Failure in Supervision and Care Planning Leads to Resident Harm
Summary
The facility's administration failed to ensure protective oversight, leading to a series of deficiencies that resulted in Immediate Jeopardy for one resident and harm to others. A resident, identified as R200, was found unresponsive in bed after being left unsupervised with a food tray for 30 minutes by a CNA. The resident, who had a diagnosis of dysphagia, expired due to choking. The facility had not developed a comprehensive care plan for R200 that addressed the need for supervision during meals, despite the resident's known condition. Additionally, the facility failed to prevent harm to other residents. One resident, R46, sustained a right femur fracture from a fall, while another, R206, suffered second-degree burns from spilled hot coffee. A third resident, R204, experienced pain and swelling from an infiltrated intravenous site, necessitating emergency room treatment. These incidents highlight the facility's failure to ensure adequate supervision and care, as well as the lack of proper care planning and staff training. Interviews with facility staff, including the DON and MDS Nurse, revealed gaps in communication and oversight. The DON admitted to not understanding why the dysphagia diagnosis was omitted from R200's care plan and acknowledged issues with the facility's audit processes due to frequent changes in ownership and leadership. The MDS Nurse confirmed the omission of therapy diagnoses in care plans and could not recall specific details about R200's condition. These deficiencies underscore the facility's failure to maintain accurate and comprehensive care plans and to ensure staff adherence to policies and procedures.
Removal Plan
- A Root Cause Analysis of the Care plans for residents with a diagnosis of dysphagia and ADL care for dependent residents who require assistance with dining system breakdown was completed by the Regional Director of Operation, Regional Director of Clinical Operations, Administrator, and DON.
- The administrator hosted an Ad Hoc QAPI meeting with the Medical Director, DON, RDCO, and Director of Operations to review the center's ADL Care for Dependent Residents and Care Plan performance improvement measures.
- The Regional Director of Operations, RDCO, Medical Director, Administrator, and DON reviewed residents receiving swallow therapy to identify residents with a diagnosis of dysphagia to ensure that care plans were updated as appropriate.
- The Administrator identified Improvement Activities and Performance Improvement Projects based on trends and identified potential opportunities upon completion of the care plan and swallowing therapy audit.
- A review of the residents receiving swallow therapy audit was reviewed by the IDT members to validate care plans were updated appropriately to identify the level of dining assistance required.
- The MDS Nurse(s) reviewed and updated care plans on residents identified with a diagnosis of dysphagia.
- The RDCO provided re-education to the Administrator and DON on the policies and procedures related to ADL Care for Dependent Residents and Comprehensive Care Plans.
- The DON will assign Nurse Managers daily to each unit to provide supervision during meal service for those residents diagnosed with dysphagia, including those who are non-verbal or visually impaired.
- The Administrator reviewed the results of the audits and shared the findings with the Ad Hoc QAPI Committee.
- A review of the diagnosis report after the facility audited the residents diagnosed with dysphagia discovered that 30 of 45 needed updates to their care plan interventions for feeding assistance.
- The assignments for meal supervision were revised to 45 residents assigned meal supervision as an intervention for their individualized risk.
- The Administrator and the DON completed a review of staffing levels to ensure adequate assistance availability during mealtimes.
- A daily assignment sheet will be used to identify residents who require assistance with ADLs, specifically dining to ensure availability of assistance, as appropriate.
- The Administrator and DON will review assignment sheets daily to monitor compliance.
- Interviews were conducted with staff to ensure that staff were in-serviced and were knowledgeable of where to retrieve assignments on a daily basis, and to ensure that staff understood requirements for supervision, one-on-one assistance, and tray set-up for residents.
- A new Dining Time for Meal Delivered to Units was implemented with new dining times for breakfast, lunch, and dinner.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with severe cognitive impairment, dementia, depression, and significant functional dependence reported that a male CNA attempted a sexual act during care, identifying him by name and description. An LPN, a social worker designee, and the HR director promptly learned of the allegation, interviewed the resident, confirmed the CNA’s description, and notified the Administrator by phone while the resident’s statements were audible on speaker. The Administrator instructed the CNA to leave but did not timely report the allegation of sexual abuse to the state as required, later entered it as physical abuse in the reporting system, and told police that facility leadership first learned of the allegation from the resident’s son days later, contrary to multiple staff accounts. This constituted a failure of effective facility administration in handling an abuse allegation.
An LPN worked while appearing to be under the influence of an illegal substance, with residents reporting late or missed medications, improper administration of pain medication after it was dropped on the floor, and the LPN falling asleep while standing and on a resident’s bed. Staff repeatedly reported the LPN’s erratic behavior to an on-call LPN, but the concerns were not promptly escalated to the DON or Administrator, and the impaired LPN completed one full shift and part of another while continuing to provide care. Residents reported not receiving medications, tube feedings, treatments, and other ordered interventions during this time. The facility’s subsequent internal review confirmed that the LPN tested positive for cocaine and that the investigation was incomplete, as not all residents were assessed or interviewed, and key oversight processes, including timely notification of the Medical Director and QAPI review, were not carried out as required by facility policies and resident care agreements.
Facility administration failed to ensure effective oversight of staff orientation and reporting of abuse and neglect concerns. A CNA was observed kicking a resident’s bed and striking the resident with a closed fist, and that CNA’s orientation record lacked completion and signatures for key safety and care topics, including falls management, safe transfers, use of mechanical lifts, alarms, and behavior management. A resident’s allegation of neglect reported to nursing staff was not communicated to administration and no investigation was initiated. Staff did not report that other staff were taking pictures of a resident during care, and bruising on another resident’s arm was not adequately reported, assessed, or monitored. The Administrator and DON acknowledged these reporting and assessment failures, and the Medical Director stated he had not been informed of these concerns.
The facility failed to maintain CNA staffing levels in accordance with its own facility assessment and staffing policy, which called for a CNA-to-resident ratio of 1:15–18. On multiple overnight shifts, only two CNAs were assigned despite censuses ranging from the high 60s to low 70s, resulting in each CNA being responsible for approximately 34–36 residents. The Administrator confirmed the census counts, overnight staffing assignments, and resulting CNA-to-resident ratios, and this deficiency affected all residents in the facility.
The deficiency centers on the administrator’s failure to lead and operate the facility in a way that supports residents’ highest practicable well-being, as required by her job description and the facility’s resident rights policy. Staff, residents, and resident representatives consistently reported that the administrator was unapproachable, rude, and condescending, frequently yelling at staff in public areas such as the nurse’s station in front of residents, visitors, and other staff, and threatening staff jobs and paychecks when they attempted to advocate or raise concerns. Multiple residents stated that the administrator rarely interacted with them, showed favoritism toward certain residents, dismissed or cut off their concerns, and did not follow up, leaving them feeling that she did not have their best interests at heart. Several staff and residents described a tense, toxic atmosphere and a pervasive fear of retaliation that made both staff and residents afraid to report issues or advocate for care, with one resident becoming tearful and expressing fear of being discharged after speaking with surveyors. Complaints about the administrator had been made to corporate HR and the compliance line, but staff perceived little or no follow-up, while the administrator also served as the facility’s compliance officer, further contributing to concerns about reporting and accountability.
Surveyors found that facility staff failed to remain awake during scheduled working hours, with multiple instances of employees sleeping on night shift in common areas and hallways. Personnel records documented disciplinary actions and terminations for a dietary aide and a CNA who were observed asleep by HR and a midnight RN supervisor. Several residents and a confidential individual reported that staff sleep during night shift. The facility’s Employee Handbook identifies sleeping on the premises during working hours as a critical offense warranting immediate discharge.
Failure to Report and Accurately Disclose Alleged Staff-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility Administrator’s failure to effectively administer the facility by not properly reporting and characterizing an allegation of staff-to-resident sexual abuse and by providing false information to police. The resident involved had multiple medical conditions including stroke, dementia with severe cognitive impairment, depression, and functional dependence requiring extensive assistance of two staff for bed mobility, transfers, and ambulation. Her care plan noted alterations in mood and behaviors, including occasional delusional thinking and yelling out. On the morning in question, the resident reported that a male staff member tried to put his “thing” in her mouth, gesturing toward her own and the nurse’s private areas, and identified the alleged perpetrator by name and description, which matched a CNA on duty. Staff interviews showed that the allegation was promptly brought to facility leadership on the same morning it occurred. An LPN, after hearing the resident’s statements, reported the concern to the social worker designee because administration was not yet on site. The social worker designee and the Human Resources Director jointly interviewed the resident, who remained upset and repeated the allegation, and they confirmed that the CNA she identified matched the description she gave. The Human Resources Director called the Administrator on speaker phone during this interview so he could hear the resident’s statements and the reported events. The Administrator then spoke with the CNA by phone, in the presence of the social worker designee and Human Resources Director, and directed the CNA to leave the facility pending investigation. Despite being made aware of the allegation on the day it occurred, the Administrator did not report the allegation of sexual abuse to the state agency as required by the facility’s abuse policy, which mandates reporting all allegations or suspicions of abuse prior to investigation. Review of the state reporting system showed no self-reported incident for sexual abuse on the date of the allegation, and when an incident was later entered, it was reported as physical abuse rather than sexual abuse. Additionally, in a subsequent police report for a sex offense, the Administrator told law enforcement that the facility was not made aware of the allegation until the resident’s son reported concerns two days after the incident, which conflicted with consistent staff statements that the Administrator had been immediately informed on the day of the alleged abuse. These actions and omissions constituted a failure of effective facility administration.
Plan Of Correction
The facility will continue to report allegations of abuse timely. Resident #171 continues to reside at the facility. Initial self-reported incident for resident #171 allegation was filed on 3/12/26 by the Administrator. Facility CNP assessed resident #171 on 3/12/26 with no noted injuries or negative effects. Psych nurse practitioner assessed residents #171 on 3/19/26 with no changes noted to psychosocial wellbeing. Resident #171 denied any complaints and appeared calm and relaxed stating to the NP that she feels safe. A thorough investigation was completed and submitted on 3/19/26. State reported incident conclusion was that abuse did not occur, there was no evidence to substantiate abuse. CNA #340, was suspended on 3/12/26 pending investigation. Police department called on 3/12/26. Final summary of State reported incident was reported to police department by the Regional Clinician on 3/19/26. HRD conducted new background check on CNA #340 on 3/26/26, no negative findings noted. The regional Clinician conducted an Audit of last 3 months of incidents and progress notes ensuring allegations of abuse were reported timely, factually documented and thoroughly investigated. Initial audit was completed on 4/6/26. No negative findings noted. On 4/6/26, the Administrator, Nurse Management team, SSD and HRD were reeducated on the facility policies and procedures for reporting allegations timely, conducting a thorough and factual investigation and ensuring perpetrators are removed from the facility for resident's safety to prevent further abuse. Reeducation was conducted by the regional clinician. On 4/6/26, Administrator was reeducated on providing accurate information when reporting allegations of abuse including date of alleged occurrence. On 4/6/26, Administrator was reeducated on obtaining all information from all eye witness and staff with knowledge of allegation to ensure thorough and accurate investigation. A QA committee meeting was held on 4/8/26 reviewing survey results and findings, investigation and medical record documentation requirements, policy and procedures for abuse prevention and reporting abuse, SS policy and procedure, and facilities change in condition policy and procedure. Weekly for 2 weeks, or as directed by the QA committee, audits will be conducted by the regional clinician ensuring abuse allegations are investigated thoroughly, factually documented and reported, and ensuring identified perpetrators are removed from the facility as indicated. Audits will include but not limited to progress notes, incident reports and clinical alerts. Negative findings will be corrected immediately by reporting allegation and conducting thorough investigation and providing reeducation. Negative findings will be reported to the QA committee for review. The Regional Administrator will ensure the completion of the weekly audits. The Administrator is responsible for the ongoing compliance.
Failure to Address Impaired Nurse and Missed Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that care and services were provided in accordance with professional standards of practice, comprehensive resident assessments, and physician orders when an LPN worked while appearing to be under the influence of an illegal substance and continued to provide resident care. Multiple residents and staff reported that on 02/22/26 the LPN appeared disheveled, very tired, was falling asleep while standing, dozing off mid-conversation, and acting "weird" or erratic. Residents reported that medications were administered late, that some medications were not received at all, and that at least one resident’s pain medication was administered after being dropped on the floor. One resident reported that the LPN entered her room and fell asleep on her bed. Another resident reported not receiving any medications that day. Staff interviews showed that concerns about the LPN’s behavior were repeatedly reported to the on-call manager, another LPN, but were not escalated to the DON or Administrator on the day of the incident. The on-call LPN stated she contacted the DON and was instructed to call and speak with the LPN in question, who reported being tired from lack of sleep; no further direction was reported. The DON later stated she was not made aware of the extent of the erratic behavior on that date, and the LPN completed the full shift on 02/22/26 and returned to work the following day, working part of another shift before residents’ complaints prompted further action. Residents and staff reported that during this period, residents did not receive medications, tube feedings, treatments, and other interventions as ordered. The facility’s own self-reported incident documentation confirmed that residents had reported the LPN was dropping pills and appeared to be under the influence of an unknown substance, and that the on-call LPN did not report the incident to the Administrator at the time. The LPN later tested positive for cocaine. The investigation documentation showed that not all residents were assessed for possible negative effects related to the incident, and statements were not obtained from all affected residents. Facility staff, including an RN and the DON, verified that the investigation was not completed thoroughly, that there was no evidence of a QAPI meeting related to the incident, and that the Medical Director was not notified until several days after the event. These actions and inactions occurred despite facility policies and resident agreements requiring protection of resident rights, provision of adequate and appropriate medical and nursing care, prohibition of illegal drug use, and immediate, thorough investigation and reporting of suspected abuse or neglect.
Failure of Administration to Ensure Effective Staff Orientation, Reporting, and Response to Abuse/Neglect Concerns
Penalty
Summary
The deficiency involves ineffective facility administration that failed to ensure appropriate staff orientation, reporting, and follow-up of resident abuse and neglect concerns. A CNA was observed kicking a resident’s bed and hitting the resident with a closed fist. Review of this CNA’s Nursing Orientation Checklist showed the second page, which should have covered multiple care and safety topics such as resident property procedures, falls management, gait belt and safe transfers, use of mechanical lifts, call system basics, alarms, shift-to-shift walking rounds, morning care, management of difficult behaviors, avoiding bruising and skin tears, dementia bathing, restraints, and mood and behavior patterns, was incomplete and lacked signatures or dates from the employee or the orienting staff. Human Resources confirmed these orientation deficiencies. In addition, one resident reported an allegation of neglect to nursing staff, but this was not reported to administrative staff and no investigation was initiated; the Administrator confirmed he had not been informed of this allegation. Staff also failed to report that other staff were taking pictures of another resident during care, and failed to report and adequately assess and monitor bruising on a different resident’s right arm, as confirmed by the Administrator and DON. The Administrator and DON stated they had taken over a failing building and were in the process of replacing staff, and the Administrator confirmed he had assumed responsibility months earlier. The Medical Director reported he was not aware of the identified concerns and would need to work with administration to correct issues for effective administration.
Failure to Maintain CNA Staffing Levels per Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to administer operations in a manner that ensured adequate staffing in accordance with its own facility assessment and staffing policy. The facility assessment dated 11/15/25 specified that CNAs would be staffed at a ratio of one CNA to every 15 to 18 residents. The facility’s written staffing policy dated 11/05/25 stated that there shall be a sufficient number of trained staff members on duty to ensure each resident’s physical, social, and emotional health, care, and safety needs are met in accordance with their individualized care plans, and that staffing levels would be based on day-to-day resident needs, activity, and intensity of staff assistance. Surveyor review of census and overnight staffing records showed that on three consecutive nights the facility did not meet its stated CNA staffing ratios. With a census of 69 residents, only two CNAs were on duty, resulting in each CNA being responsible for 34.5 residents. On the following night, with a census of 70 residents, two CNAs were again assigned, resulting in each CNA being responsible for 35 residents. On the third night, with a census of 71 residents, two CNAs were assigned, resulting in each CNA being responsible for 35.5 residents. The Administrator confirmed the overnight census numbers, the number of CNAs assigned on those nights, and the calculated CNA-to-resident ratios. This failure affected all residents in the facility, with a reported census of 71 residents at the time of the survey.
Administrator’s Conduct Creates Fearful, Non-Supportive Environment and Undermines Resident Rights
Penalty
Summary
The deficiency involves the facility’s failure to administer the facility in a manner that enabled all residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The administrator’s job description required her to lead, guide, and direct operations in accordance with regulations and facility policies, ensure compassionate quality care, perform rounds to know residents by name and sight, be available and approachable to staff and residents, manage and minimize facility risk, and promote and protect resident rights. The facility’s Resident Rights policy required that all residents be treated equally and that staff be educated on resident rights and the facility’s responsibility to properly care for residents. Resident council minutes documented that residents wanted administration to be more present with them, and the administrator was also listed on the corporate compliance poster as the facility’s compliance officer, meaning complaints called into the compliance line would be forwarded to her. Multiple interviews with staff, residents, and resident representatives described the administrator as unapproachable, rude, condescending, and prone to yelling at staff in front of residents, visitors, and other staff. Anonymous employees reported fear of retaliation if they spoke with the state survey agency or raised concerns, stating that staff who advocated for residents or voiced suggestions were threatened, demoted, or felt their jobs were at risk. Several employees described specific incidents where the administrator entered units and loudly demanded that aides leave and return for another shift, threatening that their paychecks would be affected, and where she screamed at nurses at the nurse’s station about issues such as a medication cart or mask use, took photos with her cell phone, and belittled staff in public areas. These events were witnessed by residents, visitors, and families, and staff reported that residents were startled, uncomfortable, and fearful, and that the environment felt tense and unsafe. Residents and their representatives reported that the administrator did not interact with most residents, showed favoritism toward certain residents, and did not listen to or follow up on resident concerns. A resident stated that the administrator rarely visited residents, always turned down requests, and made it hard for staff to do their jobs. Multiple residents and anonymous residents reported that when they brought up concerns, the administrator became defensive, cut them off, and did not take action, and that they felt she did not have their best interests at heart. One resident was observed crying after speaking with the state survey agency, expressing fear of being “kicked out” of the facility for reporting concerns about the administrator. Residents and staff also reported that good staff had already left and more might leave due to how the administrator spoke to them, and that residents felt they no longer had a voice and were afraid to advocate for themselves because of fear of retaliation. During a resident council meeting, after the administrator and DON left the room, residents stated they wanted a new administrator, described feeling that their concerns were dismissed or minimized with explanations about money or numbers they did not understand, and reiterated that the administrator yelled at staff in front of residents and visitors and treated residents differently. Corporate Human Resources reported that multiple complaints about the administrator had been called in over the past year, though it was unclear whether any formal disciplinary action had been taken. Staff noted that complaints to the corporate compliance line did not appear to result in follow-up and expressed concern that the administrator’s role as compliance officer might affect how complaints were handled. Across interviews, staff and residents consistently described a toxic, tense atmosphere, lack of administrative support, fear of retaliation, and a perception that the administrator did not prioritize residents’ needs, care, or interests. These actions and inactions by the administrator, in contrast to the expectations in her job description and the facility’s Resident Rights policy, resulted in the facility not being administered in a manner that enabled all residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being.
Staff Found Sleeping on Duty During Night Shift
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff remained awake during scheduled working hours, as required to effectively meet the needs of all 81 residents. Personnel records showed that a dietary aide was terminated following a disciplinary action dated 12/19/25 for sleeping on the job in the main lobby. A written statement signed by Human Resources and the Administrator documented that the HR staff member found the dietary aide asleep in the lobby, brought in the Administrator as a witness, and then woke the aide, who apologized and stated he had not slept well the previous night. Multiple interviews supported that staff slept during night shift, including interviews with two residents and a confidential individual who reported witnessing staff sleeping at night. The DON and Administrator confirmed that the dietary aide had been found sleeping and was terminated. A second staff member, a CNA, was also found sleeping while on duty. Review of the CNA’s personnel file showed a disciplinary action dated 12/30/25 for termination due to sleeping in the hallway. Interviews again corroborated that staff slept on night shift, including statements from a resident and a confidential individual. A midnight RN supervisor confirmed that the CNA was found asleep at 1:32 A.M. on 12/30/25, and the DON confirmed the CNA was found sleeping, suspended, and would be terminated. Review of the Employee Handbook dated 01/01/24 showed that sleeping on the community’s premises during scheduled working hours is listed as a critical offense that is considered serious in nature and results in immediate discharge. The survey determined that the facility failed to ensure staff were awake at all times, with the potential to affect all residents.
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