Leadership Failures in Abuse Investigation, Medication Misappropriation Response, and License Oversight
Summary
The deficiency involves a failure of the Administrator and Director of Nursing (DON) to provide effective leadership and oversight of facility operations, including abuse/misappropriation investigations, staff conduct, and license verification, resulting in ineffective use of facility resources to ensure residents attained or maintained their highest practicable well-being. The Administrator’s job description required maintaining working knowledge of and compliance with governmental regulations, promoting effective communication and prompt problem resolution, addressing family satisfaction issues, and ensuring respect for resident rights and dignity. The DON’s job description required overall management of resident care 24/7, conducting periodic reviews for compliance with state code, meeting with licensed staff to address nursing and facility issues, and ensuring plans were in place to correct employee concerns. Despite these defined responsibilities, multiple incidents showed that concerns about resident safety, abuse, and medication misappropriation were not appropriately addressed. In one set of incidents, the state Ombudsman reported that the DON was informed of resident concerns about alleged staff misappropriation of resident medications involving two residents and a specific LPN. The Ombudsman stated that when informed of the suspected LPN, the DON responded dismissively, saying the concern was "so out in left field." The Ombudsman also reported that when the same concerns were brought to the Administrator, he stated that unless the police were called, he would not do anything about it, said it did not matter, and expressed that he did not know what to say about it. A confidential staff interview corroborated that the DON was informed of concerns about misappropriation of residents’ narcotics and did not act on them, and that staff felt concerns brought to the DON were ignored or brushed aside. The DON later acknowledged being unsure how to complete a thorough investigation and reported there was no written policy on how to investigate incidents or self-reported incidents (SRIs), even though she was directly involved in narcotic misappropriation investigations. Additional leadership failures were identified regarding professional license verification and the Administrator’s and DON’s interactions with residents and staff. The DON reported that an LPN had worked at the facility for about one month after her license was suspended for narcotic diversion, and confirmed that this LPN worked 13 shifts on night shift with a suspended license. The DON believed that checking nurses’ licenses was the responsibility of the Human Resource Supervisor, and the Administrator and Human Resource Supervisor later acknowledged that, although there was a policy requiring license checks on hire, quarterly, and annually, this was not being done until after the LPN was terminated. A resident reported feeling unable to bring concerns to the Administrator because he was intimidating and would not take concerns seriously, and a staff member reported feeling frightened to report incidents to the Administrator because he raised his voice when concerns were brought to him. The facility’s handling of an alleged abuse incident between two residents further demonstrated deficiencies in leadership and investigative practices. An SRI was filed for an unwitnessed allegation of physical abuse between two residents, in which one resident reported to three CNAs that another resident placed his hands near his neck. The facility’s SRI file contained only typed staff interviews signed by the Administrator, with no written witness statements from the CNAs. The Regional Director of Clinical Operations later found the handwritten witness statements in a box in the Administrator’s office. Comparison of the handwritten statements with the Administrator’s typed versions showed that the Administrator had omitted several details, including that the alleged victim reported the other resident yelled an expletive, threatened him, approached him with a tray table, and that he was scared. The Administrator stated that staff handwriting was difficult to understand and that he preferred to type his own versions to add depth. During a meeting with corporate and regional staff and the surveyor, after the discrepancies were discussed, the Administrator was observed walking down the hall loudly stating "you can't fix stupid" within earshot of staff offices. These actions and omissions collectively demonstrated a failure of the Administrator and DON to administer the facility in a manner that ensured effective investigations, respect for resident concerns, and compliance with regulatory and professional standards.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to maintain effective wandering and elopement safeguards for cognitively impaired residents. One resident with Alzheimer’s disease and severe cognitive impairment exited through an unsecured maglock door and was found by police hours later, while another resident’s wander alert bracelet failed to alarm when tested. Staff, including the DON, ADM, and DOR, reported there was no policy or documented process for testing the current wander alert system or monitoring bracelet function, and the facility had no system for checking the maglock doors before the incident.
A facility failed to report an alleged sexual abuse incident to DOH and law enforcement within the required timeframe after a resident told an LPN they had been raped by a CNA. The resident, who had intact cognition and significant neurologic and urinary diagnoses, later described intimate care that involved pain and burning, and said they felt embarrassed and ashamed when a male NS and male officers were present. The facility also allowed the male NS to complete an assessment without another staff member present and did not provide SW involvement or psychosocial interventions despite the resident being emotionally distraught and not sleeping well.
The NHA and DON failed to manage the facility effectively to ensure allegations of abuse were reported timely and that interventions were implemented to protect residents from abuse. Review of job descriptions, facility documentation, and staff interviews showed the facility did not meet its responsibilities to protect residents from potential abuse, resulting in an Immediate Jeopardy situation.
Failure to Monitor Wandering and Elopement Safety Systems: The NHA and DON did not effectively oversee systems intended to protect a resident at risk for wandering/elopement. A resident with a history of removing an electronic monitoring device and expressing intent to leave, smoke, and return home exited through an exterior door without staff knowledge or supervision and entered an unsafe outdoor environment.
Failure to prevent resident elopement occurred when the NHA and DON did not effectively manage the facility to protect residents from exiting unsupervised, and a resident left the building without supervision. The report states this created an Immediate Jeopardy situation for one of 29 cognitively impaired residents.
Staff were observed and reported using personal cell phones in resident care areas, including a CNA sitting in a resident common area with a personal phone in hand. Residents stated aides were often on their phones while working, and one resident reported being told they were rude for interrupting a staff member who was on the phone with her boyfriend. Resident Council minutes also noted concerns that some aides were on their phones too much, despite the handbook prohibiting cell phone use in the work area.
Unsafe wandering and elopement safeguards were not effectively managed
Penalty
Summary
The facility was cited for not being administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of residents because it failed to ensure a safe environment for cognitively impaired residents who wander or are at risk for elopement. The report identified two separate events involving wandering safety systems and noted that the deficiency affected seven residents identified as at risk for unsafe wandering and elopement. Resident #1 had diagnoses including Alzheimer's disease, alcohol abuse, and COPD, and the Minimum Data Set dated 06/08/2026 assessed the resident as having severe cognitive impairment. On 06/04/2026, the resident was located by local police approximately 12 hours later and about three miles away. Staff interviews indicated that the resident exited through a door associated with the third-floor east stairwell area, and the Maintenance Assistant stated the maglock may have slipped and disengaged, causing the door to inactivate and the alarm not to sound. The Director of Maintenance stated the third-floor east wing stairwell door used a keypad and magnetic locking system, that the first-floor exit door near the parking lot had no alarm system, and that the facility had no system for checking the doors prior to the incident. Resident #2 had diagnoses including hypertension, diabetes mellitus, and depression. The Minimum Data Set documented the resident as independent with chair/bed-to-chair transfers and wheelchair mobility and as having no wandering behaviors. During testing on 06/29/2026, the resident's wander alert device failed to alarm. Staff interviews further revealed there was no documented policy for testing the wander alert system or resident bracelets, and the facility had no current system for monitoring bracelet functionality weekly per manufacturer recommendations. The Director of Maintenance stated they could not find a policy for the wander alert system and only obtained manufacturer guidance after contacting the manufacturer, while the Administrator stated they assumed the system monitored bracelet functionality.
Failure to Report Alleged Sexual Abuse and Address Resident Distress
Penalty
Summary
The facility failed to report an alleged sexual abuse incident involving a resident immediately or within 2 hours to the Department of Health and local law enforcement after the allegation was made. The resident was admitted with diagnoses including obstructive and reflux uropathy, hemiplegia, and hemiparesis following cerebral infarction, and had a BIMS score of 15 indicating intact cognition. A facility incident report documented that the resident told an LPN that they had been raped by a CNA, and the resident later described that the CNA was providing brief care, applying cream to the hip and then to the anus and vaginal area, and that they felt something enter the anus and vagina. The resident stated they told the CNA they were hurting them, that the CNA apologized and made a moaning sound, and that they later felt burning in the vaginal area. The facility also failed to protect the resident during the response to the allegation by allowing a male nursing supervisor to perform a nursing assessment with no other staff member present after the rape allegation. The resident and family member stated that when law enforcement arrived, male officers and the male nursing supervisor were present, and the resident said they felt embarrassed and ashamed and did not want to discuss the rape. The resident stated they only reported that the CNA was rough with them. The family member stated the resident was hysterically crying and said a staff member had raped them, and the family member contacted law enforcement and requested hospital transfer. The facility further failed to provide social work involvement or psychosocial interventions after the allegation. The resident stated they were not sleeping well after the incident and were emotionally distraught and tearful during the interview. The administrator stated the facility did not report the alleged rape to the state because the resident later changed the story to rough handling, and stated they did not think the resident required social work or psychosocial interventions. The primary care physician stated the facility should call law enforcement and the Department of Health if the resident alleged they were raped.
Failure to Ensure Timely Abuse Reporting and Protective Interventions
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) did not effectively manage the facility to ensure residents were free from abuse by ensuring staff reported allegations of abuse in a timely manner and by implementing interventions to prevent abuse. Review of the NHA job description showed the NHA is responsible for ensuring the facility operates in compliance with local, state, and federal regulations, and review of the DON job description showed the DON is responsible for leading the Nursing Department to provide quality care based on best practices and regulatory guidelines. Facility documentation and staff interviews showed the facility failed to ensure allegations of abuse were reported timely and that interventions were implemented to protect residents from potential abuse. This failure placed residents at risk for serious injury from abuse and resulted in an Immediate Jeopardy situation. Based on the deficiencies identified, the NHA and DON failed to fulfill essential duties and responsibilities of their positions, contributing to the Immediate Jeopardy situation.
Failure to Monitor Wandering and Elopement Safety Systems
Penalty
Summary
The facility failed to provide effective administrative oversight and to implement and monitor systems intended to protect residents identified as being at risk for wandering or elopement. The Nursing Home Administrator’s job description stated the administrator was responsible for managing the facility in accordance with policies, procedures, and applicable standards, while the Director of Nursing’s job description assigned responsibility for directing nursing services, collaborating with the Administrator and Medical Director, conducting daily rounds, reviewing nursing documentation, monitoring resident care, and assuming daily operations in the Administrator’s absence. Despite these responsibilities, the facility did not effectively use available resources to identify and correct system problems related to resident safety. On June 19, 2026, Resident CR1 exited the facility through an exterior door without staff knowledge or supervision and entered an unsafe outdoor environment while holding a cigarette. The resident had a documented history of removing safety devices, including the electronic monitoring device intended to activate the exit alarm system, and had repeatedly stated an intent to leave the facility, smoke, and return home. Even with these known risk factors, administrative oversight did not ensure effective systems were in place to identify when required safety interventions were absent or to prevent the resident from leaving the building unnoticed.
Failure to Prevent Resident Elopement
Penalty
Summary
The Nursing Home Administrator and Director of Nursing failed to effectively manage the facility to protect residents from elopement, resulting in Resident R1 exiting the building unsupervised. Review of the facility job descriptions showed the NHA was responsible for directing overall operations in accordance with applicable regulations to ensure the highest level of care, and the DON was responsible for managing and directing resident care within the nursing department to maintain standards of resident care and ensure each resident functioned at his or her highest level. The facility failed to prevent residents from exiting the facility unsupervised, and during an interview the NHA and DON confirmed that administration failed to effectively manage the facility to protect residents from elopement. The report states this created an Immediate Jeopardy situation for one of 29 cognitively impaired residents.
Staff Used Personal Cell Phones in Resident Care Areas
Penalty
Summary
The facility failed to ensure staff did not use personal cell phones in resident care areas. Resident interviews indicated that staff were often seen using personal phones while working, including one report that a staff member told a resident they were being rude for interrupting while the staff member was on the phone with their boyfriend. Other residents reported seeing staff walking by their rooms while on their cell phones, and one resident stated staff members working in the facility were often seen using personal cell phones. During observation on 06/24/26 at 5:25 A.M., CNA #838 was observed sitting in a darkened corner of a resident common area with a personal cell phone in hand, with the phone light illuminating the CNA's face. When approached by the surveyor, the CNA dimmed the phone and placed it in the pocket of scrub pants. The CNA stated she was unsure of the facility's policy on personal cell phones but knew they were prohibited during work hours, and confirmed she did not have a work cell phone. Resident Council meeting minutes also documented resident concerns that some aides were on their phones too much, and the employee handbook stated that cell phone use in resident areas may violate regulations and was prohibited in the work area.
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