Lack of Governing Body, Incomplete Facility Assessment, and Nonpayment of Vendors Disrupting Food and Supply Deliveries
Summary
The deficiency involves the facility’s failure to establish and demonstrate an active governing body that is legally responsible for setting and implementing policies for managing and operating the facility, including appointing a properly licensed administrator and ensuring an effective compliance and ethics program. Surveyors found no evidence of a governing board; the Regional Director of Operations (RDO) stated that there was no governing board, no names to provide, and that the owner was the 100% owner with no operating policy, and that “Mainstay” was described as the governing body without further clarification. The facility’s Compliance and Ethics Program policy was undated and unsigned, and although it stated the facility was committed to compliance and had designed, implemented, and enforced a compliance and ethics program with sufficient resources and authority, there was no evidence that this program was actually implemented. The RDO reported that policies came from a “compliance store” and confirmed there were no bylaws or operating policy, and continuity of business was described as being based on disaster preparedness. Surveyors also identified failures in facility assessment and financial/operational management. The facility assessment was incomplete, unsigned, and contained several blank or incomplete sections with many areas lacking supporting documentation, despite being reviewed with the QAA Committee. A Profit & Loss Budget Overview for a recent month showed a negative net income. Review of a U.S. Foods Customer Account Application showed that payment terms required timely payment of all charges, and the report notes that vendors were not getting paid, resulting in disruption in delivery of food and supplies to residents. Attempts to contact the owner and the accounts payable clerk by telephone and electronic communication were unsuccessful. The RDO indicated that the owner’s sister-in-law handled accounts payable and described reliance on corporate credit cards and a regional maintenance person with access to funds for emergency needs, but no formal governing structure, bylaws, or operating policies were provided to surveyors.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility Governing Body failed to ensure complete, consolidated, and accurate accounting of resident personal funds and balance transfers after an ownership change. A Business Office Manager said resident fund accounts were still being transitioned into a new RFIM account, records from corporate were difficult to obtain, and one resident's account remained outstanding for months. A cognitively intact resident reported receiving late, incorrect statements that did not let him verify credits and debits, while another resident's transfer timing was unclear; attempts to reach Corporate and Regional BOMs were unsuccessful.
The facility failed to have a licensed administrator and could not produce a governing body policy. Record review showed the prior administrator left and the current administrator was not hired until more than a year later, leaving the facility without an administrator for over 365 days. The DON identified 25 residents in the facility, and the administrator was unable to locate the governing body policy during the survey.
Governing body failed to appoint a licensed LNHA responsible for facility management. The DON confirmed she was acting as Administrator without an Administrator’s license, while records showed the LNHA vacancy was discussed at multiple Board of Trustees and QA meetings and only one qualified applicant was identified. Facility policy required the governing body to appoint the Administrator, and Guam law requires nursing home operation under a licensed nursing home administrator.
DSD Not Approved and Reference Checks Incomplete The facility allowed an LVN to function as DSD and provide CNA orientation and in-service training without Department approval, even though the approved NATPN listed a different DSD. The LVN stated she had not received approval and had not applied for it, while the ADM said the facility had two full-time DSDs and the LVN worked the p.m. shift. The facility also lacked a policy for former employment reference checks and hired staff without properly verifying prior employment. Personnel files showed references from friends, spouses, and co-workers instead of former employers, and the DON stated these sources could not confirm job performance, length of employment, resident abuse history, or rehire eligibility.
The facility failed to develop and implement policies and procedures for residents independently signing themselves out and leaving without supervision. The CQA Director stated nurses ask the resident’s expected return time, check the elopement book, and may send medication, but she was unaware of a specific policy for assessing whether a resident could sign out independently or with supervision. She also stated the decision would rely on resident rights, the MDS, the elopement assessment, and BIMS, and that a refusal to sign out could be treated as AMA if the BIMS score was high enough.
Lack of Governing Body Oversight: The facility failed to have a governing body in place to oversee the Administrator and facility operations. Records showed key program agreements signed by the Administrator as Owner/Administrator, and the Administrator provided a written statement identifying self as the sole governing body. The DON and an RN stated the Administrator handled all banking and monies.
Incomplete Resident Fund Accounting After Ownership Change
Penalty
Summary
The facility's Governing Body failed to timely ensure a complete, consolidated, and accurate accounting of residents' personal funds, transactions, and balance transfers after a change in ownership. During observation, interview, and record review, the Business Office Manager stated the facility was still transitioning resident funds into a new Resident Fund Management Service account and was having difficulty obtaining records from corporate to consolidate all resident funds. She said resident #1's account was still outstanding since March 2025 and that she was unaware how residents received accounting statements from the previous accounts, providing only the facility's current RFIM statements. Resident #2, a cognitively intact male, reported he had not received complete financial statements of transactions and personal funds from the facility during the prior year and had complained multiple times to the Business Office Manager. He stated the late statements he received were incorrect, did not allow him to verify credits and debits, and made him think money was missing after the ownership change. Photocopies of his 2025 statements were provided, but the documents did not show when or how they were received by the resident. The Business Office Manager further stated the consolidation of RFIM accounts was not done immediately after ownership transfer and was completed a few at a time since March 2025, and she was unaware of the exact time resident #3's account was transferred. Attempts to reach Corporate and Regional Business Office Managers were unsuccessful, and the facility's Governing Body standards and guidelines stated it was responsible for facility management, including cash management and resident interests.
Missing Licensed Administrator and Governing Body Policy
Penalty
Summary
The facility failed to have a licensed administrator and also could not produce a governing body policy for the facility. Record review showed an Oklahoma Employment Security Commission Employee Response Statement with the previous administrator’s last date of employment listed as 04/17/25, while the facility staff list showed the current administrator was hired on 05/08/26, leaving the facility without an administrator for over 365 days. The DON identified 25 residents resided in the facility. On 06/10/26 at 3:30 p.m., the administrator was unable to locate a governing body policy for the facility.
Governing Body Failed to Appoint a Licensed Nursing Home Administrator
Penalty
Summary
The facility failed to ensure its governing body appointed a Licensed Nursing Home Administrator (LNHA) who was licensed and responsible for the management of the facility, reporting and being accountable to the governing body. During the entrance conference on 06/01/26, the DON confirmed she was serving as the Acting Administrator and did not have an Administrator’s license. Review of records provided on 06/02/26 showed that a LNHA job posting was completed in January 2025 and resulted in one qualified applicant. The file also showed the Board of Trustees Human Resources Subcommittee discussed the LNHA opening at multiple meetings, including 01/13/25, 02/10/26, 03/17/26, 04/28/26, and 05/13/26. During an interview on 06/06/26, the QPSRCA confirmed the LNHA position opening was also included on the facility’s Quality Assurance agenda. Review of the facility’s Governing Body policy stated the governing body is responsible for establishing and implementing policies for the management and operation of the Skilled Nursing Unit and appointing the Administrator. Review of the Guam Code Annotated, Chapter 15, stated no nursing home shall operate except under the supervision of a nursing home administrator, and no person shall be a nursing home administrator unless licensed under that chapter.
DSD Not Department-Approved and Employment Reference Checks Not Properly Completed
Penalty
Summary
The facility failed to ensure that the designated Director of Staff Development (DSD) was approved by the Department to serve in that role. The approved Nurse Assistant Training Program Notice identified a DSD other than LVN 1, and the facility was required to notify the Department within 30 calendar days after employing a new DSD. Records showed LVN 1 began working at the facility as an LVN, was later changed to DSD on the payroll action form, and was listed on the facility’s Department Heads listing as the DSD. During interviews, the Administrator stated the facility had two full-time DSDs, with LVN 1 working the p.m. shift, while LVN 1 stated she had been functioning as a full-time DSD and had been highly involved in CNA in-services and training. LVN 1 stated she had not received Department approval to serve as DSD and had not submitted an application for such approval. The facility also failed to develop and implement policy and procedures requiring former employment reference checks before hire. The Administrator stated the facility did not have a policy addressing employment reference checks during the new employee hiring process. Review of LVN 1’s personnel file showed the Reference Check Control Form was blank for employment references, even though LVN 1 had already been hired. The DON stated the references documented were only a friend and former co-workers, and that these sources would not be able to provide relevant information such as length of employment, job performance, history of resident abuse, or eligibility for rehire. Additional personnel files showed the same pattern. LVN 4’s reference check form listed the applicant’s wife and two co-workers as references, but did not identify their job titles or positions. The DON stated the facility should verify work experience and any history of resident abuse through appropriate employment references and document the name and title of the person contacted. The DSD’s own personnel file also showed references from friends and a co-worker rather than former employers. The Administrator stated that friends or co-workers could provide information about whether a potential employee had a history of resident abuse, and that a criminal background check with no adverse findings was sufficient after reviewing the facility’s abuse, neglect, and exploitation policy.
Lack of Policy for Residents Signing Themselves Out
Penalty
Summary
The facility failed to ensure policies and procedures were developed and implemented regarding residents independently signing themselves out of the facility and leaving without supervision. During an interview, the Corporate Compliance Officer/Quality Assurance Director stated that when residents sign themselves out, a nurse asks their expected return time, checks the elopement book to confirm the resident is not a risk, and may administer or send medication if needed. She also stated that if the resident did not return, the nurse would follow up by calling to determine the return time. When asked about a policy for assessing whether residents could sign themselves out independently or with supervision, she was unaware of a specific policy and stated that resident rights included the ability to sign out if capable. She further explained that residents who could sign out independently would be presumed capable of managing ADLs and would be determined by the MDS and Elopement Assessment. She stated that if a resident refused to sign out, it would be considered AMA if the BIMS score was sufficiently high, and that the facility would consult the MD and refer the case to DHR if a resident left and the facility considered it an inappropriate placement.
Lack of Governing Body Oversight
Penalty
Summary
The facility failed to have a governing body in place to oversee the Administrator and the operations of the facility, affecting all residents residing within. Record review showed documents related to participation in Arkansas Medicaid, the Arkansas Nursing Home Program, and a Health Insurance Benefit Agreement, all signed by the Administrator as Owner/Administrator. During an interview, the Administrator provided a written statement identifying the Administrator as the sole governing body of the facility. In interviews, the DON stated the Administrator handled all banking and everything, and RN #2 stated the Administrator handled all monies and was the owner and Administrator.
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