Cadia Rehabilitation Broadmeadow
Inspection history, citations, penalties and survey trends for this long-term care facility in Middletown, Delaware.
- Location
- 500 South Broad Street, Middletown, Delaware 19709
- CMS Provider Number
- 085050
- Inspections on file
- 19
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 17 (2 serious)
Citation history
Health deficiencies cited at Cadia Rehabilitation Broadmeadow during CMS and state inspections, most recent first.
The facility’s Facility Assessment did not accurately reflect its resident population by failing to identify a distinct group of residents receiving Comfort Care, instead listing only Hospice and Palliative Care services. Facility records showed that 10 residents were on Comfort Care and two residents were on Hospice, but the Comfort Care group was not captured in the assessment. The DON and Administrator reported that the facility used the terms Palliative and Comfort Care interchangeably and tracked Comfort Care residents via an order listing with a “Palliative Care-Form on File.” The Administrator acknowledged that the Facility Assessment referenced Palliative but not Comfort Care and that staff had not differentiated the unique care needs of residents on Comfort Care versus those on Palliative Care, resulting in a deficiency under F684 Quality of Care.
The facility failed to inform two cognitively intact residents about the side effects and risks versus benefits of their prescribed psychotropic medications, including buspirone, duloxetine, and risperidone. EMR review showed no documentation of consent or risk–benefit discussions, and both residents reported either not being told about potential medication effects or not recalling any such discussion and being unsure of what medications they were taking. The DON confirmed there was no documentation of staff conversations about risks and benefits, despite a facility policy requiring resident education on psychoactive medications and documentation of that education in the medical record.
A resident with severe dementia and chronic pain developed a new right heel blister and a wound to the buttocks, but staff documented calling and leaving a message for the second-listed emergency contact instead of the primary contact when the change in condition was first identified. The primary contact later reported learning of both wounds days after the heel blister was initially noted and questioned why they had not been called first. The RN/Unit Manager and DON confirmed that facility policy requires staff to notify the first emergency contact about significant changes in condition and only proceed to the second contact if the first cannot be reached, and that this process was not followed or documented correctly for this resident.
A resident with traumatic brain injury, right-sided hemiplegia, and upper extremity contractures used a motorized wheelchair with a seat belt that staff routinely applied each morning and left on throughout the day, but this device was not assessed, ordered, or care planned as a restraint. The MDS documented no restraints, and the care plan referenced only a power chair with a back cushion, omitting the seat belt despite repeated observations of its use and the resident’s report of discomfort. CNAs stated they were trained to use seat belts on electric wheelchairs and believed some residents could remove them, while nursing and rehab leadership gave conflicting accounts and confirmed there was no EMR documentation or ongoing assessment of the seat belt, contrary to the facility’s restraint policy defining and governing physical restraints.
A resident with dementia, severe cognitive impairment, and a history of multiple falls was noted by a PTA to have increased edema on the right forearm during therapy, and later the same morning an LPN documented a hematoma, pain, and notification of the NP, who assessed right arm swelling with preserved range of motion and circulation. The resident was unable to explain the cause of the injury due to cognitive impairment, making it an injury of unknown origin. The Administrator and DON stated they determined whether such incidents needed to be reported and confirmed this event was not reported to the state, despite a facility policy requiring all alleged incidents, including injuries of unknown source, to be reported to the Administrator or designee and then to appropriate regulatory agencies and/or law enforcement.
A resident with dementia, severe cognitive impairment, and a history of multiple falls was care planned for fall risk and impaired cognition. During a therapy session, a PTA observed increased edema on the resident’s right forearm, and later an LPN documented a hematoma, resident pain, and inability to recall the cause, and notified the NP, who assessed right arm swelling in the context of multiple falls and advanced dementia. Despite the facility’s policy requiring all alleged incidents, including injuries of unknown source, to be reported to the Administrator or designee and investigated, the Administrator and DON acknowledged that this incident was neither reported to the state nor investigated.
A resident with a history of traumatic brain injury, right-sided hemiplegia, contractures, and use of a motorized wheelchair was repeatedly observed wearing a wheelchair seat belt, but the EMR contained no order or care plan addressing this intervention. The comprehensive care plan documented use of a power chair with a back cushion for safety and independence but did not identify seat belt use, despite the resident’s ongoing use of it. An RN/Unit Manager confirmed the absence of an order and care plan for the seat belt, and an MDS coordinator reported they did not capture seat belts on the MDS or review rehab assessments, though they expected staff to monitor positioning and removability. The DON acknowledged that wheelchair assessments and seat belt use should be reflected in the care plan, while the facility’s policy required interdisciplinary review and revision of comprehensive care plans after each assessment, which did not occur for this resident’s seat belt use.
A resident with moderately impaired cognition and documented need for partial assistance with oral care did not receive consistent help or supplies to brush her teeth, as evidenced by her repeated reports of not being offered morning or evening mouth care and observation of debris on her teeth and gums. Other residents reported they had to request toothbrushes and toothpaste, stating that staff would not bring these items unless reminded. Staff, including CNAs, SD, and DON, acknowledged that oral care is expected as part of routine AM/PM care and personal hygiene per facility education materials, yet one CNA stated she only sometimes offered evening oral care to this resident.
A resident on end-of-life comfort care with severe dementia and chronic pain had a care plan focused on comfort measures, but nursing documentation showed minimal assessment of pain and condition changes, with behavioral pain scores recorded on the MAR without narrative explanation. An NP ordered Hyoscyamine Sulfate for secretions and morphine for pain/SOB/comfort, yet MAR review showed an updated Hyoscyamine order with no evidence of administration, and nursing notes lacked detailed assessments of distress, restlessness, or impending death. Interviews with an RN/UM, an IP/SC, an LPN, and the DON revealed that staff relied on provider orders without a dedicated comfort care policy, did not consistently initiate alert charting for significant changes, and did not document objective pain behaviors or end-of-life assessments as required by facility policy.
A resident with COPD, chronic respiratory failure, CHF, and sleep apnea had a physician order for oxygen at 4 LPM via nasal cannula, with the care plan directing that oxygen be provided as ordered. However, on multiple observations the oxygen concentrator at the bedside was set to deliver 4.5 LPM, and the resident was unable to adjust the device independently. An RN/UM and the DON confirmed that the physician’s order specified 4 LPM, and facility policy required staff to read and note the ordered flow rate, indicating that staff did not follow the prescribed oxygen settings.
A resident with multiple chronic conditions had Comfort Care instructions listed in the EMR clinical profile, specifying no further hospitalization, no IV fluids, no weights, and allowance for labs, supplements, and antibiotics, but the corresponding physician order had been discontinued and was not active. An LPN explained that Comfort Care focuses on comfort and avoiding invasive procedures and believed there should be an active Comfort Care order, yet could not find it in the EMR. An RN/unit manager confirmed that such an order should appear in the active orders list and verified that no active Comfort Care order existed, resulting in an incomplete and inaccurate medical record.
The facility failed to follow its antibiotic stewardship policy and McGeer’s criteria when prescribing and monitoring antibiotics for a resident with Parkinson’s disease who developed respiratory symptoms and abnormal O2 saturation. Nursing staff documented low O2 saturation and lung congestion, and a chest x-ray showed bilateral lower lobe infiltrates with a right pleural effusion, after which a provider ordered a 7-day course of Amoxicillin-Clavulanate that was fully administered. A subsequent infection evaluation documented normal temperature, COPD, advanced age, no new or increased cough with purulent sputum, and concluded that protocol criteria for a lower respiratory infection were not met, while the EMR showed no fever, no lab work before starting the antibiotic, and no acute mental or functional changes. Infection surveillance logs lacked complete documentation of signs/symptoms, culture organisms, and whether McGeer’s criteria were met, and the IP later acknowledged the evaluation form did not align with McGeer’s criteria, indicating inconsistent application of the facility’s stewardship program.
A resident who was completely dependent and required two-person assistance for bed mobility and transfers was left unsupervised by a single CNA during incontinence care. The CNA, unaware of the care plan requirements, attempted to turn the resident alone, resulting in the resident falling from the bed and sustaining multiple serious injuries.
A resident with a history of stroke, chronic respiratory failure, and dysphagia choked while eating and became hypoxic and unresponsive. Despite a documented full code status, staff did not assess the airway, perform abdominal thrusts, or initiate CPR, instead applying a non-rebreather mask and preparing for transfer. Emergency personnel arrived to find the resident unresponsive and not receiving CPR, and resuscitation was started by paramedics. This failure to provide basic life support resulted in the resident's death and Immediate Jeopardy.
A resident with a history of stroke, chronic respiratory failure, and swallowing difficulties experienced a choking episode that progressed to severe respiratory distress. Nursing staff did not perform a thorough assessment or initiate CPR when the resident became unresponsive and pulseless, despite being a full code. Paramedics arrived to find the resident in cardiac arrest with no CPR performed, resulting in death.
A resident with significant medical conditions experienced a choking episode during which staff did not perform essential life-saving interventions such as airway clearance or CPR. Paramedics found the resident pulseless and noted that no emergency measures had been taken by staff. The incident was not identified or reported as neglect by facility leadership, contrary to policy requirements.
A facility failed to include staff competencies and emergency intervention skills in its assessment, resulting in inadequate response when a resident experienced respiratory distress after choking. Documentation showed staff did not identify or intervene appropriately, and the facility's assessment lacked evidence of training for such emergencies.
A resident with a history of aggressive behaviors and cognitive impairment physically struck another resident, resulting in visible injury. Despite care plan interventions for supervision and redirection, the facility did not prevent the incident, leading to a failure to protect a resident from physical abuse.
Failure to Accurately Include Comfort Care Population in Facility Assessment
Penalty
Summary
The facility failed to ensure its Facility Assessment included an accurate and comprehensive review of the resident population by omitting an identified group of residents receiving Comfort Care. The Facility Assessment for 2025–2026, dated 10/08/25 through 10/29/25, did not indicate or recognize a Comfort Care population and instead only identified residents on Hospice and Palliative Care services. Facility documentation showed that 10 residents, approximately 9.3% of the facility population, were receiving Comfort Care, while only two residents, approximately 1.9% of the population, were identified as receiving Hospice services. The Comfort Care population was therefore not reflected in the current Facility Assessment. During interviews, the DON and Administrator confirmed that the facility used the terms Palliative and Comfort Care interchangeably and that residents on Comfort Care were tracked via an Order Listing Report that documented residents with a “Palliative Care-Form on File.” The Administrator stated that a Comfort Care/Palliative Care Assessment was used in the nursing home setting like a wish list advanced directive to document care preferences, and acknowledged that the Facility Assessment used the term Palliative but not Comfort Care. The Administrator also stated that she had been told Palliative and Comfort Care were the same thing. As a result, the Facility Assessment did not distinguish or address unique and distinctive characteristics and care needs between residents receiving Comfort Care and those receiving Palliative Care, contributing to the cited deficiency under F684 Quality of Care.
Failure to Inform Residents of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure that residents were informed of psychotropic medication side effects and the associated risks versus benefits, as required by facility policy. One resident with bipolar disorder, major depressive disorder (MDD), and anxiety had an intact cognition with a BIMS score of 14/15 and was receiving buspirone for anxiety, duloxetine for MDD, and risperidone for delusional disorder. Review of the electronic medical record (EMR) showed no documentation of consent or any risk-versus-benefit discussion regarding these psychotropic medications with the resident or a representative. In an interview, this resident stated she had been told what medications she was on but not about potential effects related to the medications. The DON confirmed there was no documentation specific to review of potential effects of psychotropic medications with the resident or representative, despite the policy requiring such education and documentation. Another resident, admitted and later readmitted with diagnoses including MDD and anxiety disorder, had an intact cognition with a BIMS score of 15/15 and was receiving buspirone for anxiety and duloxetine for depression. EMR review similarly revealed no documentation of consent or risk-versus-benefit review for these medications. In an interview, this resident reported not remembering any discussion with staff about medication effects and was unsure of what medications she was taking. The DON stated there was no documentation of any staff conversation with this resident regarding risks versus benefits for the medications. Review of the facility’s psychoactive medications policy, last reviewed on 01/13/26, showed that residents are to be educated on the benefits and potential risks of these drugs and that such education is to be documented in the medical record, which did not occur for these two residents.
Failure to Notify Primary Emergency Contact of Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify the correct emergency contact of a resident’s change in condition. The resident was admitted with severe unspecified dementia with behavioral disturbance and chronic pain, and had a BIMS score of 2/15, indicating severe cognitive impairment. An annual MDS indicated the resident did not have unhealed pressure ulcers at that time. Nursing progress notes documented that on 11/03/24 a charge nurse alerted the writer that the resident was noted with a blister to the right heel, and a message was left for emergency contact #2, with no documentation that emergency contact #1 was called. During a later phone interview, the first emergency contact (FM1) reported receiving a call from a nurse on 11/06/24 stating the resident had developed a wound to the buttocks and heel, and was told the right heel blister had been first noted on 11/03/24 and that the nurse had called emergency contact #2. FM1 questioned why they were not contacted first, as they were listed as the primary contact, and the nurse could not explain. The RN/Unit Manager and the DON both stated that facility practice and policy require staff to notify the first listed emergency contact of a significant change in condition, and if that person cannot be reached, to then call the second contact and document both calls. The DON confirmed that for this resident, emergency contact #2 was called and a message left, but emergency contact #1 should have been contacted instead, contrary to the facility’s policy on provider and responsible party notification of significant changes in condition.
Unassessed Wheelchair Seat Belt Used as Physical Restraint
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical restraints when a seat belt on a motorized wheelchair was not identified or managed as a restraint. The resident had diagnoses including traumatic subarachnoid hemorrhage with loss of consciousness, lack of coordination, abnormal posture, right-sided hemiplegia, history of traumatic brain injury, aphasia following cerebral infarction, and contractures of the right elbow, wrist, and hand. The quarterly MDS documented the resident as cognitively intact with bilateral upper extremity range-of-motion limitations, use of a motorized wheelchair, and no restraints. The comprehensive care plan identified an ADL self-care performance deficit related to right hemiparesis and noted use of a power chair with a back cushion for safety and independence, but it did not identify any problem, intervention, or order related to a seat belt, despite the resident being observed repeatedly with a seat belt in use. Surveyors observed the resident on multiple occasions seated in the motorized wheelchair with a seat belt on, including observations where the buckle was off to the right side of the lap and the resident had a visible right arm contracture. When asked, the resident stated they could release the seat belt and later reported that the seat belt was not comfortable, indicating discomfort by leaning forward and touching the lower left back. CNAs reported that residents with electric wheelchairs had seat belts, that they placed the seat belt on this resident when transferring them into the wheelchair in the morning, and that it remained on all day until bedtime or toileting. CNAs also stated they had been trained during orientation and by rehab staff regarding seat belt use and believed some residents could remove the belts themselves. Interviews with nursing, MDS, and rehab leadership revealed inconsistent understanding and lack of assessment or documentation regarding the seat belt. The RN/Unit Manager confirmed there was no order or care plan for the resident’s seat belt use. The MDS coordinator stated seat belts were not captured on the MDS because rehab was believed to assess them and determine residents’ ability to remove them, and acknowledged these interventions should be care planned. The Director of Rehab stated the department did not use or assess seat belts, was unaware CNAs were applying them, and later provided a prior physical therapy plan of treatment documenting that the resident was able to unbuckle the seat belt upon command but needed assistance with buckling, and that the resident was at risk for falls and injury during power chair mobility. The last occupational therapy wheelchair assessment contained no documentation or assessment of the seat belt. The facility’s restraint policy defined physical restraints as devices that the individual cannot remove easily which restrict freedom of movement or access to the body, and required EMR documentation to support assessment and use of restraints, which was not present for this resident’s ongoing seat belt use.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency for one resident. The resident was admitted with metabolic encephalopathy, dementia, and a history of transient cerebral ischemic attack, and had a BIMS score of 7/15 indicating severely impaired cognition. The resident’s care plan identified a history of falls and increased fall risk related to deconditioning, poor safety awareness, impulsivity, muscle weakness, unsafe transfer behavior, medications, and prior falls, with interventions including following post-fall protocol, assessing for injuries, monitoring vital signs, and notifying the physician. Another care plan problem addressed impaired cognitive function related to dementia, with interventions to cue, reorient, and supervise as needed. On one morning, a PTA documented that during a therapy session the resident was noted to have increased edema on the right forearm and was unable to explain what happened or quantify pain due to cognitive impairment; nursing was notified. Later that morning, an LPN documented a hematoma to the resident’s right forearm, noted signs of pain, administered pain medication per physician order, and notified the NP. The NP’s progress note described right arm swelling in a resident with multiple falls and advanced dementia, with the resident unaware of the swelling and denying pain, and with full range of motion and intact circulation in the affected arm. During interviews, the Administrator stated that for their state, insignificant or non-serious injuries of unknown source did not have to be reported, and the DON confirmed the incident was not reported to the state. This was inconsistent with the facility’s abuse/neglect/mistreatment policy, which required that all alleged incidents, including injuries of unknown source, be reported to the Administrator or designee and then to appropriate regulatory agencies and/or law enforcement.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for one resident. The resident was admitted with metabolic encephalopathy, dementia, and a history of transient cerebral ischemic attack, and had a severely impaired cognitive status with a BIMS score of 7/15. The resident’s care plan identified a history of falls and increased fall risk related to deconditioning, poor safety awareness, impulsivity, muscle weakness, unsafe transfer behavior, medications, and prior falls, with interventions including following post-fall protocol, assessing injuries, monitoring vital signs, and notifying the physician. Another care plan problem identified impaired cognitive function related to dementia, with interventions to cue, reorient, and supervise as needed. On one date, a PTA documented on a Witness Written Summary that during a therapy session the resident was noted to have increased edema on the right forearm, and the resident was unable to explain what happened or quantify pain due to cognition; nursing was notified. Later that morning, an LPN documented on a Witness Written Summary that the resident had a hematoma to the right forearm, was unable to recall what happened, showed signs of pain, and was given pain medication per physician order, and the NP was made aware. The NP’s progress note the following day described right arm swelling in the context of multiple falls and advanced dementia, with the resident unaware of the swelling and denying pain, and with full range of motion and intact circulation in the affected arm. In interviews, the Administrator and DON stated they determine whether incidents need to be reported to the state, and the DON confirmed this incident was not reported or investigated. This was inconsistent with the facility’s abuse/neglect policy, which requires all alleged incidents, including injuries of unknown source, to be reported to the Administrator or designee and investigated, with reporting to appropriate regulatory agencies and/or law enforcement.
Failure to Update Care Plan for Resident’s Regular Wheelchair Seat Belt Use
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to review and revise a comprehensive care plan to reflect a resident’s regular use of a wheelchair seat belt. The resident had multiple neurologic and functional impairments, including traumatic subarachnoid hemorrhage with loss of consciousness, lack of coordination, abnormal posture, hemiplegia on the right dominant side, history of traumatic brain injury, aphasia following cerebral infarction, and contractures of the right elbow, wrist, and hand. The quarterly MDS showed the resident was cognitively intact with a BIMS score of 13/15, had functional limitations in bilateral upper extremity range of motion, used a motorized wheelchair, and required substantial/maximal assistance for bed mobility and transfers. The comprehensive care plan, initiated on admission and revised at later dates, identified an ADL self-care performance deficit related to right hemiparesis and documented use of a power chair with a back cushion for safety, comfort, and independence, but did not include any problem or intervention related to the use of a seat belt. During multiple observations on different days, the resident was repeatedly seen seated in a motorized wheelchair with a seat belt on. Review of the EMR by the RN/Unit Manager confirmed there was no physician order for a wheelchair seat belt and no care plan addressing seat belt use. The MDS Coordinator stated they did not capture seat belts on the MDS because they believed rehabilitation assessed residents and that residents would be capable of removing the belts, and acknowledged they did not review those assessments. The MDS Coordinator further stated they would expect staff to check positioning, security, and the resident’s ability to remove the belt, and confirmed such interventions should be identified in a care plan. The DON acknowledged that wheelchairs should be assessed on admission and quarterly and that the seat belt should be part of the care plan, and also confirmed there was no specific policy for care plan revisions, only a general comprehensive care plan policy. The facility’s care planning policy required that comprehensive care plans be developed, reviewed, and revised by the interdisciplinary team after each assessment, but this was not done for the resident’s seat belt use.
Failure to Provide Required Assistance With Oral Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs), specifically oral care, to a resident who required help. One resident, identified as R73, had diagnoses including dysphagia, cognitive communication deficit, bipolar disorder, and osteoarthritis, and a BIMS score of 12/15 indicating moderately impaired cognition. The quarterly MDS documented that R73 required partial/moderate assistance with oral care. During multiple interviews, R73 reported not being offered help to brush her teeth in the mornings or evenings and stated that supplies to brush her teeth were not brought to her. On observation, R73’s teeth and gums had a buildup of white and brown debris, and she did not have a toothbrush at the bedside. Other cognitively intact residents reported that they had to ask staff to bring their toothbrush and toothpaste, and that if they did not remind staff, the supplies would not be brought. Staff interviews, including with the Staff Development nurse, DON, and CNAs, confirmed that the facility’s expectation and CNA orientation education were that oral care is part of routine AM and PM care and that staff should offer mouth care and set up or perform oral care for residents unable to do it themselves. One CNA who usually worked with R73 in the evenings stated that she sometimes offered to have R73 brush her teeth. These findings show that, despite facility expectations and training materials stating that mouth care should be given in the morning, at bedtime, and as part of personal hygiene, R73 did not consistently receive the necessary assistance and supplies for oral care.
Failure to Monitor Comfort Care and Administer Ordered Hyoscyamine at End of Life
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and document comfort care for a resident on end-of-life care and failure to follow physician orders for Hyoscyamine Sulfate. The resident had severe cognitive impairment, was on a care plan focused on comfort care, and had diagnoses including severe unspecified dementia with behavioral disturbance, anxiety disorder, and chronic pain. The care plan specified comfort care parameters such as no hospitalization, no lab work, no tube feeding, no IV fluids, and liberalized diet and supplements, with pain assessment and physician contact for uncontrolled pain. From the beginning of November through early November, nursing progress notes and the MAR showed no documented pain or SOB, and pain assessments using a behavioral pain scale consistently recorded a pain level of 0, with no narrative documentation explaining the assessments. On a later NP visit, the NP documented that the resident had decreased oral intake but no respiratory distress or signs of pain or discomfort, and ordered Hyoscyamine Sulfate sublingual for excessive secretions, lorazepam PRN for agitation/restlessness, and morphine sulfate concentrate PRN for pain/SOB/comfort. Subsequent nursing documentation on the night a PRN morphine dose was given recorded that the resident was in distress and received morphine for comfort, but there was no detailed nursing note describing what type of distress the resident was experiencing. The MAR documented a behavioral pain score of 4/10 at that time, but there was no documentation of how that score was derived using the behavioral assessment, and no corresponding nursing note explaining the assessment. Later that same day, another note documented decreased responsiveness and inability to take PO food/fluids, with the daughter requesting that PRN morphine be made routine; the NP assessed the resident and ordered scheduled sublingual morphine every four hours along with PRN dosing. The MAR for that day showed the resident continued to be assessed each shift with a pain level of 4, again without documentation of how the behavioral pain score was determined or narrative nursing notes describing the assessment. The NP later changed the Hyoscyamine Sulfate order to 0.125 mg every four hours routinely, and then, after the resident was seen again for increased secretions, the order was increased to 0.25 mg every two hours for increased secretions/end of life. The DON, upon review, noted that the order for Hyoscyamine Sulfate 0.125 mg two tablets every two hours had administrative times marked with Xs and no documentation that the medication was administered, and could not explain why it was not given. Nursing notes from the time the increased Hyoscyamine order was written through the time of the resident’s death did not reflect ongoing assessments or documentation of further signs of impending death. Interviews with nursing staff and leadership confirmed that detailed assessments, alert charting, and documentation of pain behaviors and changes in condition were not completed, that there was no specific comfort care policy, and that staff education on comfort care was limited to general advance directive training.
Failure to Follow Physician Order for Oxygen Flow Rate
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy according to the physician’s ordered flow rate for a resident with chronic respiratory conditions. The resident’s face sheet showed diagnoses including COPD, and the quarterly MDS documented that the resident was cognitively intact with a BIMS score of 13 and was receiving oxygen therapy. The resident’s care plan, dated 07/22/24, identified altered respiratory status related to chronic respiratory failure, COPD, CHF, and sleep apnea, with an intervention specifying oxygen as ordered. Physician orders in the EMR, dated 06/30/25, directed oxygen at 4 LPM via nasal cannula. Despite this order, surveyor observations on three separate dates found the resident in bed with an oxygen concentrator delivering 4.5 LPM via nasal cannula. The concentrator was located approximately two feet from the left side of the bed, and the resident was not able to get out of bed to adjust the concentrator independently, as confirmed by the RN/Unit Manager. During an interview, the RN/Unit Manager verified that the oxygen was set at 4.5 LPM and that the physician’s order specified 4 LPM. The DON also confirmed that the order for the resident’s oxygen was 4 LPM. The facility’s policy on Nasal Oxygen Administration required staff to read and note the physician’s written order for nasal oxygen with the stated flow rate in liters per minute, which was not followed in this case.
Incomplete Physician Orders for Comfort Care Program
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident when the electronic medical record (EMR) did not contain an active physician order for the resident’s Comfort Care Program. The resident was admitted with multiple diagnoses, including heart failure, peripheral vascular disease, cerebral infarction with right-sided weakness, history of falls, and chronic obstructive pulmonary disease. The resident’s Clinical Profile in the EMR listed special instructions for “COMFORT CARE: NO further hospitalization, NO IV fluids, NO discontinuation of medication, NO weights, YES lab work, YES supplements, YES antibiotics.” However, review of the Order Summary in the EMR showed that the Comfort Care order had been discontinued on two separate dates and was not present as an active order at the time of review. During interviews, an LPN described Comfort Care as focused on keeping the resident comfortable and pain free, avoiding invasive or aggressive procedures while still treating conditions such as UTIs. The LPN stated that the unit manager would inform staff when a resident was placed on Comfort Care and that there was supposed to be an active Comfort Care order for this resident, but she was unable to locate it in the EMR. The RN/unit manager confirmed that there should be an active physician order for Comfort Care listed among the resident’s active orders and, upon review of the EMR, verified that no such active order was present. This discrepancy between the Clinical Profile instructions and the absence of an active physician order constituted the identified deficiency.
Failure to Follow Antibiotic Stewardship and McGeer’s Criteria for Pneumonia
Penalty
Summary
The deficiency involves the facility’s failure to implement an antibiotic stewardship program consistent with its policy and McGeer’s criteria when prescribing an antibiotic for one resident reviewed for antibiotic stewardship. The resident, admitted with Parkinson’s disease, was documented by nursing staff as not feeling well, with O2 saturation of 89–90% on room air improving to 96% on 2L oxygen, and a congested right upper lobe. A stat chest x-ray was ordered, which showed bilateral lower lobe infiltrates and a right pleural effusion. Based on these findings, a provider ordered Amoxicillin-Clavulanate 875-125 mg twice daily for seven days for bilateral lobe infiltrates, and the MAR showed the resident completed the full antibiotic course. The facility’s Potential Infection Evaluation dated two days after antibiotic initiation documented a normal temperature, O2 saturation of 89%, presence of COPD, age over 65, and no new or increased cough with purulent sputum, concluding that nursing home protocol criteria for a lower respiratory infection were not met and that the resident did not need an immediate antibiotic prescription but might need additional observation. The EMR showed no lab work prior to starting the antibiotic, no documented fever, and no change in function or mental status. The provider’s progress note confirmed the resident was started on Augmentin for pneumonia based on the chest x-ray. Review of the Infection Control Surveillance Log for the year revealed missing documentation of residents’ signs and symptoms, organisms from culture results when obtained, and whether McGeer’s criteria were met. The Infection Preventionist acknowledged that the Potential Infection Evaluation form used did not align with McGeer’s criteria, and the DON stated her expectation that residents’ symptoms meet McGeer’s criteria for antibiotic use, demonstrating that the facility did not consistently apply its Antibiotic Stewardship policy and McGeer’s criteria in this case.
Failure to Provide Required Supervision and Assistance During Incontinence Care
Penalty
Summary
A deficiency occurred when a completely dependent resident, with diagnoses including dementia, muscle weakness, contractures, and hemiplegia, was not provided adequate supervision and assistance during incontinence care. The resident's care plan specified the need for two staff members to assist with rolling side to side and for transfers using a Hoyer lift, due to her inability to move or assist herself. However, the care plan did not clearly document the required number of staff for all activities of daily living, and there was no care plan addressing safety or bed mobility related to the use of a low air loss mattress. On the day of the incident, a CNA who was new to the facility provided incontinence care to the resident alone. The CNA was not shown where to find the resident's transfer and bed mobility information and had observed other aides providing care alone, leading her to believe that single-person assistance was sufficient. While turning the resident onto her side, the resident rolled out of bed and fell face down onto the floor, resulting in multiple rib fractures, a clavicle fracture, and a splenic laceration. The resident was completely dependent and unable to assist in her own care or maintain her position in bed. Interviews with facility staff confirmed that the resident required two-person assistance for rolling and transfers, and that this requirement was not communicated or implemented during the incident. The facility's failure to ensure that the resident's care plan for two-person assistance was followed during incontinence care directly led to the resident's fall and subsequent injuries.
Failure to Initiate CPR for Choking Resident with Full Code Status
Penalty
Summary
A deficiency occurred when staff failed to initiate CPR for a resident who was choking, became hypoxic, and unresponsive, despite the resident's documented full code status. The RN supervisor did not assess the resident's airway or respiratory status after the choking incident and only delegated the application of a non-rebreather mask and preparation for transfer, without initiating CPR or further emergency intervention. The resident was admitted with a history of stroke, chronic respiratory failure with hypoxia, and dysphagia, and was cognitively intact at admission. The resident's resuscitation form indicated full code status, requiring CPR in the event of cardiac or respiratory arrest. On the day of the incident, the resident choked while eating, was unable to speak, and exhibited signs of respiratory distress with low oxygen saturation and a high heart rate. Staff did not perform a thorough assessment, such as listening to lung sounds or performing abdominal thrusts, and did not initiate CPR when the resident became unresponsive. Emergency medical personnel arrived to find the resident unresponsive and not receiving CPR, and subsequently initiated resuscitation efforts. The failure to provide basic life support and initiate CPR as required resulted in the resident's death, and an Immediate Jeopardy was declared.
Failure to Recognize and Respond to Choking and Respiratory Distress
Penalty
Summary
Licensed nursing staff failed to demonstrate the necessary competencies to recognize and respond to an emergent situation involving a resident with a history of stroke, right-sided paralysis, chronic respiratory failure with hypoxia, and trouble swallowing. The resident, who was a full code, experienced a choking episode that progressed to respiratory distress, with oxygen saturation dropping to 64% and a heart rate of 149-150 beats per minute. Despite these critical changes, staff did not perform a thorough assessment, such as listening to lung sounds, and did not initiate CPR when the resident became pulseless and unresponsive. The non-rebreather mask used was not inflating, and the resident's oxygen saturation only improved slightly after being switched back to an oxygen tank at a higher flow rate. Video surveillance and interviews confirmed that the resident was brought back to her room in a wheelchair with her head down and chin to chest, appearing very pale and not breathing when paramedics arrived. Paramedics found the resident in cardiac arrest with no CPR having been performed by staff. The facility's policy required continuous monitoring and appropriate interventions for significant changes in condition, but these were not followed, resulting in the resident's death. The failure to provide competent nursing care and initiate life-saving interventions led to the declaration of Immediate Jeopardy.
Failure to Identify and Report Neglect After Choking Incident
Penalty
Summary
A resident with a history of stroke resulting in right-sided paralysis, chronic respiratory failure with hypoxia, and dysphagia experienced a choking episode. During this incident, staff failed to provide essential life-saving interventions, such as airway clearance, assessment of lung air movement, and initiation of CPR. Paramedic records indicated that upon arrival, the resident was pulseless and exhibiting agonal respirations, and no life-saving measures had been performed by facility staff prior to their arrival. An LPN present at the scene reported that after being alerted by the resident's spouse, he checked vital signs and increased supplemental oxygen but did not assess lung sounds or initiate further emergency interventions. The facility did not identify or report the incident as an allegation of neglect, as required by their own policies and state regulations. The DON stated during an interview that the incident was not reported to the State because he was unaware of any allegations of inappropriate care. The failure to recognize and report the lack of essential assessment and intervention following the choking event constituted a deficiency in the facility's abuse and neglect reporting procedures.
Failure to Assess and Train Staff for Emergency Response
Penalty
Summary
The facility failed to ensure its facility-wide assessment included nursing staff competencies and the necessary skill sets to provide the required level and types of care for its resident population. Specifically, when a resident experienced respiratory distress after choking on food, staff did not identify or appropriately intervene despite being informed of the situation. Documentation showed that the resident had decreased oxygen levels and became unresponsive, yet the facility's assessment lacked evidence of staff training and interventions for medical emergencies such as choking with respiratory distress. The incident was reviewed with facility leadership during the exit conference. A review of the facility's assessment document for 2024-2025 revealed no evidence of staff training or protocols for handling medical emergencies, including choking incidents with respiratory distress, which contributed to the deficiency.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency was identified when a resident with moderately intact cognition, who used a manual wheelchair, reported being physically struck in the face by another resident. The incident occurred after dinner, and the charge nurse observed redness on the affected resident's left eyelid. The resident who committed the act had a history of dementia, depression, anxiety disorder, and was care planned for impaired cognition and potential physically aggressive behaviors, including hitting and striking out. Interventions for this resident included redirection, allowing time to calm down, and speaking in a calm voice. Despite these interventions being documented in the care plan, the facility failed to prevent the occurrence of resident-to-resident physical abuse. The incident was reported to the State Agency, and the facility's policy stated a commitment to protect residents and prevent abuse. However, the measures in place were not sufficient to ensure the safety of the resident who was struck, resulting in a failure to protect the resident from physical abuse.
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Multiple cognitively impaired residents with known behavioral issues, including wandering, agitation, and physical aggression, were not adequately protected from resident‑to‑resident abuse. In one case, a resident with dementia and PTSD was pushed to the floor by another resident who had a history of combative behavior, resulting in multiple fractures and facial lacerations after staff initially documented the event as an unwitnessed fall. In another case, two residents with dementia and psychotic features engaged in a physical altercation in a dayroom after one placed his hand on the other’s chest, leading to mutual punching. A separate incident occurred when a resident with dementia and behavioral disturbances entered another resident’s room, pulled at the bedcovers, yelled that the room was his house, and allegedly struck the other resident, who was later noted with puffiness around one eye. In all incidents, the involved residents had documented behavioral care plans and significant cognitive impairment, yet physical confrontations still occurred.
A resident with dementia, spinal stenosis, and total dependence for transfers, care-planned for Hoyer lift use with two-person assist, was being transferred from a shower bed to a Geri-chair when the Hoyer lift tipped sideways. Staff reported the lift’s legs had been widened and that one CNA manually pushed the feet apart instead of using the control, and straps may have been unevenly positioned. The resident was lowered to the floor while still in the sling and sustained a small skin tear to the elbow; imaging later showed no fractures. The DON stated that three CNAs were involved, including one on light duty who was not supposed to be using the lift, and that no mechanical defect was found with the lift.
The facility failed to thoroughly investigate several allegations of verbal and potential physical abuse involving four cognitively intact residents with conditions including hemiplegia, rheumatoid arthritis, type 2 DM, epilepsy, and heart disease. In each case, the facility’s investigations were limited, often including only the directly involved resident and omitting interviews with other potentially knowledgeable residents or staff. One resident reported a verbal altercation with a CNA after a fall to the floor, another reported being verbally abused by a roommate’s family member, a third reported a male CNA was too rough and upset while changing linens, and a fourth reported a staff member insulted her and refused brief care. Investigation files lacked broader resident and staff interviews, timely physical and psychosocial assessments, and review of the accused staff member’s employee record, contrary to the facility’s abuse policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
A resident with rectal cancer and intact cognition reported that an RN on night shift confronted him when he returned from smoking off campus, spoke to him loudly about his smoking, used profanity, and threatened to have staff refuse to buzz him back into the building. A CNA corroborated that the RN was upset about being called in to work and used curse words toward the resident, but did not report the incident at the time because the RN was the night supervisor. The resident reported the event to the Social Services Director the next day, yet the facility initially treated it as a grievance rather than abuse and delayed submitting a report to the State Survey Agency until weeks later, after determining it was a reportable abuse incident.
Two residents did not receive required ADL and hygiene care as care planned. One resident with dementia and osteoarthritis, dependent for toileting and personal hygiene, was not toileted during an evening shift, with CNA documentation showing no toileting and the oncoming CNA finding the resident’s clothing, linens, and mattress saturated with urine; the assigned CNA reported care resistance but did not notify an RN or LPN. Another resident with dementia and stroke, requiring assistance with dressing and personal hygiene, remained in bed in pajamas into the afternoon without having received morning care, despite CNA documentation indicating dressing was completed; the CNA later confirmed that care was only provided after being questioned by an RN supervisor following a family complaint.
A resident with left-sided weakness after a stroke, high fall risk, and total dependence for ADLs and bed mobility was being turned onto their side for peri care by an aide when they fell from the bed to the floor, sustaining head trauma and a scalp laceration while on blood thinners. The care plan required extensive to total assistance with two-person support for bed mobility, but the fall occurred during care without documentation of the required level of assistance, indicating the facility did not provide adequate supervision and assistance to prevent accidents as outlined in its own fall prevention practices.
A resident with significant upper extremity weakness and recent surgery was discharged home to a multi-story residence without confirmed DME delivery, home health services, or caregiver support. Although referrals for home health, skilled nursing, and DME were made and family attended a discharge care plan meeting, staff did not verify that services were active, did not set or confirm a start-of-care date with the agency, and did not confirm delivery of a hospital bed. The resident, who lived alone and could not manage fine motor tasks, arrived home without in-home assistance, reported difficulty with eating and self-care, and was later found by an HHA RN in unsafe conditions, unable to access food or medications, leading to emergency transport back to the hospital.
A resident with dementia, Parkinson’s disease, CHF, and a history of AKI had documented fluid goals and was identified as at risk for dehydration and malnutrition, yet daily intake records repeatedly showed fluid consumption well below the recommended amounts. Despite severely impaired cognition, poor oral intake, and documented changes in mentation, lethargy, falls, and restlessness, the facility did not consistently implement or document enhanced monitoring, assistive feeding measures, or timely provider consultation focused on hydration. The resident was hospitalized twice with AKI, dehydration, hypotension, and anemia, and staff interviews confirmed that while expectations existed to encourage fluids and notify providers when goals were not met, there was no clear evidence that these expectations were carried out for this resident.
A resident with cardiac conditions was discharged home with a documented post-discharge plan for home health aide, home health RN/LPN, and PT/OT, but the facility did not complete the home health referral before discharge. The resident went home with a family member and, according to a complaint, did not receive PT, OT, or a nursing wellness check for about a week. The SW later confirmed the referral for home health and therapy services was not requested until several days after discharge, and services did not begin until even later, despite therapy recommendations that are typically communicated to social services to arrange home care.
The facility failed to consistently revise care plans to reflect residents’ current needs and behaviors and did not ensure a cognitively intact resident was involved in ongoing care planning. One resident participated in an initial care conference but was not included in later care plan updates. Another resident with an order for a palm protector was frequently observed without it and often refused it, yet the care plan did not address refusals. Two cognitively impaired residents whose MDS assessments showed dependence for bathing had care plans that still listed only setup or one‑person assist. A cognitively impaired resident with combative behaviors and an incident of striking another resident had a behavior care plan that was not updated to include attempts to hit other residents or the risk of resident‑to‑resident altercations.
Failure to Prevent Resident‑to‑Resident Physical Abuse Among Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from resident‑to‑resident physical abuse. One resident with dementia, agitation, depression, anxiety, and PTSD, and a BIMS score indicating moderate cognitive impairment, was pushed to the floor by another resident after that resident entered his room and followed him into the hallway. Staff initially documented the event as an unwitnessed fall after hearing loud screaming and finding the resident on the floor with complaints of right shoulder and left wrist pain, active bleeding from facial lacerations, and clamminess. Subsequent review of surveillance footage showed that another resident walked into the victim’s room, then followed him out and pushed him, causing the fall that resulted in multiple fractures, including a closed left distal radius fracture, a closed, displaced comminuted right proximal humerus fracture, and a closed, displaced distal clavicle fracture. The resident who pushed him had dementia with mood disturbances, bipolar disorder with psychotic features, PTSD, insomnia, and depression, and a BIMS score indicating severe cognitive impairment. His care plan identified a behavior problem related to bipolar disorder and dementia, including wandering, refusal of care, and physical aggression toward staff and others, such as biting a CNA and swinging a walker at a CNA. The care plan directed staff to anticipate and meet his needs, divert him with alternative objects or activities, intervene to protect the rights and safety of others, and conduct safety checks. Despite these identified risks and interventions, he was able to enter another resident’s room and subsequently push that resident in the hallway, resulting in serious injury. Another incident involved two residents with significant cognitive impairment and behavioral symptoms, including delusions, physical behaviors toward others, agitation, and a tendency to invade others’ personal space. One resident, who was described as aggressive toward others, easily agitated, and prone to getting into others’ personal space, walked next to another resident sitting in a dayroom chair and placed his hand on that resident’s chest. The seated resident responded by punching him in the face with the back of his fist, and the first resident then punched back. Staff and psychiatric documentation noted this altercation and ongoing behavioral concerns such as combativeness with care, agitation, and wandering, but the record contained no additional progress notes describing the incident itself beyond the brief psychiatric follow‑up entry. A further incident occurred when a resident with anxiety, major depressive disorder, dementia with behavioral disturbances, agitation, and severe cognitive impairment entered another resident’s room on the memory care unit. The resident in the room, who had depression, anxiety, dementia without behavioral disturbances, PTSD, insomnia, hallucinations, verbal behaviors toward others, other behavioral symptoms, and wandering, reported that he was hit in the face. Staff heard yelling and found the intruding resident pulling covers at the foot of the bed and yelling that the room was his house, while the other resident sat on the side of the bed and stated that he had been hit and told staff to get a gun and shoot the other resident. Slight puffiness was noted around the reporting resident’s left eye. The intruding resident’s care plan documented compulsiveness, invading others’ personal space, yelling, restlessness, physical aggression, and attempts to assist other residents he believed needed help, with interventions to divert him, familiarize him with his surroundings, and intervene to protect the rights and safety of others. Despite these identified behaviors and interventions, he was able to enter another resident’s room, engage in a confrontation, and allegedly strike the resident.
Resident Injury from Improper Hoyer Lift Operation During Transfer
Penalty
Summary
The deficiency involves the facility’s failure to prevent an accident during a Hoyer lift transfer, resulting in a fall and skin tear injury to a resident. The resident had diagnoses including spinal stenosis, Alzheimer’s disease, vascular dementia with behavioral disturbance, bipolar disorder, and pain, and was documented on the MDS as dependent on staff for transfers from bed to chair. The care plan and physician orders specified that the resident required a Hoyer lift with assistance of two staff for transfers. On the day of the incident, the resident was being transferred via Hoyer lift after a shower, from a shower bed back to a Geri-chair. Progress notes and the post-fall evaluation documented that the fall occurred in the bathroom during a Hoyer transfer with staff assistance of two, and that the Hoyer lift tipped sideways. The resident was found on the floor in the sling, with staff reporting that the Hoyer lift’s legs were widened and that as the resident was being positioned over the chair, the lift tipped to the side. Staff held the sling on each side of the resident’s head and lowered the resident to the floor, after which a skin tear measuring 1.0 cm x 0.1 cm was noted on the elbow. The facility’s investigation determined that the Hoyer tipped because one CNA pushed the lift’s feet apart manually instead of using the designated button to open the legs. Interviews indicated that the manual mechanical lift used at the time was considered less steady and required manual operation of a foot pedal to open the legs, and that the straps may have been more to one side than the other. The DON reported that three CNAs were involved with operating the lift at the time of the incident, including one CNA on light duty who was not supposed to be using the Hoyer lift, and that the lift itself was later found to have no mechanical problems. As a result of the tipping incident, the resident sustained a skin tear to the elbow and required diagnostic imaging to rule out fractures.
Incomplete Investigations of Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of verbal or potential physical abuse as required by its abuse, neglect, and exploitation policy. One cognitively intact resident with hemiplegia following a stroke reported a verbal altercation with a CNA after sliding to the floor while being assisted back to bed. The resident requested use of a Hoyer lift, the CNA told him he could get himself up, and an argument ensued in which the CNA told the resident it was not his room and did not leave until directed by an LPN. The facility’s investigation file for this incident contained only the resident’s interview and no interviews with other residents on the unit who might have had knowledge of similar verbal abuse by the CNA. Another cognitively intact resident with rheumatoid arthritis, hypertension, and peripheral vascular disease reported that her roommate’s daughter came into her room and verbally abused her after the roommate had been relocated due to aggression. The daughter allegedly cursed at the resident, calling her an offensive name and telling her she was going to hell. The investigation file for this incident contained no interviews with other residents on the unit to determine whether they had experienced verbal abuse by this family member or had knowledge of the event. The DON acknowledged that no such interviews were conducted. A third cognitively intact resident with type 2 diabetes and epilepsy reported, through her daughter, that a male CNA wearing a red shirt was too rough with her and appeared upset about having to change her linens. The facility’s investigation into this potential staff-to-resident abuse included an interview with the resident but did not include interviews with other interviewable residents in the same area who might have had knowledge of the incident. A fourth cognitively intact resident with type 2 diabetes and heart disease, later discharged, reported that a staff member entered her room, called her a poor excuse for a human being, and refused to assist with changing her brief. The investigation documentation for this allegation lacked interviews with additional residents or staff, did not show that the resident was promptly assessed physically and psychosocially in relation to the allegation, and did not include a review of the accused staff member’s employee record, resulting in an incomplete investigation contrary to facility policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
Failure to Protect Resident From Verbal Abuse and Delay in Reporting Incident
Penalty
Summary
The facility failed to protect a cognitively intact resident from verbal abuse by a staff member. The resident, admitted with rectal cancer and independently ambulatory with a rolling walker, reported that during an overnight shift he left the campus to smoke and, upon returning and walking toward the nursing station, was confronted by an RN. According to the resident’s report, the RN told him that when she was on the night shift he was not allowed to go outside, using profanity toward him, and further stated that if he went out the door she would instruct staff not to buzz him back into the building. A CNA later confirmed that the RN had been upset about being called in to work, spoke loudly to the resident about his smoking, and used curse words when he responded to her. The incident was not promptly reported to facility administration despite occurring during the night shift, with the CNA stating that the RN involved was the supervisor at the time. The resident reported the incident the following day to the Social Services Director, but the facility did not immediately recognize or treat the allegation as reportable abuse. Instead, the administration initially considered it a grievance and investigated it in that manner. The incident report was not submitted to the State Survey Agency until several weeks after the resident’s report, and only after the facility later determined that the event constituted a reportable abuse incident.
Failure to Provide Required ADL and Hygiene Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL assistance to maintain grooming and personal hygiene for two dependent residents. One resident with dementia, osteoarthritis, and moderately impaired cognition was care planned to receive partial to substantial assistance with personal and oral care, scheduled toileting every two hours, and assistance with toilet transfers. CNA documentation for an evening shift showed “N/A” for all scheduled toileting times, and a facility incident report stated that the CNA assigned to this resident failed to provide incontinence care during that shift. The oncoming night-shift CNA later found the resident’s clothing, linens, and mattress saturated and soaked with urine and provided the needed care, with the prior-shift LPN confirming the condition when notified. The assigned CNA reported the resident was resistant to care but did not notify the LPN or RN for assistance or document the issue. The second resident, with dementia, stroke, weakness, and moderately impaired cognition, was care planned for an ADL self-care deficit requiring setup or cleanup assistance with eating, partial to substantial assistance with personal hygiene and oral care, and substantial assistance with toileting, showering/bathing, and lower body dressing. On a morning shift, the resident’s daughter-in-law reported to the LSW that she did not believe the resident had received morning care because he was still in bed wearing pajamas and had not yet received his lunch tray. A CNA statement indicated the resident had eaten breakfast and was later found asleep in bed, and CNA documentation for that shift showed the dressing task as completed. However, the facility’s follow-up summary documented that the CNA confirmed care had not been provided to the resident prior to being questioned by the RN supervisor, and the LSW confirmed that the CNA changed the resident only after the family reported the concern and nursing was notified.
Failure to Provide Adequate Supervision and Assistance During Bed Mobility for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for a resident with significant functional and cognitive impairments. The resident was admitted with left-sided weakness after a stroke and was care planned as extensively to totally dependent for bed mobility, requiring the support of two persons. A fall risk evaluation documented a score of 10, indicating high fall risk, and a quarterly MDS assessment showed the resident was unable to participate in a cognitive assessment and was completely dependent on staff for all ADLs. Despite these identified needs and risks, the resident was being turned onto their side for peri care by an aide when they fell from the bed to the floor. During this incident, the resident sustained head trauma and a small scalp laceration, and was on blood thinners at the time of the fall. The fall occurred while the aide was providing peri care and turning the resident, but the report does not document the presence of a second staff member, despite the care plan indicating the need for two-person assistance for bed mobility. The facility’s own policy on falls emphasized instituting individualized practices to minimize fall risk and maximize safety for residents identified as high risk, but the resident’s documented high fall risk and total dependence were not adequately addressed in the supervision and assistance provided at the time of the fall.
Failure to Ensure Safe Discharge with Confirmed Home Services and Support
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s discharge home included confirmed durable medical equipment (DME), home health services, and adequate caregiver support. The resident was admitted with spinal stenosis, cervical disc disorder, muscle weakness, carpal tunnel syndrome, and a recent post-fasciotomy to the right arm, and was documented as cognitively intact with a BIMS score of 14/15. Despite these physical limitations, the facility discharged the resident home in the evening via medical transport to a three-story residence, where no caregiver support was present. The facility’s own policy required a post-discharge plan of care developed with the resident and representative, and orientation to ensure a safe and orderly transfer or discharge, but the record lacked evidence that services were confirmed as in place prior to discharge. Prior to discharge, the social worker documented that the resident would have a safe discharge home with services and supports in place, and that referrals for home health care, skilled nursing services, and DME had been made, with family members in attendance at the discharge care plan. However, the clinical record did not contain confirmation that these services were actually arranged and active before the resident left the facility. The resident was discharged with medications called to the pharmacy for home delivery, but there was no documentation that the hospital bed had been delivered or that home health nursing, therapy, or home health aide services were scheduled to start at the time of discharge. The social worker later acknowledged not informing the agency of a specific start-of-care date, assuming the agency and VA would contact the resident, and confirmed not calling to verify delivery of the hospital bed. After discharge, it was discovered that the hospital bed ordered days earlier was not delivered until the morning after the resident arrived home, and that therapy, RN, and HHA services had not yet begun or contacted the resident by the time the facility followed up. The resident reported living alone, being unable to use their hands, needing a caretaker, and having to rely on a sister-in-law for limited assistance with hygiene, meals, and rearranging furniture for the bed that arrived later. The significant other confirmed that no one lived with the resident, that they had their own health issues, and that neither they nor their son stayed with the resident after discharge. When a home health RN eventually visited, the resident was found sitting on a couch in minimal clothing, reporting not having eaten adequately for two days, having little or no accessible food, and being unable to open medications or bottles due to impaired fine motor skills. The RN observed the resident’s inability to grip or perform fine motor tasks, assisted with toileting, and then contacted the agency director and emergency services due to the unsafe conditions in which the resident had been left. These events led surveyors to determine that the facility failed to ensure services and caregiver support were in place prior to discharge, resulting in an immediate jeopardy situation.
Removal Plan
- Audited discharge documentation related to home health services, appropriate caregiver/family support, and any necessary services to meet residents' care needs to determine if any residents were affected.
- Reviewed planned discharges by the Administrator, DON, Director of Social Services, and Director of Rehabilitation to ensure home health services, appropriate caregiver/family support, and necessary services to meet the resident's care needs are in place before discharge.
- Completed a root cause analysis identifying failure to have a robust discharge care plan meeting with the interdisciplinary team (IDT), resident, and resident representative.
- Reviewed the procedure for safe and effective discharge planning with the IDT.
- Re-educated the discharge planning IDT on the discharge policy and procedure to ensure sufficient preparation and orientation for a safe discharge.
- Implemented review of residents scheduled to be discharged to ensure appropriate discharge planning is in place.
- Implemented review of residents scheduled for discharge to ensure ADL support is in place, durable medical equipment is available prior to or on the discharge date, medications are available upon discharge, and identified needs/support are available.
- Implemented review of residents scheduled for discharge to ensure safe discharge planning is in place and to address any issues identified.
- Implemented oversight during utilization review by the NHA/designee to ensure discharge planning preparation and services are in place prior to discharge.
- Initiated audits and educational in-services to the IDT team and conducted staff interviews to confirm education received regarding discharge to the community and/or transfers to other facilities.
Failure to Maintain Adequate Hydration Resulting in Recurrent AKI and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate hydration for a resident with significant medical conditions, including acute kidney injury (AKI), congestive heart failure (CHF), dementia, and Parkinson’s disease. Upon admission, the resident’s care plan identified potential for altered nutrition and included interventions such as assisting at meals, encouraging oral fluids, and monitoring for additional nutrition interventions. A nutrition assessment established an initial fluid goal of 1943–2098 mL/day and documented that the resident was at risk for dehydration and malnutrition, with early labs showing a BUN of 29, creatinine of 1.4, and eGFR of 53. The admission MDS documented that the resident was severely cognitively impaired and required setup assistance for feeding and hydration. Daily fluid intake records from CNA task flow sheets and the MAR showed that the resident’s intake frequently fell below the recommended fluid goals, with multiple days of intake under 1200 mL and some days as low as 360–720 mL. A malnutrition risk assessment identified the resident as at risk for malnutrition due to severe dementia and tremors. A subsequent nutrition note on 5/12/25 documented that the resident’s average fluid intake was 330 mL/day, recommended discontinuing a prescribed hydration pass due to CHF, and set a new fluid goal of 1635–1766 mL/day, while continuing to recommend encouraging oral fluids. Despite these documented risks and low intakes, there is no evidence in the record of intensified monitoring or additional interventions to ensure the resident met the revised fluid goals. The resident experienced multiple clinical deteriorations associated with poor intake and changes in condition. On 6/1/25, after a day with only 360 mL of recorded intake, the resident was transferred to the hospital following falls, hypotension, and confusion, and was admitted with AKI and dehydration. After readmission to the facility, nursing documentation noted low oral intake and a plan to discuss adding the resident to an assist-to-feeding list, but the record lacked evidence that this occurred. Subsequent notes documented lethargy, increased confusion, agitation, restlessness, and continued poor intake, yet a physician progress note following two unwitnessed falls did not include an assessment of hydration status or interventions to improve hydration. On 6/19/25, labs showed a BUN of 62 mg/dL and creatinine of 1.7 mg/dL, and the resident was again sent to the hospital and admitted with AKI, hypotension, and anemia, requiring IV fluid resuscitation. Staff interviews confirmed expectations to monitor intake, encourage fluids, and notify providers when fluid goals were not met, but there was no documentation that the provider was consistently notified or that appropriate interventions were implemented in response to the resident’s ongoing inadequate fluid intake and changes in condition.
Failure to Arrange Timely Home Health Services Prior to Discharge
Penalty
Summary
The facility failed to ensure a timely referral for home health care services prior to discharge for one resident. Facility policy dated 5/1/25 required sufficient preparation and orientation to residents to ensure an orderly transfer or discharge. The resident was admitted on 7/28/25 with diagnoses including aortic valve replacement, aortic regurgitation, and congestive heart failure. A discharge summary dated 8/11/25 documented a post-discharge plan for home health aide, home health RN/LPN, and occupational and physical therapy. The resident was discharged home with a family member on 8/12/25. A complaint received by the Division on 9/30/25 stated that the resident was discharged to a family member's home without a home health care agency referral and that, after one week at home, the resident had not received any physical or occupational therapy or a wellness check from a nurse. During an interview on 2/16/26, the social worker reported needing to check if a referral was made and later confirmed that the referral for home health and therapy services was not requested until 8/15/25, with services opened on 8/20/25. The director of therapy confirmed that physical and occupational therapy were recommended for the resident and stated that such recommendations are typically communicated to social services to set up home care. Findings were reviewed with facility leadership during the exit conference.
Failure to Revise Care Plans and Involve Resident in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise person‑centered care plans and to involve a cognitively intact resident and/or representative in the care planning process. One resident with an intact BIMS score of 15 was admitted and had a documented care conference shortly after admission, but there was no evidence of any subsequent care conferences during the following year despite multiple care plan updates. The resident reported not recalling quarterly care plan meetings, and staff confirmed that no care conferences occurred after the initial one, with no documentation that the resident or representative participated in the later care plan revisions. Additional residents’ care plans were not revised to reflect current, individualized needs and behaviors. One resident had a physician’s order for a right palm protector or substitute, was repeatedly observed without it in place, and routinely refused it according to nursing and CNA interviews, yet the care plan did not address potential refusals. Two cognitively impaired residents whose MDS assessments documented dependence for bathing had care plans that continued to list only setup assistance or one‑person assist, without updating to reflect full dependence. Another cognitively impaired resident with documented combative behaviors toward staff and a reported incident of striking another resident with a remote had a behavior care plan that was not revised to include the new behavior of attempting to hit other residents or the potential for resident‑to‑resident altercations.
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