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 facility failed to maintain effective wandering and elopement safeguards for cognitively impaired residents. One resident with Alzheimer’s disease and severe cognitive impairment exited through an unsecured maglock door and was found by police hours later, while another resident’s wander alert bracelet failed to alarm when tested. Staff, including the DON, ADM, and DOR, reported there was no policy or documented process for testing the current wander alert system or monitoring bracelet function, and the facility had no system for checking the maglock doors before the incident.
A facility failed to report an alleged sexual abuse incident to DOH and law enforcement within the required timeframe after a resident told an LPN they had been raped by a CNA. The resident, who had intact cognition and significant neurologic and urinary diagnoses, later described intimate care that involved pain and burning, and said they felt embarrassed and ashamed when a male NS and male officers were present. The facility also allowed the male NS to complete an assessment without another staff member present and did not provide SW involvement or psychosocial interventions despite the resident being emotionally distraught and not sleeping well.
The NHA and DON failed to manage the facility effectively to ensure allegations of abuse were reported timely and that interventions were implemented to protect residents from abuse. Review of job descriptions, facility documentation, and staff interviews showed the facility did not meet its responsibilities to protect residents from potential abuse, resulting in an Immediate Jeopardy situation.
Failure to Monitor Wandering and Elopement Safety Systems: The NHA and DON did not effectively oversee systems intended to protect a resident at risk for wandering/elopement. A resident with a history of removing an electronic monitoring device and expressing intent to leave, smoke, and return home exited through an exterior door without staff knowledge or supervision and entered an unsafe outdoor environment.
Failure to prevent resident elopement occurred when the NHA and DON did not effectively manage the facility to protect residents from exiting unsupervised, and a resident left the building without supervision. The report states this created an Immediate Jeopardy situation for one of 29 cognitively impaired residents.
Staff were observed and reported using personal cell phones in resident care areas, including a CNA sitting in a resident common area with a personal phone in hand. Residents stated aides were often on their phones while working, and one resident reported being told they were rude for interrupting a staff member who was on the phone with her boyfriend. Resident Council minutes also noted concerns that some aides were on their phones too much, despite the handbook prohibiting cell phone use in the work area.
Unsafe wandering and elopement safeguards were not effectively managed
Penalty
Summary
The facility was cited for not being administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of residents because it failed to ensure a safe environment for cognitively impaired residents who wander or are at risk for elopement. The report identified two separate events involving wandering safety systems and noted that the deficiency affected seven residents identified as at risk for unsafe wandering and elopement. Resident #1 had diagnoses including Alzheimer's disease, alcohol abuse, and COPD, and the Minimum Data Set dated 06/08/2026 assessed the resident as having severe cognitive impairment. On 06/04/2026, the resident was located by local police approximately 12 hours later and about three miles away. Staff interviews indicated that the resident exited through a door associated with the third-floor east stairwell area, and the Maintenance Assistant stated the maglock may have slipped and disengaged, causing the door to inactivate and the alarm not to sound. The Director of Maintenance stated the third-floor east wing stairwell door used a keypad and magnetic locking system, that the first-floor exit door near the parking lot had no alarm system, and that the facility had no system for checking the doors prior to the incident. Resident #2 had diagnoses including hypertension, diabetes mellitus, and depression. The Minimum Data Set documented the resident as independent with chair/bed-to-chair transfers and wheelchair mobility and as having no wandering behaviors. During testing on 06/29/2026, the resident's wander alert device failed to alarm. Staff interviews further revealed there was no documented policy for testing the wander alert system or resident bracelets, and the facility had no current system for monitoring bracelet functionality weekly per manufacturer recommendations. The Director of Maintenance stated they could not find a policy for the wander alert system and only obtained manufacturer guidance after contacting the manufacturer, while the Administrator stated they assumed the system monitored bracelet functionality.
Failure to Report Alleged Sexual Abuse and Address Resident Distress
Penalty
Summary
The facility failed to report an alleged sexual abuse incident involving a resident immediately or within 2 hours to the Department of Health and local law enforcement after the allegation was made. The resident was admitted with diagnoses including obstructive and reflux uropathy, hemiplegia, and hemiparesis following cerebral infarction, and had a BIMS score of 15 indicating intact cognition. A facility incident report documented that the resident told an LPN that they had been raped by a CNA, and the resident later described that the CNA was providing brief care, applying cream to the hip and then to the anus and vaginal area, and that they felt something enter the anus and vagina. The resident stated they told the CNA they were hurting them, that the CNA apologized and made a moaning sound, and that they later felt burning in the vaginal area. The facility also failed to protect the resident during the response to the allegation by allowing a male nursing supervisor to perform a nursing assessment with no other staff member present after the rape allegation. The resident and family member stated that when law enforcement arrived, male officers and the male nursing supervisor were present, and the resident said they felt embarrassed and ashamed and did not want to discuss the rape. The resident stated they only reported that the CNA was rough with them. The family member stated the resident was hysterically crying and said a staff member had raped them, and the family member contacted law enforcement and requested hospital transfer. The facility further failed to provide social work involvement or psychosocial interventions after the allegation. The resident stated they were not sleeping well after the incident and were emotionally distraught and tearful during the interview. The administrator stated the facility did not report the alleged rape to the state because the resident later changed the story to rough handling, and stated they did not think the resident required social work or psychosocial interventions. The primary care physician stated the facility should call law enforcement and the Department of Health if the resident alleged they were raped.
Failure to Ensure Timely Abuse Reporting and Protective Interventions
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) did not effectively manage the facility to ensure residents were free from abuse by ensuring staff reported allegations of abuse in a timely manner and by implementing interventions to prevent abuse. Review of the NHA job description showed the NHA is responsible for ensuring the facility operates in compliance with local, state, and federal regulations, and review of the DON job description showed the DON is responsible for leading the Nursing Department to provide quality care based on best practices and regulatory guidelines. Facility documentation and staff interviews showed the facility failed to ensure allegations of abuse were reported timely and that interventions were implemented to protect residents from potential abuse. This failure placed residents at risk for serious injury from abuse and resulted in an Immediate Jeopardy situation. Based on the deficiencies identified, the NHA and DON failed to fulfill essential duties and responsibilities of their positions, contributing to the Immediate Jeopardy situation.
Failure to Monitor Wandering and Elopement Safety Systems
Penalty
Summary
The facility failed to provide effective administrative oversight and to implement and monitor systems intended to protect residents identified as being at risk for wandering or elopement. The Nursing Home Administrator’s job description stated the administrator was responsible for managing the facility in accordance with policies, procedures, and applicable standards, while the Director of Nursing’s job description assigned responsibility for directing nursing services, collaborating with the Administrator and Medical Director, conducting daily rounds, reviewing nursing documentation, monitoring resident care, and assuming daily operations in the Administrator’s absence. Despite these responsibilities, the facility did not effectively use available resources to identify and correct system problems related to resident safety. On June 19, 2026, Resident CR1 exited the facility through an exterior door without staff knowledge or supervision and entered an unsafe outdoor environment while holding a cigarette. The resident had a documented history of removing safety devices, including the electronic monitoring device intended to activate the exit alarm system, and had repeatedly stated an intent to leave the facility, smoke, and return home. Even with these known risk factors, administrative oversight did not ensure effective systems were in place to identify when required safety interventions were absent or to prevent the resident from leaving the building unnoticed.
Failure to Prevent Resident Elopement
Penalty
Summary
The Nursing Home Administrator and Director of Nursing failed to effectively manage the facility to protect residents from elopement, resulting in Resident R1 exiting the building unsupervised. Review of the facility job descriptions showed the NHA was responsible for directing overall operations in accordance with applicable regulations to ensure the highest level of care, and the DON was responsible for managing and directing resident care within the nursing department to maintain standards of resident care and ensure each resident functioned at his or her highest level. The facility failed to prevent residents from exiting the facility unsupervised, and during an interview the NHA and DON confirmed that administration failed to effectively manage the facility to protect residents from elopement. The report states this created an Immediate Jeopardy situation for one of 29 cognitively impaired residents.
Staff Used Personal Cell Phones in Resident Care Areas
Penalty
Summary
The facility failed to ensure staff did not use personal cell phones in resident care areas. Resident interviews indicated that staff were often seen using personal phones while working, including one report that a staff member told a resident they were being rude for interrupting while the staff member was on the phone with their boyfriend. Other residents reported seeing staff walking by their rooms while on their cell phones, and one resident stated staff members working in the facility were often seen using personal cell phones. During observation on 06/24/26 at 5:25 A.M., CNA #838 was observed sitting in a darkened corner of a resident common area with a personal cell phone in hand, with the phone light illuminating the CNA's face. When approached by the surveyor, the CNA dimmed the phone and placed it in the pocket of scrub pants. The CNA stated she was unsure of the facility's policy on personal cell phones but knew they were prohibited during work hours, and confirmed she did not have a work cell phone. Resident Council meeting minutes also documented resident concerns that some aides were on their phones too much, and the employee handbook stated that cell phone use in resident areas may violate regulations and was prohibited in the work area.
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