Failure of Administrative Oversight for Physician-Ordered Consults and Diagnostic Tests
Summary
The deficiency involves the Administrator’s failure to provide effective oversight and necessary resources to ensure that physician-ordered consultations and diagnostic tests were scheduled, carried out, and documented in the electronic medical record (EMR) for multiple residents. The Administrator was the direct supervisor of the Social Services Director (SSD) and was responsible, per the job description, for directing day-to-day operations, ensuring policies and procedures were implemented, and reviewing the competence of the workforce. Despite this, the Administrator was not aware that the SSD was not consistently scheduling ordered appointments or documenting referral activities in the EMR, and allowed the SSD to maintain paper records in a personal folder and use a temporary communication board that was not part of the permanent medical record. For one resident with COPD, dysphagia, and altered mental status, a physician ordered a Modified Barium Swallow (MBS) to rule out silent aspiration. Nursing documented that the SSD was notified of the order, and the expectation was that the SSD would schedule the test and document follow-up. However, there was no documentation in the EMR that the MBS was scheduled, completed, or refused, and the SSD later stated that the resident had refused the MBS and that the responsible party had also refused, but she had not documented this in the resident’s medical record. For another resident with seizures, dystonia, traumatic brain injury, and a gastrostomy, a physician ordered a Barium Swallow consult. Nursing notes indicated that the Social Services Assistant or SSD was notified, but the SSD acknowledged that although she contacted the resident’s sister and the hospital, she did not document her attempts to schedule the MBS or her contacts with the responsible party in the EMR, nor did she follow up with the speech therapist after being unable to schedule the test. A third resident with hemiplegia, hemiparesis following cerebral infarction, dysphagia, aphasia, and a gastrostomy had physician orders for an ENT consult to assist with vocal cord mobility and an MBS to rule out silent aspiration and determine if oral diet was possible. The SSD stated that an in-house ENT consult had been scheduled but not documented in the EMR and that the MBS had not been scheduled because they were waiting for the ENT consult and insurance authorization. The SSD did not document any attempts to obtain authorization, schedule the MBS, or notify the speech therapist or primary physician of delays. The SSD described a referral process in which orders were left under her office door when she was absent and acknowledged that she did not routinely document referral attempts or follow-up in the EMR, instead keeping papers in a folder and using a communication section of the EMR that was automatically cleared and not part of the permanent record. The facility’s policy required Social Services to collaborate with nursing to arrange ordered services and to document referrals in the resident’s medical record, but this was not done. The Administrator confirmed that he was aware the SSD was documenting on paper and in a non-permanent communication board, and that he expected physician orders to be followed and referrals documented, but he had not ensured that this occurred, resulting in ordered consultations and tests for several residents not being timely scheduled or properly documented. The surveyors also observed one resident with a gastrostomy lying in bed with an enteral feeding pump at bedside not connected to the gastrostomy tube, and this resident was verbally nonresponsive. While this observation did not directly reference a missed order, it occurred in the context of broader concerns about the facility’s management of residents requiring specialized nutritional support and diagnostic evaluation for swallowing. Across the reviewed cases, there was no evidence in the EMR of timely scheduling, follow-up, or clear documentation of refusals or barriers to completing ordered tests and consultations. The SSD herself stated that if something was not documented, it was considered not done, and acknowledged that she should have documented her attempts and follow-up in the EMR so they would be part of the medical record. The Administrator’s lack of effective oversight and failure to ensure adherence to the facility’s referral and documentation policies contributed to these gaps in care coordination and recordkeeping for multiple residents. The facility’s written policy on Social Services referrals required that referrals for medical services be based on physician evaluation, that Social Services collaborate with nursing and other disciplines to arrange ordered services, and that Social Services document the referral in the resident’s medical record. The Administrator’s job description required development and maintenance of policies and procedures, routine inspections to ensure implementation, consultation with department directors to correct problem areas, and review of staff competence. Despite these requirements, the Administrator did not detect or correct the SSD’s practice of using non-medical-record systems (paper folders and a temporary communication board) for tracking referrals, did not ensure that physician orders for MBS and ENT consults were carried out, and did not ensure that all referral-related activities were documented in the EMR. This lack of administrative oversight and failure to enforce established policies led to physician-ordered consultations and tests for several residents not being timely scheduled or properly documented in the medical record.
Penalty
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The NHA and DON failed to manage the facility effectively to protect a resident known to be at risk for elopement. A resident exited the assigned nursing unit unsupervised, and the report states this created an Immediate Jeopardy situation for one of fourteen residents documented as elopement risks. The NHA and DON confirmed the administrative failure during interview.
Ineffective administration led to multiple failures in fall management, staffing, nutrition, immunization education, and abuse prevention. The facility did not follow fall interventions or complete accurate fall assessments and investigations, and two residents sustained serious injuries, including rib fractures and a thoracic burst fracture after an improper transfer. The report also cites inadequate RN coverage, insufficient staffing, missed dialysis transport, inaccurate documentation, falsified bathing records, failure to provide snacks and adaptive equipment, and abuse-related issues including verbal abuse and misappropriation of resident funds and property.
Failure to Timely Report Abuse and Neglect Allegations: The facility failed to maintain an effective system for timely reporting allegations of abuse and neglect after a prior F609 citation for the same issue. Surveyors found nine late reports involving multiple residents, and staff and the administrator acknowledged ongoing difficulty tracking when reports were due, with most late reports occurring during the monitoring period after the earlier deficiency.
A resident with dementia and wandering tendencies was not protected from elopement after staff failed to follow instructions to place a Wander Guard and move him to the Secured Memory Unit. The resident was seen in the lobby, later could not be located, and was found miles from the facility after leaving unsupervised; the front entry door also lacked an operational Wander Guard system.
Failure to Ensure Supervision and Elopement Prevention: The facility failed to consistently supervise and maintain safety interventions to prevent elopement for residents. Review of records, job descriptions, and staff interviews showed the NHA and DON did not effectively manage the facility to ensure proper supervision and elopement prevention interventions were implemented, and they failed to fulfill their essential duties to ensure federal and state guidelines and regulations were followed.
Unqualified Social Service Director Hired: The facility failed to ensure the Social Service Director met the stated qualification of a bachelor's degree and 1 year of social services experience. The Administrator stated the current SSD was still in school and had not completed her degree, while a behavioral health director with a degree only helped with social services at times and was not the SSD. The job description and facility policy did not align with current regulatory requirements, and the facility census was 182 residents.
Failure to Protect a Known Elopement Risk
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility to protect residents from elopement. Review of the facility’s job descriptions showed that the NHA was responsible for supervising department heads, ensuring compliance with regulatory guidelines, and reviewing complaints and trends, while the DON was responsible for directing nursing services, coordinating care, overseeing staffing, and investigating and reporting incidents and complaints. Despite these responsibilities, the facility failed to prevent and protect residents from exiting their assigned nursing unit unsupervised. The deficiency involved Resident R1, who was documented as an elopement risk. Survey findings showed that R1 exited the resident’s assigned nursing unit without supervision. During an interview, the NHA and current DON confirmed that facility administration failed to effectively manage the facility to protect residents from elopement. The report states that this failure created an Immediate Jeopardy situation for one of fourteen residents documented as elopement risks.
Ineffective Administration Affecting Falls, Staffing, Nutrition, Immunizations, and Abuse Prevention
Penalty
Summary
The facility failed to administer operations in a manner that used resources effectively and efficiently, with ineffective administration affecting multiple residents across several care areas. The report states that the facility did not maintain effective systems for fall prevention and accident hazard control, including failure to follow fall interventions and the smoking policy, and failure to complete accurate fall assessments, investigations, and care plans. These issues affected Residents #6, #9, #24, #56, #113, and #115, and the report notes actual harm to Resident #56, who sustained multiple right and left rib fractures, a hematoma to the right chest wall, bruising across the breasts, right flank, back, both arms, both sides of the ribs, and both legs, with no actual determination of the cause of injuries. The report also describes a serious injury to Resident #113 after a fall from bed, when staff inappropriately transferred the resident and she was thrown onto the bed. The resident sustained a thoracic burst fracture and multiple ecchymoses on both hands, wrists, forearms, and upper extremities. In addition, Residents #6, #9, #24, and #115 had falls with inadequate investigations, incomplete documentation, updated care plans, and inaccurate assessments. The facility also failed to provide effective dietary services by not ensuring substantial snacks for the secured memory care unit, honoring food preferences, and providing needed adaptive equipment, affecting Residents #29, #49, #80, #83, #86, #96, and #99. Other findings included inadequate nursing services and staffing, with no RN coverage at least eight hours daily and insufficient staffing to meet resident needs, affecting Residents #6, #12, #13, #16, #39, #40, #45, #88, #93, #99, and #110. The report states that nursing staff did not implement care-planned interventions for Resident #45, did not follow discharge instructions or provide timely incontinence care for Resident #13, did not ensure dialysis transport for Resident #106, did not accurately document advance directives for Resident #93, and did not accurately transcribe a physician order that led to a significant medication error for Resident #88; it also states that bathing documentation for Resident #88 was falsified. Additional deficiencies involved an ineffective immunization program for Residents #9, #24, #32, and #72, and failures in abuse, neglect, misappropriation, and exploitation prevention, including verbal abuse toward Resident #93, misappropriated funds from Resident #61, misappropriated personal property from Resident #117, unnecessary medications for Residents #25 and #30, and delayed abuse reporting and investigations for Residents #56, #82, #93, and #117.
Failure to Timely Report Abuse and Neglect Allegations
Penalty
Summary
The facility failed to ensure an effective system for timely reporting allegations of abuse and neglect after a previous F609 deficiency for the same concern. Based on interview and record review, the facility continued to submit late reports for allegations involving 9 of 19 residents, identified as residents 4, 5, 9, 10, 11, 12, 13, 14, and 16. The report states that the late reporting placed residents at risk for delays in notification, investigation, protection, and response following allegations of abuse or neglect. A prior F609 deficiency dated 1/29/26 showed the facility had already been cited for late reporting of allegations of neglect and abuse for three residents. During an interview on 7/29/26, staff member A stated, "I'm still learning . there's been a lot going on here ." The administrator also stated, ". I need to develop a system, so I know when they are due." The current complaint investigation found that the facility administrator and staff continued to report allegations throughout the plan of correction monitoring period, and eight of the nine late reports occurred between 2/22/26 and 5/22/26.
Failure to Protect Resident from Elopement
Penalty
Summary
The facility administration failed to manage the facility in a manner that protected residents and safeguarded them from elopement. The Administrator and DON job descriptions stated they were responsible for directing and overseeing facility operations in accordance with federal, state, and local regulations, but the facility was aware that the front entry door did not have an operational Wander Guard system and corrective measures were not implemented. The report identified this as an Immediate Jeopardy related to F689 and F835, with the noncompliance beginning on July 16, 2026. Resident 1 was admitted with a dementia diagnosis and an elopement assessment was completed on admission, with staff noting wandering tendencies and that the resident was suitable for the Secured Memory Unit. On July 16, 2026, the resident was seen in his room at 3:30 AM, then in the front lobby at 4:30 AM, and was later unable to be located at 5:45 AM. The elopement protocol was initiated at 6:10 AM, and the resident was found about one hour later three miles from the facility. The Administrator stated the resident had been instructed to be placed on a Wander Guard device and moved to the Secured Memory Unit, but those instructions were not followed. The receptionist also stated she did not recognize the resident as a resident and thought he was a visitor.
Failure to Ensure Supervision and Elopement Prevention
Penalty
Summary
The facility failed to consistently supervise and maintain safety interventions to prevent elopement for residents. Based on review of facility records and job descriptions, and staff interviews, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure proper supervision and elopement prevention interventions were implemented. The NHA job description stated that the NHA directs the overall operations of the care community in accordance with current local, state, and federal regulations to ensure the highest level of quality care is provided to each resident, and the DON job description stated that the DON manages and directs resident care within the nursing department to maintain resident standards of care and ensure each resident functions at his/her highest level. The report states that the NHA and DON failed to fulfill their essential job duties to ensure federal and state guidelines and regulations were followed.
Unqualified Social Service Director Hired
Penalty
Summary
The facility failed to administer the facility by failing to ensure a qualified individual was hired as the social service director. During interview, the Administrator stated the requirement for the social services director was a minimum of a bachelor's degree and 1 year of experience in social services, and stated that the current Social Service Director, V4, was still in school and had not completed her bachelor's degree. The Administrator also stated she did the hiring and hired V4 in collaboration with the facility consultant. The Administrator further stated that a behavioral health director helped with social services at times, but that person had a degree and was not the social service director. The facility's Social Service Director job description listed qualifications of a high school diploma or GED and knowledge of federal and state LTC social service regulations, and the facility policy did not align with current regulatory requirements for the position. The Facility Assessment Tool dated 7/13/26 identified a Social Service Director as a needed resource, and the staffing plan included one social service director, one social service designee, and one behavioral health director. The Facility Data Sheet dated 7/24/26 showed a census of 182 residents.
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