Administrative Instability and Inadequate Oversight Leading to Widespread Care Failures
Summary
The deficiency involves the facility’s failure to be administered in a manner that enabled effective and efficient use of resources to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Surveyors identified frequent turnover in key leadership positions, including five administrators since June 2023 and seven DONs since June 2025, with no additional information provided by current leadership to demonstrate effective administrative systems. The facility assessment documented that 27.9% of residents were clinically complex and that the facility provided a wide range of required services, but the staffing assessment was not specific regarding the number of staff needed to meet residents’ total care needs. Resident council minutes over multiple months documented ongoing concerns about delayed call light response, lack of CNA availability for showers, and CNAs using phones instead of assisting residents. Residents and families reported repeated concerns related to inadequate staffing and delayed care. Multiple residents stated that there were not enough staff, especially at night and on weekends, and that call lights could take from 30 minutes to several hours to be answered. One resident reported waiting five hours for a call light to be answered, and another resident’s family member reported finding the resident lying on a mattress with minimal bedding and no staff coming in to turn, reposition, or get the resident up. In a special resident council meeting, residents described having to help other residents who were sliding out of chairs because staff were not present, and one resident kept a personal calendar of showers because the shower schedule was not being followed. Staff interviews corroborated these concerns, with LPN supervisors and CNAs reporting that there were often only one or very few CNAs on certain halls or shifts, making it difficult to complete showers, incontinence care, turning and repositioning, and timely call light response. Staff also reported that mechanical lift transfers were sometimes performed by one person despite the requirement for two staff. As a result of the lack of consistent and necessary administrative oversight and frequent leadership changes, multiple care and treatment failures were identified across several regulatory areas. One resident with lethargy and a critically elevated blood glucose had delayed reassessment and continued limited intake, later becoming unresponsive and requiring hospital admission with diagnoses including severe sepsis with septic shock, acute encephalopathy, acute kidney injury, hyperglycemia, urinary tract infection, and hypernatremia, and subsequently returned with hospice and later died. Another resident, cognitively impaired and requiring substantial assistance with toileting and assessed as incontinent, had no documented bowel movement for several days, was later hospitalized, and was found on CT scan to have a moderately stool-distended rectal vault with developing stercoral colitis, requiring disimpaction and an 11-day hospital stay; this same resident also had deficiencies in implementation of urinary catheter orders and individualized catheter care planning. Additional findings included failures to ensure treatments for conditions such as CHF, vascular wounds, UTIs, and glaucoma; failures to provide necessary ADL care for residents unable to perform self-care, including assistance with eating, nail care, and bathing/showering; failures to provide ordered pressure ulcer care; failures in accurate and timely weight monitoring leading to an undetected significant weight loss; and failures in the infection prevention and control program for multiple residents. The administrator job description indicated responsibilities for supporting recruitment and retention to lower turnover and developing a strong management team, but the survey findings showed that these administrative functions were not effectively carried out.
Penalty
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The facility failed to effectively administer operations when leadership did not thoroughly investigate or act on repeated concerns about the DON’s performance and possible alcohol use while on duty. Staff and a behavioral health provider reported the DON’s poor attendance, lack of communication, failure to address clinical issues such as falls and showers, and multiple instances of the DON smelling of alcohol and appearing impaired. CNAs and an LPN described fear of retaliation, difficulty reaching the DON for resident care issues, and unsafe staffing conditions when the DON left or arrived late. Although a performance improvement plan identified substantiated concerns including failure to meet RN coverage, unprofessional conduct, and allegations of working under the influence, there was no evidence that the Administrator or corporate HR monitored the DON’s behavior, audited staffing or documentation, or conducted a documented investigation into these allegations.
Facility leadership failed to provide effective oversight of operations, including abuse and misappropriation investigations, staff conduct, and license verification. The DON dismissed concerns from the Ombudsman and staff about alleged narcotic misappropriation by an LPN and acknowledged uncertainty about how to conduct thorough incident and SRI investigations. An LPN with a suspended license for narcotic diversion worked multiple full-time night shifts before the lapse in license verification was recognized, despite an existing policy requiring regular checks. A resident and staff reported feeling unable or afraid to bring concerns to the Administrator due to his intimidating behavior and raised voice. In a separate alleged abuse incident between two residents, the Administrator omitted key details from CNAs’ handwritten witness statements when creating typed versions for the SRI file and initially failed to maintain those original statements in the investigation record, later justifying his practice by criticizing staff handwriting and claiming to add depth to their accounts.
A resident with severe cognitive impairment, dementia, depression, and significant functional dependence reported that a male CNA attempted a sexual act during care, identifying him by name and description. An LPN, a social worker designee, and the HR director promptly learned of the allegation, interviewed the resident, confirmed the CNA’s description, and notified the Administrator by phone while the resident’s statements were audible on speaker. The Administrator instructed the CNA to leave but did not timely report the allegation of sexual abuse to the state as required, later entered it as physical abuse in the reporting system, and told police that facility leadership first learned of the allegation from the resident’s son days later, contrary to multiple staff accounts. This constituted a failure of effective facility administration in handling an abuse allegation.
An LPN worked while appearing to be under the influence of an illegal substance, with residents reporting late or missed medications, improper administration of pain medication after it was dropped on the floor, and the LPN falling asleep while standing and on a resident’s bed. Staff repeatedly reported the LPN’s erratic behavior to an on-call LPN, but the concerns were not promptly escalated to the DON or Administrator, and the impaired LPN completed one full shift and part of another while continuing to provide care. Residents reported not receiving medications, tube feedings, treatments, and other ordered interventions during this time. The facility’s subsequent internal review confirmed that the LPN tested positive for cocaine and that the investigation was incomplete, as not all residents were assessed or interviewed, and key oversight processes, including timely notification of the Medical Director and QAPI review, were not carried out as required by facility policies and resident care agreements.
Facility administration failed to ensure effective oversight of staff orientation and reporting of abuse and neglect concerns. A CNA was observed kicking a resident’s bed and striking the resident with a closed fist, and that CNA’s orientation record lacked completion and signatures for key safety and care topics, including falls management, safe transfers, use of mechanical lifts, alarms, and behavior management. A resident’s allegation of neglect reported to nursing staff was not communicated to administration and no investigation was initiated. Staff did not report that other staff were taking pictures of a resident during care, and bruising on another resident’s arm was not adequately reported, assessed, or monitored. The Administrator and DON acknowledged these reporting and assessment failures, and the Medical Director stated he had not been informed of these concerns.
The facility failed to maintain CNA staffing levels in accordance with its own facility assessment and staffing policy, which called for a CNA-to-resident ratio of 1:15–18. On multiple overnight shifts, only two CNAs were assigned despite censuses ranging from the high 60s to low 70s, resulting in each CNA being responsible for approximately 34–36 residents. The Administrator confirmed the census counts, overnight staffing assignments, and resulting CNA-to-resident ratios, and this deficiency affected all residents in the facility.
Failure to Investigate DON Misconduct and Alleged Impairment
Penalty
Summary
The deficiency involves the facility’s failure to effectively and efficiently administer operations so that residents could attain or maintain their highest level of well-being, specifically related to the performance and conduct of the Director of Nursing (DON) and the Administrator’s failure to investigate and implement protective measures. The DON’s personnel file showed she was hired and later terminated without any reference checks, a written job description, or termination documents explaining the reason for her discharge. A three‑month performance appraisal listed several goals for the DON, including proper scheduling, use of support systems, staying current with state survey regulations, and working on staffing and retention, but there was no indication of how these goals would be monitored after the evaluation period. Multiple written statements and interviews documented ongoing concerns about the DON’s attendance, communication, and possible impairment while on duty. A typed statement from the Social Service Designee (SSD) described months of poor communication, lack of support, and lack of attendance by the DON, resulting in the SSD having to manage residents’ medical questions and concerns. The SSD reported that there had been no fall reports for months, that the DON arrived late one day with a strong odor of alcohol, and that the DON ignored issues related to orders, advance directives, and family concerns. The SSD also reported that residents complained about not receiving showers, that she personally provided showers to reduce residents’ stress, and that residents stated they did not know who the DON was. There was no documentation of an investigation into these specific concerns, including the reported alcohol odor on the DON or the missed fall reports. Additional statements from a contracted behavioral health provider and the Assistant Director of Nursing (ADON) further detailed concerns about the DON’s reliability and conduct. The behavioral health provider reported a consistent lack of attendance and communication from the DON, noted smelling alcohol on the DON’s breath on multiple occasions, and stated that staff had been instructed by the DON not to speak with the provider about residents. The ADON reported that the DON frequently did not show up, especially when the Administrator was on vacation, took frequent smoke breaks, failed to follow up on concerns, left the building when staffing was inadequate, and was difficult to reach when staff had resident care issues. Staff interviews with CNAs and an LPN corroborated repeated observations of the DON smelling of alcohol, slurred speech, late arrivals, and erratic attendance, as well as staff fear of retaliation if they reported concerns. A performance improvement/reset plan was eventually developed that listed numerous substantiated concerns about the DON, including failure to meet RN coverage requirements, unreliable presence in the building, removal from on‑call duties without approval, unprofessional conduct toward staff, creating unsafe staffing conditions, allegations of reporting to work smelling of alcohol, dishonesty, retaliation against employees who raised concerns, undermining the chain of command, and a breakdown in communication with leadership and staff. However, there was no evidence that the Administrator or corporate human resources implemented or documented any monitoring of the DON’s performance or behavior after these issues were identified. The Administrator acknowledged that no audits of time punches, schedules, staffing, documentation, or interviews with staff and residents were conducted regarding the DON’s attendance, conduct, or possible impairment. The corporate human resources director confirmed receiving reports that the DON smelled strongly of alcohol and gave verbal instructions about testing, but there was no documented investigation or protective measures. Overall, the record showed that despite multiple reports and statements about the DON’s conduct and possible impairment, the Administrator did not complete a thorough investigation or implement timely and necessary protective actions to safeguard residents.
Leadership Failures in Abuse Investigation, Medication Misappropriation Response, and License Oversight
Penalty
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.
Failure to Report and Accurately Disclose Alleged Staff-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility Administrator’s failure to effectively administer the facility by not properly reporting and characterizing an allegation of staff-to-resident sexual abuse and by providing false information to police. The resident involved had multiple medical conditions including stroke, dementia with severe cognitive impairment, depression, and functional dependence requiring extensive assistance of two staff for bed mobility, transfers, and ambulation. Her care plan noted alterations in mood and behaviors, including occasional delusional thinking and yelling out. On the morning in question, the resident reported that a male staff member tried to put his “thing” in her mouth, gesturing toward her own and the nurse’s private areas, and identified the alleged perpetrator by name and description, which matched a CNA on duty. Staff interviews showed that the allegation was promptly brought to facility leadership on the same morning it occurred. An LPN, after hearing the resident’s statements, reported the concern to the social worker designee because administration was not yet on site. The social worker designee and the Human Resources Director jointly interviewed the resident, who remained upset and repeated the allegation, and they confirmed that the CNA she identified matched the description she gave. The Human Resources Director called the Administrator on speaker phone during this interview so he could hear the resident’s statements and the reported events. The Administrator then spoke with the CNA by phone, in the presence of the social worker designee and Human Resources Director, and directed the CNA to leave the facility pending investigation. Despite being made aware of the allegation on the day it occurred, the Administrator did not report the allegation of sexual abuse to the state agency as required by the facility’s abuse policy, which mandates reporting all allegations or suspicions of abuse prior to investigation. Review of the state reporting system showed no self-reported incident for sexual abuse on the date of the allegation, and when an incident was later entered, it was reported as physical abuse rather than sexual abuse. Additionally, in a subsequent police report for a sex offense, the Administrator told law enforcement that the facility was not made aware of the allegation until the resident’s son reported concerns two days after the incident, which conflicted with consistent staff statements that the Administrator had been immediately informed on the day of the alleged abuse. These actions and omissions constituted a failure of effective facility administration.
Plan Of Correction
The facility will continue to report allegations of abuse timely. Resident #171 continues to reside at the facility. Initial self-reported incident for resident #171 allegation was filed on 3/12/26 by the Administrator. Facility CNP assessed resident #171 on 3/12/26 with no noted injuries or negative effects. Psych nurse practitioner assessed residents #171 on 3/19/26 with no changes noted to psychosocial wellbeing. Resident #171 denied any complaints and appeared calm and relaxed stating to the NP that she feels safe. A thorough investigation was completed and submitted on 3/19/26. State reported incident conclusion was that abuse did not occur, there was no evidence to substantiate abuse. CNA #340, was suspended on 3/12/26 pending investigation. Police department called on 3/12/26. Final summary of State reported incident was reported to police department by the Regional Clinician on 3/19/26. HRD conducted new background check on CNA #340 on 3/26/26, no negative findings noted. The regional Clinician conducted an Audit of last 3 months of incidents and progress notes ensuring allegations of abuse were reported timely, factually documented and thoroughly investigated. Initial audit was completed on 4/6/26. No negative findings noted. On 4/6/26, the Administrator, Nurse Management team, SSD and HRD were reeducated on the facility policies and procedures for reporting allegations timely, conducting a thorough and factual investigation and ensuring perpetrators are removed from the facility for resident's safety to prevent further abuse. Reeducation was conducted by the regional clinician. On 4/6/26, Administrator was reeducated on providing accurate information when reporting allegations of abuse including date of alleged occurrence. On 4/6/26, Administrator was reeducated on obtaining all information from all eye witness and staff with knowledge of allegation to ensure thorough and accurate investigation. A QA committee meeting was held on 4/8/26 reviewing survey results and findings, investigation and medical record documentation requirements, policy and procedures for abuse prevention and reporting abuse, SS policy and procedure, and facilities change in condition policy and procedure. Weekly for 2 weeks, or as directed by the QA committee, audits will be conducted by the regional clinician ensuring abuse allegations are investigated thoroughly, factually documented and reported, and ensuring identified perpetrators are removed from the facility as indicated. Audits will include but not limited to progress notes, incident reports and clinical alerts. Negative findings will be corrected immediately by reporting allegation and conducting thorough investigation and providing reeducation. Negative findings will be reported to the QA committee for review. The Regional Administrator will ensure the completion of the weekly audits. The Administrator is responsible for the ongoing compliance.
Failure to Address Impaired Nurse and Missed Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that care and services were provided in accordance with professional standards of practice, comprehensive resident assessments, and physician orders when an LPN worked while appearing to be under the influence of an illegal substance and continued to provide resident care. Multiple residents and staff reported that on 02/22/26 the LPN appeared disheveled, very tired, was falling asleep while standing, dozing off mid-conversation, and acting "weird" or erratic. Residents reported that medications were administered late, that some medications were not received at all, and that at least one resident’s pain medication was administered after being dropped on the floor. One resident reported that the LPN entered her room and fell asleep on her bed. Another resident reported not receiving any medications that day. Staff interviews showed that concerns about the LPN’s behavior were repeatedly reported to the on-call manager, another LPN, but were not escalated to the DON or Administrator on the day of the incident. The on-call LPN stated she contacted the DON and was instructed to call and speak with the LPN in question, who reported being tired from lack of sleep; no further direction was reported. The DON later stated she was not made aware of the extent of the erratic behavior on that date, and the LPN completed the full shift on 02/22/26 and returned to work the following day, working part of another shift before residents’ complaints prompted further action. Residents and staff reported that during this period, residents did not receive medications, tube feedings, treatments, and other interventions as ordered. The facility’s own self-reported incident documentation confirmed that residents had reported the LPN was dropping pills and appeared to be under the influence of an unknown substance, and that the on-call LPN did not report the incident to the Administrator at the time. The LPN later tested positive for cocaine. The investigation documentation showed that not all residents were assessed for possible negative effects related to the incident, and statements were not obtained from all affected residents. Facility staff, including an RN and the DON, verified that the investigation was not completed thoroughly, that there was no evidence of a QAPI meeting related to the incident, and that the Medical Director was not notified until several days after the event. These actions and inactions occurred despite facility policies and resident agreements requiring protection of resident rights, provision of adequate and appropriate medical and nursing care, prohibition of illegal drug use, and immediate, thorough investigation and reporting of suspected abuse or neglect.
Failure of Administration to Ensure Effective Staff Orientation, Reporting, and Response to Abuse/Neglect Concerns
Penalty
Summary
The deficiency involves ineffective facility administration that failed to ensure appropriate staff orientation, reporting, and follow-up of resident abuse and neglect concerns. A CNA was observed kicking a resident’s bed and hitting the resident with a closed fist. Review of this CNA’s Nursing Orientation Checklist showed the second page, which should have covered multiple care and safety topics such as resident property procedures, falls management, gait belt and safe transfers, use of mechanical lifts, call system basics, alarms, shift-to-shift walking rounds, morning care, management of difficult behaviors, avoiding bruising and skin tears, dementia bathing, restraints, and mood and behavior patterns, was incomplete and lacked signatures or dates from the employee or the orienting staff. Human Resources confirmed these orientation deficiencies. In addition, one resident reported an allegation of neglect to nursing staff, but this was not reported to administrative staff and no investigation was initiated; the Administrator confirmed he had not been informed of this allegation. Staff also failed to report that other staff were taking pictures of another resident during care, and failed to report and adequately assess and monitor bruising on a different resident’s right arm, as confirmed by the Administrator and DON. The Administrator and DON stated they had taken over a failing building and were in the process of replacing staff, and the Administrator confirmed he had assumed responsibility months earlier. The Medical Director reported he was not aware of the identified concerns and would need to work with administration to correct issues for effective administration.
Failure to Maintain CNA Staffing Levels per Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to administer operations in a manner that ensured adequate staffing in accordance with its own facility assessment and staffing policy. The facility assessment dated 11/15/25 specified that CNAs would be staffed at a ratio of one CNA to every 15 to 18 residents. The facility’s written staffing policy dated 11/05/25 stated that there shall be a sufficient number of trained staff members on duty to ensure each resident’s physical, social, and emotional health, care, and safety needs are met in accordance with their individualized care plans, and that staffing levels would be based on day-to-day resident needs, activity, and intensity of staff assistance. Surveyor review of census and overnight staffing records showed that on three consecutive nights the facility did not meet its stated CNA staffing ratios. With a census of 69 residents, only two CNAs were on duty, resulting in each CNA being responsible for 34.5 residents. On the following night, with a census of 70 residents, two CNAs were again assigned, resulting in each CNA being responsible for 35 residents. On the third night, with a census of 71 residents, two CNAs were assigned, resulting in each CNA being responsible for 35.5 residents. The Administrator confirmed the overnight census numbers, the number of CNAs assigned on those nights, and the calculated CNA-to-resident ratios. This failure affected all residents in the facility, with a reported census of 71 residents at the time of the survey.
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