Unverified Individual Assigned to Provide Direct Resident Care Without Screening or Orientation
Summary
The deficiency involves the facility’s failure to administer an effective screening and onboarding system for non-employee staff, which allowed an unknown individual (S12) to be assigned to provide direct resident care without verification of employment, credentials, or required training. On the morning of 03/12/2026, S12 entered the locked building after inquiring about job openings and was allowed entry by a CNA (S14). She was directed to the nurses’ station to speak with LPNs identified as S10 and S13. After briefly leaving to change her footwear at the request of S10, she re-entered the building and was allowed back in by staff member S9R. Upon her return, S12 told S10, S11, and S13 that she was agency staff reporting for an open shift. Without verifying her identity, employment with the staffing agency, or CNA credentials, S11 provided S12 with a temporary ID badge and assigned her to a group of residents (R1 through R10) on the daily assignment sheet, where her name was handwritten. These residents had significant medical conditions, including hemiplegia and hemiparesis following cerebral infarction or other cerebrovascular disease, chronic obstructive pulmonary disease with acute exacerbation, gastrostomy malfunction, unspecified atrial fibrillation, non-traumatic subarachnoid hemorrhage, hypertensive urgency, acute infarction of the spinal cord, and encephalopathy. S12 reported that she rounded on residents, answered call lights, and obtained snacks from the kitchen for some residents. She specifically described answering a call light for one resident on barrier precautions, donning gown and gloves, entering the room, rolling the resident to remove a brief, and becoming soiled with feces before calling other CNAs for assistance and then leaving the room. Interviews with administrative nursing staff confirmed that there was no process in place at the time to verify the identity of non-employees upon entry, to confirm agency assignment and credentials, or to provide facility orientation, abuse/neglect training, or competency evaluation before assigning resident care. S13, identified as part of the administrative staff, acknowledged that when S12 presented herself as agency staff, neither she nor S10 verified S12’s agency status or credentials before S11 placed S12 on the assignment sheet for residents R1–R10. S11 confirmed she did not verify that S12 was agency staff and still issued a temporary ID and resident assignment. S10 and the DON (S2) both confirmed that the facility frequently used agency staff but had no existing process to pre-screen non-employees, verify credentials, or ensure completion of orientation and abuse/neglect training prior to allowing them to provide direct care. The administrator (S1) further confirmed that there was no process to verify the identity of non-employees upon entry and that S12 was not employed by the facility or its staffing agency, yet was allowed to provide care to residents for approximately two hours before the issue was discovered. The surveyors determined that this failure to verify and approve agency personnel prior to assignment of resident care created an Immediate Jeopardy situation beginning at 8:00 a.m. on 03/12/2026, when S12 first presented herself as agency staff and was subsequently assigned to provide direct care to residents R1 through R10. The facility’s ineffective administrative system for screening and onboarding agency personnel resulted in residents being placed at a likelihood of serious harm, injury, impairment, or death, as stated in the report. The visitor log for that day did not list S12, further evidencing the lack of a functioning entry and verification process for non-employees.
Removal Plan
- Removed the individual (S12) from the facility and ensured only verified nursing staff were permitted to provide resident care.
- Conducted an immediate search of the facility to locate S12 and confirmed she was no longer present in the building.
- Verified with the staffing agency that S12 was not employed by the agency and confirmed through the facility staffing system that she was not an active employee.
- Ensured S12 was not permitted to provide resident care and confirmed she was no longer present in the building.
- Contacted the Police Department to document the incident and obtain identifying information related to S12.
- Implemented monitoring of the front entrance to ensure all individuals entering are identified, verified, and logged in before entering.
- Interviewed residents assigned to the unit where S12 was listed on the assignment sheet to determine whether she provided care or performed CNA duties.
- Interviewed all residents with a BIMS score of 8 or greater regarding concerns related to care provided by unknown staff.
- Completed head-to-toe assessments for residents with a BIMS score less than 8 to evaluate for signs of injury, neglect, abuse, or improper care.
- Implemented a trained facility staff member as a front desk monitor to verify all individuals entering the facility.
- Required all staff and visitors entering the building to sign in and out at the front desk.
- Continuously monitored the front desk to ensure the entry process is followed and unknown individuals are not allowed entry.
- Changed keypad door codes throughout the facility, deleted previously stored codes, and input new codes to prevent unauthorized access.
- Educated all staff in all departments on verification of agency staff to be completed by the scheduler and/or Payroll Benefits Coordinator and maintained on file prior to placement on the daily schedule; on weekends/holidays verification to be performed by the DON.
- Verified abuse training requirements for agency staff by obtaining documentation from the agency and providing facility abuse training at the beginning of the agency staff member’s first scheduled shift.
- Educated staff on the responsibility to report unknown individuals attempting to provide resident care immediately to the DON or Administrator after ensuring resident safety.
- Educated staff on facility entry procedures and sign-in requirements.
- Educated staff on abuse prevention and resident safety.
- Completed education for staff not present during initial sessions prior to their next scheduled shift.
- Provided education/training for leadership/administrative staff by the Chief Nursing Officer with the Regional Director of Clinical.
- Implemented regional/corporate onsite monitoring of administrative staff compliance with agency staff verification and abuse training, and compliance with sign-in/out and continuous front desk monitoring.
- Restricted resident care assignments to only nursing staff whose employment status, credentials, and agency authorization have been verified by facility leadership prior to assignment.
- Administrator and DON to review the entry sign-in log daily and ongoing to ensure all staff entering are verified.
- Administrator, DON, ADON, and SDC to conduct random audits of staffing assignments and ongoing to confirm only verified employees/agency staff provide resident care.
- Required verification of agency staff credentials and agency confirmation to be completed prior to assigning any agency staff to provide resident care by the Scheduler/Payroll Benefits Coordinator.
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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