The facility experienced frequent turnover in the administrator and DON positions and lacked effective administrative systems to ensure adequate staffing and oversight of resident care. Residents and families reported chronic understaffing, long call light response times, missed showers, and lack of assistance with turning and repositioning, while staff confirmed that halls were often staffed with only one CNA and that mechanical lifts were sometimes done by a single staff member. Due to this lack of consistent oversight, multiple residents experienced serious care failures, including delayed response to acute changes in condition, unmanaged constipation progressing to stercoral colitis, inadequate management of CHF, wounds, UTIs, and glaucoma, insufficient ADL assistance, missed or incomplete pressure ulcer treatments, unrecognized significant weight loss, and deficiencies in infection prevention and control practices.
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.
The deficiency centers on the administrator’s failure to lead and operate the facility in a way that supports residents’ highest practicable well-being, as required by her job description and the facility’s resident rights policy. Staff, residents, and resident representatives consistently reported that the administrator was unapproachable, rude, and condescending, frequently yelling at staff in public areas such as the nurse’s station in front of residents, visitors, and other staff, and threatening staff jobs and paychecks when they attempted to advocate or raise concerns. Multiple residents stated that the administrator rarely interacted with them, showed favoritism toward certain residents, dismissed or cut off their concerns, and did not follow up, leaving them feeling that she did not have their best interests at heart. Several staff and residents described a tense, toxic atmosphere and a pervasive fear of retaliation that made both staff and residents afraid to report issues or advocate for care, with one resident becoming tearful and expressing fear of being discharged after speaking with surveyors. Complaints about the administrator had been made to corporate HR and the compliance line, but staff perceived little or no follow-up, while the administrator also served as the facility’s compliance officer, further contributing to concerns about reporting and accountability.
Surveyors found that facility staff failed to remain awake during scheduled working hours, with multiple instances of employees sleeping on night shift in common areas and hallways. Personnel records documented disciplinary actions and terminations for a dietary aide and a CNA who were observed asleep by HR and a midnight RN supervisor. Several residents and a confidential individual reported that staff sleep during night shift. The facility’s Employee Handbook identifies sleeping on the premises during working hours as a critical offense warranting immediate discharge.
The facility failed to provide proper wound care and physician oversight for two residents, resulting in hospitalization and severe outcomes, and did not conduct required background checks for multiple staff members. Investigations into abuse, neglect, and misappropriation were incomplete, and the facility did not maintain a safe environment, with ongoing issues of illicit drug use among residents and no effective policy to address it. These deficiencies demonstrated significant breakdowns in administrative oversight and had the potential to affect all residents.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account