Systemic Administrative and Clinical Failures Leading to Missed Care, Worsening Wounds, and Medication Errors
Summary
The deficiency involves a failure of facility administration and nursing leadership to provide adequate oversight of wound care, medication administration, treatment administration, quality assurance, and basic activities of daily living. The Administrator-in-Training did not hold a temporary license and had been functioning in the role since July 2025 under a regional VP of Operations who was not present in the building daily. The DON role was filled on an interim basis, and staff reported that management kept office doors closed, was not consistently present in the building, and did not effectively address staffing or care problems. The facility did not have a full-time Activity Director, and activities were not provided daily, with no activity calendar posted and no planned activities after 4:00 PM or on weekends. Multiple residents experienced missed or delayed wound care, skin assessments, and gastrostomy tube (g-tube) care. One resident was admitted without pressure ulcers and later developed a stage 3 coccyx ulcer for which treatment was delayed 24 hours and then missed 16 times, ultimately progressing to a stage IV sacral ulcer with concern for osteomyelitis and hospitalization for severe sepsis. Another resident with a pre-existing stage IV sacral ulcer was hospitalized for sepsis related to the wound and osteomyelitis, returned to the facility, and then had multiple missed wound treatments. This same resident’s rectal tube was accidentally removed and not replaced due to lack of supplies, leaving the sacral wound exposed to fecal matter for extended periods, and g-tube site care and residual checks were repeatedly not completed, with subsequent hospitalization for sepsis with suspected sources including g-tube site infection and the stage IV sacral wound. Medication administration was not reliably carried out as ordered. One resident missed 18 scheduled doses of significant medications, including anticoagulants, anticonvulsants, antihypertensives, nutritional supplements, and stimulants, with documentation indicating medications were on order or not available. Another resident did not receive any scheduled doses of ordered Norco over several days, and additional residents missed multiple doses of anticonvulsants, antihypertensives, and anticoagulant injections. The facility nurse practitioner reported awareness of problems with medication availability. Documentation and oversight of showers and basic hygiene were also deficient, as several residents had no evidence of receiving showers over a two-month period, and the interim DON confirmed that no one was overseeing whether showers were completed and documented. Staff interviews and observations further demonstrated systemic failures in supervision and quality assurance. CNAs and nurses reported chronic short staffing, heavy reliance on agency staff, delayed call light response, missed pain medications, and wound treatments not being done daily. Staff stated that management told them not to disclose issues to surveyors and that concerns about staffing and care were not addressed. The wound nurse/infection preventionist reported not being educated on the wound process, not having wound logs when starting in December 2025, and not being delegated responsibility for monitoring MARs and TARs until early February 2026. The medical director stated that continuity of care was affected by staff and management changes and that he had not been informed of widespread missing treatments, medications, and care concerns. The facility lacked documentation of annual QAPI training for staff, required CNA in-service hours, and quarterly QAA meetings, with leadership confirming that QAA meetings had not been held since July 2025.
Removal Plan
- V2 (Interim DON) and V4 (ADON/Wound Nurse) in-serviced all licensed nurses on Physician Orders—Entering and Processing and Documentation in the Health Record, including the Physician Orders—Entering and Processing policy; orders are entered into the EMR by V2 and V4.
- V2 and V4 in-serviced all licensed nurses on Pressure Injury and Skin Condition Assessment and Documentation—Electronic Health Record policy (entries must be timely, accurate, relevant, and complete by V2 or V1).
- V2 and V4 in-serviced all staff on Change of Condition and Physician-Family Notification, including the Physician-Family Notification—Change in Condition policy.
- V2 and V4 in-serviced all staff on Comprehensive Care Plan/Baseline Care Plan, including the Baseline Care Plan.
- V2 and V4 in-serviced all staff on admission of residents, including the Admission of Resident Care Plan.
- V2 and V4 in-serviced all staff on the Resident/Admission–Readmission Checklist, including the admission checklist.
- V2 and V4 in-serviced the IDT on Comprehensive Care Plan, including the Comprehensive Care Plan.
- V2 and V4 in-serviced all staff on Infection Prevention and Control Program, including the Infection Prevention and Control Program policy.
- Initiated a facility audit to identify all residents with pressure ulcers, including completing wound assessments, contacting the physician and wound nurse, reassessing wounds in 24 hours, and obtaining consents to see the wound physician; 56 residents were assessed.
- V2 and V4 in-serviced staff on Pressure Injury and Skin Condition Assessment and implemented a process requiring the direct care nurse to review the TAR prior to providing wound care.
- V2 and V4 in-serviced staff on Pressure Ulcer Prevention and multiple related policies (Med Error/Adverse Drug Reaction, Physician Orders—Entering and Processing, Documentation—Health Record, Comprehensive Care Plan/Baseline Care Plan) and implemented a process to train staff on pressure ulcer prevention/worsening prevention interventions (review care plan before care; follow skin policy; weekly skin assessments; follow physician orders; identify residents dependent for repositioning; dietary/clinical follow meal ticket/orders for diet/supplements; review MAR/TAR prior to med pass and wound care; skin assessments on return from hospital; open risk management for skin breakdown and notify wound nurse/DON).
- V2 and V4 in-serviced all staff on Pressure Injury and Skin Condition Assessment and Skin Condition Assessment and Monitoring Pressure and Non-Pressure, including the Pressure Injury and Skin Condition Assessment policy.
- V2 and V4 in-serviced all nurses and CNAs on Pressure Ulcer Prevention, including the Pressure Ulcer Prevention policy.
- Began a facility-wide audit of all residents’ wound care plans and updated wound care plans.
- Completed a facility-wide review/audit of residents with wounds for needed changes and updated the physician; produced a wound report.
- Educated all licensed nurses on the complete Gastrostomy Tube—Feeding and Care policy (by V2, V3, and V4).
- Completed a facility-wide audit of all residents with gastrostomy tubes to ensure stoma site treatment orders, tube feeding orders in EHR, residual checks on MAR, monitoring/notification for GI symptoms, documentation of stoma abnormalities and physician notification, and care plan review/updates on TAR by the nurse (V2/designee).
- V3, V4, and V46 in-serviced all licensed staff and CNAs on the facility’s Pain Management Policy.
- V3, V4, and V46 in-serviced all licensed staff and CNAs on the facility’s Pain Assessment Policy.
- V3 and V4 in-serviced all licensed nurses on Medication Administration General Guidelines.
- V3 and V46 in-serviced all licensed nurses and CNAs on the Resident Rounds Policy and procedure.
- V3 and V46 in-serviced all clinical staff on the Bathing—Shower and Tub Policy.
- V3 and V4 in-serviced all staff on the Incontinence Care Policy and Procedures.
- V1 (AIT) in-serviced V25 (Housekeeping Supervisor) on the Activities Program Policy.
- V1 (AIT) in-serviced all staff on the Residents Rights and Dignity Policy.
- V14 (Corporate President of Operations) in-serviced facility leadership on the facility Quality Assurance Performance Improvement (QAPI) Program Procedure.
- V14 in-serviced facility leadership on the Program of Angel Round to ensure leadership availability to residents, families, and staff.
- V14 in-serviced facility leadership on ensuring oversight and implementing policies for wound care, medication administration, treatment administration, quality assurance measures, and basic ADL resident care, including review of job descriptions.
- V14 re-oriented V1 (AIT) on Administrator duties for the facility.
- Held an impromptu meeting with the medical director and interdisciplinary team to discuss the deficiency and facility action plan.
- Performed an audit on one resident per day to ensure residents with pressure injuries have wound prevention orders in EMR and that wound assessments are completed upon admission/re-admission or weekly per policy.
- Performed an audit on one resident per day to ensure treatments were performed and initialed/dated per policy.
- Performed an audit on one resident per day to ensure care plans are revised timely and interventions are linked to the Kardex; treatments are charted and signed off in PCC.
- Performed an audit on one resident per day to ensure wound physician progress notes are reviewed and the Physician Order Sheet is updated (treatments, labs, supplements, pressure-relieving devices) prior to the next scheduled wound care.
- Performed an audit on one resident per day to ensure weekly skin assessments are completed by the responsible nurse.
- Performed an audit on one resident per day (five days per week) to ensure nurses review the TAR prior to performing wound care procedures.
- Performed an audit on one resident per week to ensure the Dietary Department provides the correct diet/supplements.
- Performed an audit on one resident per day to ensure Infection Prevention Guidelines are followed when performing wound care.
- Performed an audit on one new admission per day to ensure all required equipment and supplies are obtained and in the facility.
- Completed the missed administration report and medication administration report daily to ensure MAR accuracy and completeness per policy/procedure.
- Completed a daily audit to ensure residents with gastrostomy tubes have stoma site treatment orders, TAR sign-off for completion, tube feeding orders in EHR, residual checks on MAR, physician notification/documentation for GI symptoms, and documentation/notification for stoma abnormalities.
- Planned to monitor all residents’ MARs daily to ensure residents are not going without medication (including visibility of medications documented as on hold).
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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