Failure to Ensure Safe Discharge Planning for Cognitively Impaired Resident
Summary
The facility failed to administer its resources effectively and efficiently to ensure the highest practicable well-being of a resident who was discharged home. The Administrator (ADM) and Director of Nursing (DON) directed staff to discharge a resident with a diagnosis of dementia, confusion, and altered mental status, who had no power of attorney (POA), to her home without confirming appropriate supervision or care arrangements. The Interdisciplinary Team (IDT) did not notify the nurse practitioner (NP) or physician (MD) about the resident's discharge home alone and without services. The discharge planning process did not include a thorough assessment of the resident's cognitive and functional abilities at the time of discharge, and the discharge Minimum Data Set (MDS) was incomplete and unsigned by authorized personnel. The resident's care plan indicated she required assistance with activities of daily living (ADLs), supervision for mobility and transfers, and was at risk for falls due to her cognitive impairment. Despite these documented needs, the resident was discharged via a ride-share service to an apartment that, according to family, lacked electricity and was unsanitary. The family member who was listed as an emergency contact expressed concerns about the resident's ability to live alone and the unsafe home environment, but these concerns were not adequately addressed by the facility. The facility did not ensure that home health services or necessary durable medical equipment were arranged prior to discharge, and other potential family contacts were not involved in the discharge planning process. Interviews with facility staff and family revealed that the discharge was driven by the end of the resident's insurance coverage, and the ADM did not investigate the home environment or seek alternative family support before proceeding. The resident arrived home without a walker or wheelchair and was left alone, with the family member only able to assist after the fact. The NP later confirmed that the resident's confusion was progressive and that she required supervision if discharged home. The facility's actions resulted in the resident being returned to an unsafe environment without adequate planning or support, as documented by multiple staff and family interviews.
Removal Plan
- Residents and family members will be instructed to provide their own transportation upon discharge. Courtesy transportation will no longer be provided.
- Discharge paperwork will be presented to the power of attorney, responsible party, and/or resident if they are their own RP with intact cognition to be reviewed and signed upon discharge.
- A discharge summary/plan of care will be provided to the cognitively intact resident, responsible party, and/or power of attorney.
- Post discharge services such as home health will be set up prior to discharge.
- Physicians and NPs will be notified of discharges to address resident's needs.
- An in-service will be completed with the Administrator by the Regional President of Operations that details the entire discharge planning process including the completion of discharge summaries, contacting RP/POA's, confirmation of transportation, and home health set up confirmation.
- An in-service will be completed with the Social Worker and Case Manager by the Administrator that details the entire discharge planning process including the completion of discharge summaries, contacting RP/POA's, confirmation of transportation, and home health set up confirmation.
- An in-service will be completed with the IDT by the Administrator regarding the completion of the discharge summary, notifying the Physicians and NPs of discharges to address resident's needs, providing discharge paperwork to the power of attorney, responsible party, and/or resident if they are their own RP with intact cognition to be reviewed and signed upon discharge.
- All discharges will be reviewed by the IDT in a weekly standards of care meeting to ensure care/summary was completed, Discharge Summary completed, signatures on the discharge summary by the appropriate party, confirmation of home health orders, and means of discharge transportation were completed.
- All residents that are not cognitively intact and do not have a Power of Attorney or Responsible Party at the time of discharge, the facility social worker and/or administrator will contact the ombudsmen and seek assistance if needed for guardianship.
- The DON/Designee will review all discharge orders for upcoming discharges for completion.
- The DON/Designee will communicate with the NP/Physician prior to discharge to address any additional post discharge needs.
- The Administrator/Designee will audit all discharges for discharge summaries, discharge location, means of transportation, and confirmation of home health.
- A Quality Assurance and Performance Improvement review of the removal plan will be completed with the Medical Director for agreement with this plan.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Facility leadership failed to oversee resident care and staff performance effectively. Staff reported a week-long shortage of insulin syringes, during which nurses borrowed insulin pens and vials from other residents and gave them to different residents, while one resident missed insulin and another had delayed blood sugar checks and insulin coverage. Interviews also described an LPN threatening a resident, delayed incontinence care, intimidation of staff who reported concerns, and other allegations of misconduct, while the DON and RN/ADON did not fully investigate several of the reported issues.
The NHA and DON failed to effectively manage the facility to implement sufficient monitoring and supervision to prevent an elopement. Facility records and job descriptions showed the NHA was responsible for maintaining effective systems and overseeing staff, care, supplies, and facilities, while the DON was responsible for nursing management, resident care standards, policy implementation, and supervision of the nursing department. The report states the facility failed to properly supervise a resident and failed to respond appropriately to the elopement.
Administrator Living in Facility and Alleged Alcohol Use Not Addressed: The facility failed to follow its drug-free workplace policy and failed to address repeated concerns that the Administrator was drinking alcohol, appeared intoxicated, and smoked in non-designated areas. Staff reported seeing alcohol in the Administrator’s office, smelling alcohol on his breath, and observing behavior they believed was impaired, while the DON and other leaders learned he was living in a room at the facility. The Area Admin did not investigate the allegations and stated he considered the Administrator exempt from policy during evenings and weekends because he lived at the facility.
Failure to Plan for Facility Closure and Resident Discharge: The facility received an eviction notice but did not have a closure plan for the 30 residents. The ADM said he was out of money, had no specific plan, could not pay for a DON or RN supervisor, and was relying on agency staff while delinquent on supplies and pharmaceuticals. Residents were distressed about being moved, and the ADM had not notified residents or RPs about the eviction.
The NHA and DON failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. The facility did not have working laundry equipment to ensure clean and sanitized linens and laundry, and this was identified as an Immediate Jeopardy for all 67 residents. The NHA and DON confirmed the failure during interview.
A resident eloped from the facility after staff failed to ensure proper supervision, and the event was identified as an IJ for all residents at risk for elopement. The NHA and DON were found to have failed to effectively manage the facility and to fulfill their job duties related to overseeing operations and nursing services.
Leadership and Oversight Failures Affecting Resident Care
Penalty
Summary
The facility failed to demonstrate effective leadership of overall operations to ensure residents received care as ordered and that staff actions were appropriately overseen. Review of job descriptions showed the Administrator was responsible for directing overall operations, the DON for overall management of resident care, and the RN/ADON for assisting with nursing management and training and for ensuring staff understood expectations for resident care. During the investigation, multiple staff interviews and resident statements showed breakdowns in oversight, communication, and response to care concerns across the facility. One major concern involved insulin administration and supply management. An Ombudsman asked the facility whether insulin needles were available for residents who had insulin orders. Staff reported that the facility was out of insulin syringes for about a week. During that time, LPNs stated they borrowed insulin pens or vials from other residents and administered those medications to different residents because they had no syringes available. One LPN stated she notified the RN/ADON that the facility was out of syringes and that nurses were taking and using other residents’ insulin. Another LPN stated she took another resident’s unopened insulin pen and gave it to a different resident. A third LPN stated she took one resident’s insulin vial and gave it to another resident. The RN/ADON stated she was responsible for ordering supplies but said she was not aware nurses were taking and administering other residents’ insulin. The DON stated she learned of the syringe shortage from the Ombudsman and did not interview residents or nurses about whether insulin had been missed or investigate beyond checking whether syringes were currently available. A resident also stated he missed insulin one day because there were no syringes, and on other days nurses took insulin from another resident so he would not miss his dose. The investigation also identified delayed insulin administration for another resident. That resident stated her blood sugar was supposed to be checked at breakfast, lunch, and dinner, but a former LPN did not check her breakfast or lunch blood sugar or give insulin as ordered. The former LPN acknowledged he was several hours late with the lunch blood sugar check and insulin coverage and said he did not contact the DON or physician when he fell behind. In addition, a resident reported an interaction with staff in which an LPN told him to leave the unit and threatened to call the police, while another nurse observed the resident was calm and not behaving aggressively. The RN/ADON stated she did not investigate that incident further after being notified. Additional interviews described prolonged incontinence care delays, intimidation of staff who reported concerns, allegations of inappropriate sexual conduct, theft of a resident’s bank card and jacket, and drug-related allegations involving staff and residents. The RN/ADON also acknowledged that wound care oversight, wound assessments, treatment completion, infection control, supply ordering, and day-to-day operational oversight were difficult to keep up with and that a surgical wound had not been fully assessed or treated as ordered.
Failure to Supervise and Respond Appropriately to Elopement
Penalty
Summary
The facility failed to administer operations in a manner that enabled effective and efficient use of its resources because the NHA and DON did not effectively manage the facility to implement sufficient monitoring and supervision to prevent an elopement. The NHA job description stated that the NHA is responsible for establishing and maintaining systems that are effective and efficient to safely meet resident needs and comply with federal, state, and local requirements, including overseeing staff, medical care, medical supplies, and facilities. The DON job description stated that the DON is responsible for providing nursing management, setting resident care standards for all direct care providers, and providing complete supervision and management for the nursing department, including developing and implementing policies and supervising all aspects of nursing services. Based on the facility records and job descriptions reviewed, the facility failed to properly supervise a resident and failed to respond appropriately to an elopement, and the report states that the NHA and DON failed to fulfill their essential job duties to ensure that Federal and State guidelines and regulations were followed.
Administrator Living in Facility and Alleged Alcohol Use Not Addressed
Penalty
Summary
The facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently because it did not ensure the Administrator followed the internal drug and alcohol policy, did not ensure the Administrator had his own residence and did not reside in the facility, and did not ensure Area Admin followed up on reported concerns that the Administrator was drunk, drinking alcohol at the facility, and smoking in areas that were not designated for smoking. On observation, a man identified as the Administrator was seen outside the facility smoking while wearing a blue hairnet and using a walker. Later, a room in the facility appeared occupied even though no resident name was on the door; the room contained a suitcase, clothing on the floor, clothing in a fallen laundry basket, and men’s clothing in the closet. During interview, the DON stated she had been told the previous day that the Administrator had been seen drunk and that corporate was at the facility to investigate. She also stated the Administrator was residing in the room and had been living at the facility since about a week before her arrival. Multiple staff members reported concerns about the Administrator’s conduct. The SW stated she heard a rumor that he had been drunk at the facility, saw a box of alcoholic beverages in his office, and observed him smoking in non-designated areas. The DTA C stated she smelled alcohol on his breath on one occasion and had seen him parked at a local liquor store. The ADON stated she saw a person believed to be the Administrator sitting outside by the dumpster in a red car and later walking into the building appearing impaired, with pinkish color and walking sideways. The Administrator stated he lived at the facility five nights a week because the facility needed him. The Area Admin stated he had been told the Administrator might have been intoxicated at night or on weekends, but he did not investigate and believed the Administrator was exempt from facility policies during non-working hours because he lived at the facility. The facility policy required a drug-free workplace and stated that when a supervisor is notified or suspects a violation, the supervisor must observe the behavior and immediately complete the reasonable suspicion testing checklist.
Failure to Plan for Facility Closure and Resident Discharge
Penalty
Summary
The facility failed to use its resources effectively and efficiently to prevent an eviction and facility closure for 1 of 1 facility reviewed for administration. The facility received a 30-day eviction notice on 05/08/2026, but did not submit a closure plan for the 30 residents who were living in the facility at that time. The eviction notice stated the tenant owed approximately $430,000, including back rent, property taxes, and advanced operating expenses, and the landlord intended to terminate the lease on 07/01/2026. During interviews, the Administrator stated he was on the path of closure and that the previous DON and prior Administrator had resigned. He said he had spoken with nearby facilities about possible discharges if closure occurred, but he did not have a specific plan in place. He stated that providing food and medical supplies, including medication, was a top priority, and that he had an agreement with an agency staffing company to provide staffing. He also stated he was out of money, could not pay for a DON or RN supervisor, and was using an RN to provide supervision every other day for several hours. The Administrator stated he had not notified residents or their responsible parties about the eviction, although word had gotten out. He also stated he was delinquent in payment for supplies and pharmaceuticals and had been cut off by one agency staffing company due to non-payment, while working with another agency to keep direct care staff in place. Residents interviewed described distress related to the move, including one resident who was crying and upset after living in the facility for 19 years, another who said the move was stressful because she did not know where she would be going, and another who was crying and upset about having to move.
Failure to Maintain Infection Control Program
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections from resident to resident. The report states that the facility failed to have working laundry equipment to ensure clean and sanitized linens and laundry, and this was identified as creating an Immediate Jeopardy for 67 of 67 residents. Review of the facility job descriptions showed that the NHA was responsible for leading, directing, and managing overall operations in accordance with applicable standards and for organizing, developing, and directing resources to maintain the highest degree of quality care. The DON was responsible for organizing, developing, managing, and directing nursing services and for working with the Administrator and Medical Director to ensure the highest degree of quality care, while following health, sanitary, and infection control policies. During interview, the NHA and DON confirmed the facility's failure to maintain the infection control program related to the laundry equipment issue.
Failure to Supervise Resident Resulted in Elopement
Penalty
Summary
The Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility by not ensuring proper supervision for Resident R1, who eloped from the facility on 5/10/26. The report states that the resident exited to an unsupervised and unauthorized location without staff's knowledge, and this event was identified by surveyors as creating an immediate jeopardy situation for all residents identified as an elopement risk. The job description for the NHA stated responsibility for leading, directing, and managing overall operations in accordance with applicable policies, procedures, and regulations, while the DON was responsible for organizing, developing, managing, and directing the Nursing Service Department and working with the Administrator and Medical Director to ensure the highest degree of quality care. Based on the findings, the facility failed to ensure proper supervision for the resident, and the NHA and DON were notified on 5/20/26 that they had failed to effectively manage the facility to prevent the elopement.
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