the contracted behavioral health staff, not facility staff, controlled the behavior documentation and submission process. The Assistant Administrator and Administrator confirmed that treatment and documentation for residents in the behaviorally complex care program were completed by the vendor’s behavioral health staff. A Lead Behavior Coordinator from the vendor acknowledged awareness that a Behavior Coordinator was using other initials to sign paperwork and that terms such as spanking and corporal punishment had appeared on the sheets. The vendor’s Chief Clinical Officer later determined that a single employee had documented interventions that were not actually implemented at the facility and that this employee had used an AI tool to generate interventions instead of obtaining real-time intervention information from facility staff, contrary to expectations and the consulting agreement that required accurate labeling and verification of patient data for claims submission.
Governing Body and Administrative Failures Leading to Widespread Regulatory Noncompliance
Penalty
Summary
The governing body failed to establish and implement effective policies for managing and operating the facility and did not maintain a consistent, properly functioning Administrator responsible for regulatory compliance. Surveyors identified multiple deficiencies across numerous regulatory areas, including repeat deficiencies related to providing a safe, clean, comfortable, homelike environment (F584), developing and implementing comprehensive care plans (F656), revising care plans in a timely manner (F657), and ensuring influenza and pneumococcal immunizations (F883). Additional cited deficiencies included failures in resident dignity (F550), notification of providers and resident representatives about changes in condition (F580), protection from abuse and neglect (F600), reporting injuries of unknown origin to the State Survey Agency (F609), and thoroughly investigating all allegations of abuse, neglect, exploitation, or mistreatment (F610). The scope of deficiencies also extended to discharge/transfer documentation and notification (F628), activities programming (F679), and ensuring that services, including respiratory care, met professional standards (F684, F695). The facility’s Quality Assurance and Performance Improvement (QAPI) program, as documented in an undated policy, described a structure for feedback, data systems, monitoring, and Performance Improvement Projects (PIPs) based on high-volume, high-risk, or problem-prone activities, and input from various data sources such as incident reports, infection control reports, consultant reports, and department head meetings. The policy listed objectives to establish and maintain an ongoing QAPI program, assist departments with performance improvement projects, evaluate results of actions taken, and centralize quality improvement activities. However, the document provided to surveyors was incomplete, ending abruptly after the word “All,” and the last two pages consisted of a QAPI test. Administrator #1 reported not recalling ever doing a Performance Improvement Project or Plan with any individuals in the facility, despite the written QAPI policy describing such activities as part of the facility’s quality program. Interviews further demonstrated instability and inconsistency in facility leadership and administration. Ombudsman #1 reported being in the facility weekly and not seeing the Administrator for extended periods, sometimes a month or more, and stated that the Assistant Administrator was effectively administering the building and was viewed by residents as the actual Administrator. Assistant Administrator #1 stated that Administrator #1 was only periodically in the facility but was accessible by phone and in frequent contact. Administrator #1 stated they became Administrator in August 2025 after the prior Administrator abruptly left, that they owned 9% of the facility, and that they had previously been in the building every other week when the prior Administrator was in charge. Administrator #1 acknowledged that residents might not know they were the Administrator and stated they were unaware of some issues identified during the survey and had not conducted PIPs. The DON, who had been in the building for about a week at the time of interview, stated that the facility “needed revamping” and that they were actively interviewing for a local administrator. Collectively, these observations and statements supported the finding that the governing body did not ensure stable, effective administrative leadership or fully implemented policies and systems necessary to manage operations and maintain regulatory compliance. The deficiencies extended into multiple operational domains, including staffing, pharmacy, dietary, maintenance, and training. Surveyors cited failures to ensure sufficient and competent nursing staff (F725, F726), to provide pharmaceutical services that met residents’ needs (F755), and to ensure physician notes were accurately entered and maintained (F711). Dietary-related deficiencies included failure to provide palatable, attractive food at safe and appetizing temperatures (F804) and to store, prepare, distribute, and serve food in accordance with professional food safety standards (F812). The facility also failed to maintain mechanical, electrical, and patient care equipment in safe operating condition (F908). Training-related deficiencies included failure to develop, implement, and maintain an effective training program for all new and existing staff (F940), failure to include mandatory QAPI training as part of the QAPI program (F944), and failure to provide at least 12 hours per year of in-service training to ensure nurse aide competence (F947). The facility was also cited for failing to submit accurate staffing information based on payroll data to CMS (F851) and for failing to ensure effective QAPI feedback, data systems, and monitoring (F867), as well as for failures related to providing and/or documenting required influenza and pneumococcal immunizations (F883). These findings collectively demonstrated that the governing body had not effectively implemented the policies and oversight necessary to ensure compliance with regulatory requirements across multiple areas of facility operation.
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