Cadia Rehabilitation Capitol
Inspection history, citations, penalties and survey trends for this long-term care facility in Dover, Delaware.
- Location
- 1225 Walker Road, Dover, Delaware 19904
- CMS Provider Number
- 085048
- Inspections on file
- 21
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Cadia Rehabilitation Capitol during CMS and state inspections, most recent first.
A resident with dementia and impaired cognition, who had an order for 0.25 mL (5 mg) concentrated morphine sulfate solution PRN for pain and a separate order for 15 mg MS Contin tablets, received a massive overdose when an LPN misinterpreted 15 mg as 15 mL and administered 15 mL of the liquid morphine instead of 0.25 mL. The LPN reported relying on the MAR display of 15 mg and, after asking a supervisor a general question about narcotic administration, proceeded to give the incorrect volume. The error was recognized at shift change, and documentation by nursing and the medical director confirmed that the resident received 300 mg instead of 5 mg, requiring two doses of naloxone to reverse the overdose and leading surveyors to cite an immediate jeopardy deficiency for a significant medication error.
Two residents reported that CNAs were rough during care and, in one case, that clothing was torn. In both situations, staff received the abuse allegations but did not ensure they were reported to the state agency within the facility’s required two-hour timeframe. Leadership later confirmed awareness of the policy requirement and acknowledged that the reporting timeframes were not met.
The facility failed to ensure food safety by not requiring dietary aides with beards to wear beard nets during food preparation, risking contamination for 109 residents. Additionally, expired and undated food items were found in the main refrigerator and freezer, indicating lapses in food storage protocols.
A resident with moderate cognitive impairment and limited use of one hand was repeatedly found without access to their call light, as it was placed under the bed. Staff interviews confirmed awareness of the need for accessibility, but the facility lacked a specific policy on call lights.
Two incidents of resident-to-resident abuse occurred in the facility, involving residents with cognitive impairments and aggressive behaviors. In one case, a resident struck another after a hallway incident, and in another, a resident slapped another during a dinner dispute. Both incidents were confirmed as abuse by the DON, indicating a failure to implement the facility's abuse prevention policy effectively.
An LTC facility failed to report a resident-to-resident abuse incident to the State Agency within the required two-hour timeframe. A resident with severe cognitive impairment urinated on the floor, prompting another cognitively impaired resident to yell and strike him. The DON learned of the incident later and reported it, but the nurse on duty did not follow the reporting protocol.
A facility failed to thoroughly investigate an abuse allegation involving a resident who reported rough treatment by a CNA. The investigation only included an interview with one female resident, neglecting to interview other male residents who received care from the same CNA, contrary to the facility's policy.
A resident with hemiplegia and hemiparesis was found with a mattress that did not fit the bed frame, creating a gap between the mattress and footboard. This gap, observed to be up to 11 inches, posed a risk of entanglement for the resident's feet. The facility did not provide a policy on mattress fitting by the survey exit.
A resident with severe cognitive impairment and multiple health conditions was found without a functioning call light or alternative device due to a malfunction in the facility's call light system. Despite other residents receiving doorbell-like devices, this resident had no means to call for assistance, relying solely on their voice. The facility's staff were aware of the issue, but the resident's room remained without a functioning call system due to wiring problems.
Significant Morphine Dosing Error Due to Misinterpretation of mg and mL
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when an incorrect dose of concentrated morphine sulfate oral solution was administered. The resident had dementia and a quarterly MDS showing moderately impaired cognition with a BIMS score of 10 and was receiving opioids for pain. The physician’s order in place directed that the resident receive 0.25 mL (5 mg) of morphine sulfate concentrate oral solution every three hours as needed for pain, and on a later date a new order was entered for MS Contin (morphine sulfate) 15 mg extended-release tablets by mouth twice daily for pain. On the morning of the incident, the assigned LPN administered 15 mL of the concentrated morphine sulfate solution instead of the ordered 0.25 mL dose. In a written statement, the LPN reported that the electronic system displayed an ordered dose of morphine 15 mg, while the bottle label stated 0.25 mL, and that after seeking clarification from a supervisor, she was told to follow the dose listed in the MAR. The LPN then incorrectly interpreted 15 mg as 15 mL and administered that amount. Another nurse later confirmed that she had previously worked with the resident, was familiar with the correct 0.25 mL PRN dose, and had left 17.25 mL of morphine sulfate concentrate in the bottle at the end of her prior shift, while the LPN reported having given 15 mL to the resident. The error was discovered during shift exchange when the outgoing nurse recognized the discrepancy between milligrams and milliliters. Nursing notes documented that the resident had received 15 mL of liquid morphine, and the medical director’s note confirmed that, given the concentration of 20 mg/mL, the resident received 300 mg instead of the prescribed 5 mg. The facility determined that the nurse failed to perform the rights of medication administration when she misinterpreted 15 mg as 15 mL, resulting in the resident receiving 59 times the ordered dose of morphine sulfate solution. The resident required administration of naloxone intramuscularly on two occasions to reverse the overdosage, and the situation was identified by surveyors as immediate jeopardy, past non-compliance.
Removal Plan
- Upon discovery of the medication error, R5 was immediately assessed and the physician was notified; a new order for Narcan (Naloxone) was obtained and administered; R5's responsible party and Hospice were notified; R5 was placed on alert charting to monitor vital signs and respiratory status.
- An audit was completed on residents with orders for liquid morphine and no other errors were identified.
- An audit of residents receiving controlled substances was completed to determine if any other residents had orders for the same medication in two different forms and no other residents were identified.
- The facility conducted a root cause analysis.
- Education with licensed nurses was completed on the five rights of medication administration.
- The medication error was reviewed with the medical director at an ad hoc QAPI meeting.
- The Director of Nursing will conduct audits of liquid morphine medication administration weekly until 100% compliance is achieved for 3 consecutive weeks, then monthly until 100% compliance is achieved for 3 consecutive months; all audits will be reviewed by the QAPI Committee.
Failure to Timely Report Allegations of Abuse to State Agency
Penalty
Summary
The facility failed to timely report allegations of abuse to the state agency for two residents. For one resident, a CNA documented in a written statement on 10/26/25 that on the previous night at approximately 11:15 PM, the resident reported that a CNA had torn her clothes and was rough with her. The CNA confirmed in an interview that this allegation was reported to a nurse on 10/25/25. However, the facility did not submit the allegation of staff-to-resident abuse to the state agency until 11:08 AM on 10/26/25, which was more than two hours after the resident’s initial report to facility staff. The ADON later stated that leadership only became aware of the incident by reading notes and that no one had made leadership aware at the time of the allegation. For another resident, the clinical record showed that the resident reported on 10/25/25 at 7:15 PM that a CNA was rough while providing care. The facility did not report this allegation of abuse to the state agency until 11:09 AM on 10/27/25, which exceeded the required two-hour reporting timeframe. In interviews, both the DON and the NHA confirmed that allegations of abuse must be reported within two hours and acknowledged that the alleged abuse was not reported within that timeframe. The facility’s abuse policy, last updated on 1/9/26, specified that allegations of abuse must be reported to the appropriate state regulatory authority within two hours, and the survey findings were reviewed with facility leadership during the exit conference.
Failure to Adhere to Food Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not ensuring that beard guards were worn during food production. Observations during multiple meal preparations revealed that two male dietary aides with beards did not wear beard nets while working at the food preparation station. This was confirmed during interviews with the Food Service Director and the dietary aides, who acknowledged the requirement to wear beard guards but admitted to forgetting to do so. This oversight had the potential for physical contamination of the food served to all 109 residents consuming meals from the kitchen. Additionally, the facility did not store food in accordance with professional standards for service safety. During an inspection of the main refrigerator and freezer, several food items were found to be expired or lacked current dates. Items such as potato salad, salad dressing, hard-boiled eggs, grape jelly, chicken salad, chicken cutlets, and hamburger patties were either undated or past their expiration dates. The Food Service Director noted that the weekend kitchen staff were responsible for checking and discarding out-of-date food items, indicating a lapse in the facility's food safety protocols.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident had access to their call light, which is essential for meeting their needs. The resident, who was moderately cognitively impaired with a BIMS score of 12 out of 15, was observed multiple times with the call light underneath the bed, making it inaccessible. The resident, admitted with conditions such as adjustment disorder with depressed mood, congestive heart disease, chronic kidney disease stage three, and gout, was unable to locate the call light and expressed that he did not know where it was. This situation was observed on several occasions, indicating a consistent issue with the call light's accessibility. Interviews with staff, including an LPN and a CNA, revealed that the staff were aware that the call light should be within reach of the resident's right hand, as the resident could not use his left hand. However, the call light was repeatedly found under the bed, and the staff admitted to not realizing its inaccessibility. The Director of Nurses confirmed that CNAs were responsible for ensuring call lights were accessible, but the facility lacked a specific policy on call lights, as stated by the Nurse Consultant.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two incidents of resident-to-resident abuse. In the first incident, a resident with severe cognitive impairment and a history of aggressive behavior struck another resident in the back after the latter began urinating on the floor. Both residents were known to exhibit aggressive behaviors, and the incident was confirmed as abuse by the Director of Nursing (DON). The facility's abuse policy, which aims to protect residents and prevent abuse, was not effectively implemented in this case. In the second incident, a resident with moderate cognitive impairment and a history of verbal aggression slapped another resident during a dispute over a chair at dinner. The resident who was slapped did not sustain any visible injuries and denied provoking the other resident. The DON also confirmed this incident as resident-to-resident abuse. Both incidents highlight the facility's failure to ensure a safe environment for residents, as required by their abuse prevention policy.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an incident of resident-to-resident abuse to the State Agency within the required two-hour timeframe. The incident involved a resident with severe cognitive impairment, who was ambulating in the hallway and began to urinate on the floor. Another resident, also severely cognitively impaired, yelled at the first resident and then struck him in the back. This incident was documented in the facility's incident report. The Director of Nursing (DON) became aware of the incident while reviewing notes from home and subsequently called to gather more information. It was revealed that the nurse on duty at the time of the incident did not follow the reporting requirement to notify the DON, resulting in a delay in reporting the incident to the State Agency. The DON reported the incident as soon as she became aware, but acknowledged that it should have been reported within the mandated two-hour period.
Inadequate Investigation of Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation of an abuse allegation involving a resident, identified as R11, who was cognitively intact with a BIMS score of 15 out of 15. R11 reported to the Director of Nurses (DON) that on December 25, 2024, a Certified Nurse Aide (CNA9) was rough during care, specifically pulling on his genitals. Despite R11's report, the facility's investigation was insufficient as it only included an interview with one female resident and did not involve other male residents who received care from CNA9 on the same day. The facility's policy on abuse and neglect requires that all persons involved or with knowledge of the occurrence be interviewed. However, the investigation did not adhere to this policy, as it lacked interviews with other male residents who could have provided relevant information about CNA9's conduct. The DON acknowledged that the investigation should have included interviews with other male residents, indicating a lapse in following the facility's established procedures for handling abuse allegations.
Improper Mattress Fit Creates Hazard for Resident
Penalty
Summary
The facility failed to ensure that a resident's mattress fit the bed frame properly, creating a potential hazard. The resident, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was observed with a significant gap between the mattress and the footboard of the bed. This gap measured 11 inches during one observation and six inches during another, posing a risk of the resident's feet becoming entangled. The resident confirmed that she had slid down towards the footboard and had her feet entangled in the gap on previous occasions. During an observation with the Administrator, Director of Nurses (DON), and Nurse Consultants, the gap was measured and confirmed to be six inches. The resident reiterated that her feet had gotten caught in the gap when the bed was adjusted. Despite being asked, the facility did not provide a policy on ensuring that residents' mattresses fit bed frames properly by the time of the survey exit.
Resident Lacked Alternative Call Light Device
Penalty
Summary
The facility failed to ensure that a resident had an alternative call light device available when the call light system malfunctioned. Resident 50, who was admitted with chronic obstructive pulmonary disease, congestive heart failure with hypoxia, and interstitial pulmonary disease, was found without a call light or substitute device. The resident, who was severely cognitively impaired with a BIMS score of six out of 15, stated that the previous call light device had broken and that they had no means to call for assistance other than using their voice. The facility's call light system had failed in May 2024, and while most rooms were restored to normal functioning, two rooms, including the one occupied by Resident 50, remained without a functioning system due to wiring issues. Although other residents in similar situations were provided with doorbell-like devices, Resident 50 did not have such a device. The facility's staff, including the Administrator and DON, were aware of the issue, and the Administrator acknowledged that CNAs were instructed to check on residents and ensure they had a bell. However, during an interview, a CNA was unsure of what happened to Resident 50's bell.
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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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