Cadia Rehabilitation Pike Creek
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, Delaware.
- Location
- 3540 Three Little Bakers Blvd, Wilmington, Delaware 19808
- CMS Provider Number
- 085054
- Inspections on file
- 22
- Latest survey
- July 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cadia Rehabilitation Pike Creek during CMS and state inspections, most recent first.
A resident with a history of subdural hemorrhage and recent craniotomy experienced a fall and subsequently showed significant neurological decline, including lethargy, slurred speech, and inability to eat or take medications. Despite these symptoms, staff did not escalate care or arrange timely hospital transfer, resulting in delayed treatment for an acute subdural hematoma that required emergency surgery.
Two residents who required two-person assistance for bed mobility and transfers were left unsupervised by only one staff member during care, contrary to their care plans. As a result, both residents fell from their beds; one sustained a head laceration requiring emergency treatment, while the other suffered minor injuries. In both cases, staff admitted to not following the required level of assistance.
A resident's right to receive visitors at any time was not honored when her family member was restricted from visiting during evening and nighttime hours, despite the resident's wishes and no complaints from her roommate. Staff cited the presence of a roommate and posted recommended visiting hours, but there was no documentation of disruptive behavior or a formal visitation policy in place.
A resident with total incontinence and complex medical needs experienced urine odors in their room after staff disposed of soiled briefs in the room's trash can rather than the soiled utility room. Multiple staff, including CNAs and LPNs, were either unaware of or not trained on the correct disposal procedure, and family and housekeeping staff also noticed the resulting odors. The facility lacked a specific policy addressing the maintenance of a homelike environment related to this issue.
A resident who was totally dependent on staff and required two-person assistance for bed mobility sustained a fractured and dislocated shoulder. Although the injury was reported to the State Survey Agency, the facility did not conduct a thorough internal investigation, as no staff interviews or witness statements were collected, contrary to facility policy.
A resident admitted with a stage 2 sacral pressure ulcer did not receive timely wound treatment orders or documented care. Nursing staff provided undocumented treatments without provider notification, and communication lapses led to delays in wound management. The wound worsened and required debridement before appropriate orders and care were established.
Surveyors found that multiple residents with tracheostomies and complex respiratory needs did not consistently receive required tracheostomy and respiratory mouth care as ordered and documented in their care plans. Review of treatment records showed several missed or undocumented care opportunities, and staff interviews confirmed that the respiratory therapy department was responsible for these interventions.
Two residents did not receive required post-fall assessments and monitoring according to physician orders and facility policy. Nursing staff failed to obtain and document current vital signs each shift for a resident placed on alert charting after a fall, instead recording outdated information. Another resident with a seizure disorder was not properly monitored or assessed after a fall with seizure activity, with missing documentation of vital signs and seizure monitoring on subsequent shifts.
Two residents with seizure disorders did not have required lab tests for their antiseizure medications obtained or documented as ordered by providers. In one case, lab results were missing entirely, and in another, only partial results were uploaded and not reviewed by the NP for several months. These deficiencies were confirmed by facility leadership.
The facility failed to provide a safe, clean, comfortable, and homelike environment for five residents, with issues including broken and stained privacy curtains, trash and clutter in rooms, and poor communication between housekeeping and maintenance.
The facility failed to accurately code the MDS assessment for a resident, incorrectly marking a planned discharge home as a discharge to hospital. The MDS Coordinator confirmed the error and noted the absence of a specific policy for MDS coding.
The facility failed to provide advance notice of care plan meetings to a resident and did not ensure another resident was invited to participate in his quarterly care plan meeting. Both residents were cognitively intact, and the facility's policy required advance notice to promote participation, which was not followed.
The facility failed to reweigh a resident within 48 hours after a significant weight loss of 26.3 pounds, despite the resident's dependence on tube feeding and multiple diagnoses. The dietician was not informed of the weight loss in a timely manner, and there was no documentation of family notification.
A resident with chronic pain and other medical conditions experienced multiple missed doses of narcotic pain medication due to the facility's failure to ensure timely delivery and lack of alternative pain management options. The facility's policy did not address the ordering process for controlled substances or procedures for pharmacy delivery issues, leading to unresolved pain and increased anxiety for the resident.
The facility failed to provide trauma-informed, culturally competent care for two residents, leading to potential re-traumatization. Both residents had care plans that did not identify specific triggers or address the effects of trauma on their well-being, despite having diagnoses of PTSD.
The facility failed to ensure timely delivery of pain medications for a resident with chronic pain, resulting in unresolved pain. The facility lacked a policy on ordering controlled substances and did not effectively collaborate with the pharmacy, leading to multiple missed doses of Oxycodone. Interviews revealed inconsistencies in the process of ordering and delivering these medications.
Failure to Provide Timely Treatment for Change in Condition After Fall
Penalty
Summary
A deficiency occurred when a resident with a history of traumatic subdural hemorrhage and recent craniotomy was not provided timely treatment following a fall and subsequent change in condition. After being admitted to the facility with severe cognitive impairment, the resident experienced a fall, hitting his head and sustaining facial injuries. Although neurological checks were initiated and the nurse practitioner was notified, the resident began to exhibit significant changes in mental status, including increased lethargy, inability to wake for medications or meals, slurred speech, and decreased responsiveness over the following days. Despite these clear signs of neurological decline, the facility staff did not escalate care or send the resident to the hospital in a timely manner. Documentation shows that the resident's condition worsened, with persistent lethargy and confusion, and therapy notes indicated a marked decline in functional status. The on-call nurse practitioner was notified but only advised holding medications and monitoring, without further intervention. The resident's family expressed concern and ultimately insisted on hospital transfer, at which point the resident was found to have a large subdural hematoma with midline shift, requiring emergency craniotomy and intubation. Interviews with facility staff revealed that the change in the resident's condition was recognized but not acted upon appropriately, and there was a lack of escalation to higher-level providers or the medical director. The facility failed to identify the seriousness of the resident's symptoms and did not implement any corrective measures following the incident, resulting in a delay in treatment for a life-threatening condition.
Failure to Provide Required Two-Person Assistance During Bed Mobility and Transfers
Penalty
Summary
The facility failed to ensure that two residents who required assistance from two staff members for bed mobility and transfers were provided with the necessary supervision and support, resulting in accidents. In both cases, only one staff member provided care despite the residents' care plans and transfer status sheets clearly indicating the need for two-person assistance. This failure to follow the prescribed care plans led to both residents falling from their beds during care. One resident, who had anoxic brain damage and was in a persistent vegetative state, was completely dependent on staff for mobility and required two-person assistance for rolling side to side. During incontinence care, a CNA attempted to roll the resident alone, resulting in the resident falling from the bed and sustaining a laceration to the skull that required emergency room treatment and stitches. The CNA admitted to providing care alone because she was unable to find another staff member to assist, despite knowing the resident's care plan required two staff for such tasks. Another resident, also in a vegetative state with multiple medical conditions and dependent on staff for all activities of daily living, experienced a similar incident. While being cleaned, the resident was turned by a single CNA, contrary to the care plan that required two staff and the use of a mechanical lift for transfers. The resident fell from the bed, sustaining minor injuries including excoriations and a small hematoma. The CNA involved confirmed she did not wait for another staff member to assist, as required by the care plan.
Failure to Honor Resident's Right to Unrestricted Visitation
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of her choosing at the time of her choosing, resulting in restricted family visitation for one resident. The resident, who was cognitively intact with a BIMS score of 15, had a family member who regularly visited during evening and nighttime hours to ensure her safety and assist with her needs. The family member reported that he was told by staff he could no longer visit at night due to the presence of a roommate, despite there being no complaints from the roommate and no documentation of any disruptive behavior. The facility posted recommended visiting hours and staff informed the family member that he would not be allowed to visit outside these hours, at one point threatening to call the police if he did not leave. Interviews with staff, including the administrator, DON, LPN, CNA, and social services, revealed inconsistent understanding and communication regarding visitation policies. While some staff stated that 24-hour visitation was allowed with recommended hours, others enforced restrictions specifically against the family member's nighttime visits. There was no evidence in the resident's records of any issues caused by the family member, and the roommate had not raised any concerns. The facility did not have a formal visitation policy in place at the time of the incident.
Failure to Maintain Homelike Environment Due to Improper Disposal of Soiled Briefs
Penalty
Summary
Facility staff failed to maintain a homelike environment for one resident who was always incontinent of bowel and bladder and had significant medical conditions, including a vegetative state and acute respiratory failure. Observations revealed that soiled briefs saturated with urine were disposed of in the resident's room trash can, resulting in a noticeable urine odor. Multiple staff interviews confirmed that nursing assistants had disposed of soiled briefs in the resident's trash can instead of the soiled utility room, as expected. Some staff members were unaware of the proper disposal procedure, and at least one CNA stated she had not been trained to remove soiled briefs from the room during her orientation. Family members and housekeeping staff also reported noticing the improper disposal of soiled briefs and the resulting odors. The facility's staffing coordinator acknowledged that while incontinence care competencies were provided, they did not specifically address the disposal of briefs. The Director of Nursing and the Administrator both stated that soiled briefs should be disposed of in the soiled utility room, but there was no homelike environment policy in place at the time of the incident.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an allegation of an injury of unknown origin for one resident. The facility's policy required the Nursing Home Administrator or designee to investigate all allegations and interview all persons involved or with knowledge of the occurrence. The resident in question was totally dependent on staff for all activities of daily living and required two staff members for bed mobility. The resident had a history of chronic left shoulder dislocation and was found to have a fractured humerus or scapula with a dislocated right shoulder, as confirmed by hospital records. The injury was reported to the State Survey Agency in a timely manner, and a five-day follow-up summary was provided. However, the facility's internal investigation did not include interviews with potential witnesses or staff who may have had knowledge of the incident. Interviews with the current DON, Clinical Consultant, and Administrator confirmed that no staff interviews or witness statements were collected as part of the investigation. The current abuse coordinator also stated that her process would include gathering witness statements and interviewing any suspects, but this was not done in this case.
Failure to Obtain Timely Wound Treatment Orders and Provide Pressure Ulcer Care
Penalty
Summary
The facility failed to obtain wound treatment orders and provide appropriate wound care upon admission for a resident who was admitted with a stage 2 pressure ulcer on the sacrum. Upon admission, the wound was documented and a new dressing was applied, but no treatment orders were obtained, and there was no alert charting or documentation of wound care in the medical record. The resident's weekly skin checks continued to note the presence of the sacral wound, but it was not until several days later that a treatment order was finally obtained. During this period, nursing staff reported providing wound care without an order, but did not document these interventions or notify the provider as required. Interviews with facility staff revealed that the wound nurse who initially assessed the resident resigned without obtaining a treatment order, and subsequent staff were unaware of the wound due to lack of communication in nursing reports and absence of alert charting. The wound physician was not made aware of the lack of treatment until after the delay, and the wound was later found to be unstageable and required debridement. The facility's policy required prompt identification and individualized care planning for pressure ulcers, but this was not followed in the resident's case, resulting in a delay in appropriate wound management.
Failure to Provide Consistent Tracheostomy and Respiratory Mouth Care
Penalty
Summary
Surveyors identified that the facility failed to provide safe and appropriate respiratory care, including tracheostomy and respiratory mouth care, for five residents with significant respiratory needs. Each resident had documented diagnoses such as acute or chronic respiratory failure, tracheostomy, ventilator dependence, or persistent vegetative state, and all were dependent on staff for activities of daily living. Care plans and physician orders for these residents specified the need for tracheostomy care and respiratory mouth care at regular intervals, such as every shift or multiple times per day. Record reviews revealed multiple instances where the required respiratory care was not documented as provided. For example, one resident's treatment administration record (TAR) lacked evidence of tracheostomy and mouth care on two out of 24 opportunities, while another resident's TAR showed missing documentation for these interventions on four out of 60 opportunities. Similar deficiencies were found for the other residents, with missed or undocumented care ranging from one to four instances out of 60 possible opportunities per resident. These lapses were confirmed through review of the TARs and were consistent across all five residents reviewed. Interviews with facility staff, including a respiratory therapist and the chief nursing officer, confirmed that the respiratory therapy department was responsible for providing the required care. The findings were reviewed and acknowledged by facility leadership during the exit conference. The deficiency centers on the facility's failure to ensure that respiratory and tracheostomy care was consistently provided and documented according to professional standards and the residents' individualized care plans.
Failure to Complete Post-Fall Assessments and Monitoring per Orders
Penalty
Summary
Two residents experienced deficiencies in care and services following falls, as the facility failed to provide post-fall assessments and monitoring in accordance with physician orders and professional standards. For one resident, after a fall, the physician ordered alert charting every shift for three days. However, nursing staff repeatedly failed to obtain and document current vital signs each shift as required. Instead, they documented outdated vital signs from previous shifts, and this pattern continued even when the resident was placed on alert charting for other symptoms. This failure was acknowledged by the nurse practitioner and confirmed by the chief nursing officer during interviews. For another resident with a history of seizure disorder, ventilator dependence, and persistent vegetative state, the facility did not provide evidence of appropriate monitoring and assessment after a fall that included seizure activity. The resident was found on the floor experiencing a seizure, and staff were unable to obtain a blood pressure reading on the arms due to the severity of the seizure. The clinical record lacked documentation of vital signs, clinical assessments, and seizure monitoring for the day following the incident on two nursing shifts. The facility's own policy required heightened observation and documentation of objective data, including vital signs, for residents placed on alert charting after incidents such as falls. Despite this, the required assessments and documentation were not completed for both residents, as confirmed by staff interviews and record review.
Failure to Obtain and Document Ordered Laboratory Tests for Seizure Medications
Penalty
Summary
The facility failed to obtain and document laboratory services as ordered by providers for two residents with seizure disorders. One resident was admitted with a diagnosis of seizure disorder and had active physician orders for Phenobarbital and Keppra levels to be drawn every six months starting on a specified date. Review of the clinical record showed that the required lab results for that date were absent, and this was confirmed by the Chief Nursing Officer (CNO) during an interview. Another resident, also with a seizure disorder and additional complex medical needs, had physician orders for Phenobarbital and Keppra levels to be drawn every six months. Although the lab draw was scheduled, records indicated that the labs were drawn three days later, and only the Phenobarbital result was eventually uploaded into the clinical record. There was no evidence that the Keppra level was obtained, and the available lab result was not reviewed by the nurse practitioner until more than three and a half months after the draw. These findings were confirmed by facility staff and during the exit conference.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for five residents. Resident 85's room had a privacy curtain that was partially detached from the track and had broken ends. Resident 90's room had reddish stains on the ceiling and a large water stain on the privacy curtain, which was also partially detached and broken. Both observations were confirmed by the Manager of Housekeeping (MH). Resident 25's room was observed to have trash on the floor, a towel under the bed, dark marks under the bed and ventilation system, and a windowsill cluttered with spoons, medical supplies, and a landline phone covered in beard/hair trimmings. The air conditioning unit and television stand were covered in dust and stains. These observations were confirmed by the MH. Resident 40's room had a privacy curtain with multiple spatter stains, damaged netting, and large holes, along with brown spatter stains on the ceiling and under the bed. These issues were also confirmed by the MH. Resident 98's room had red spatter marks on the ceiling and a partially detached privacy curtain with broken ends. The MH confirmed these observations. Interviews with the MH and the Maintenance Director revealed a lack of communication between housekeeping and maintenance regarding environmental issues. The Director of Nursing (DON) stated that environmental checks on residents' rooms were completed once a week, but the deficiencies observed indicate that these checks were not effective in maintaining a homelike environment for the residents.
Incorrect MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident reviewed for MDS assessments. Specifically, the discharge MDS for the resident, with an Assessment Reference Date (ARD) of 01/23/24, was incorrectly coded as a discharge to hospital when it should have been coded as a discharge to home/community. The resident's progress notes indicated a planned discharge home, not to a hospital. During an interview, the MDS Coordinator confirmed the incorrect coding and noted that the facility did not have a specific policy for following the MDS, relying instead on the MDS manual for coding.
Failure to Provide Advance Notice and Ensure Resident Participation in Care Plan Meetings
Penalty
Summary
The facility failed to provide advance notice of care plan meetings to Resident 16 and did not ensure Resident 25 was invited to participate in his quarterly care plan meeting. Resident 16, who was cognitively intact with a BIMS score of 14 out of 15, reported that the facility conducted a care conference in her room without prior notice. The review of her care conference progress notes confirmed the absence of advance notice documentation. Similarly, Resident 25, who had a BIMS score of 15 out of 15, stated he was not invited to his care conference. The review of his care conference progress notes indicated his last participation was in November, but there was no evidence of his participation in the February quarterly care conference. During interviews, the Social Services Director (SSD) acknowledged that care conferences should be scheduled with advance notice and that the facility staff did not document the residents' invitations in the EMR. The Director of Nursing (DON) also confirmed that residents should have been given advance notice and allowed to participate in their care conferences. The facility's policy required care plan meetings to be held at least quarterly with advance notice to residents and their representatives to promote participation, which was not adhered to in these cases.
Failure to Reweigh Resident After Significant Weight Loss
Penalty
Summary
The facility failed to obtain a reweigh within 48 hours after a significant weight loss of 26.3 pounds for a resident who was dependent on tube feeding. The resident, who had multiple diagnoses including gastroesophageal reflux disease, enterocolitis due to clostridium difficile, Parkinson's disease, tracheostomy, ventilator dependence, and dysphagia, experienced a weight drop from 203 pounds to 176.5 pounds over a period of approximately two months. Despite the facility's policy requiring reweighs within 48 hours of significant weight changes, this was not done, and the dietician was not informed of the weight loss in a timely manner. The resident's feeding formula was changed multiple times due to intolerance, and the resident continued to receive tube feeding and liquid protein supplements. However, the resident experienced vomiting and had a distended abdomen, leading to orders to hold tube feeding temporarily. Interviews with staff revealed that the significant weight loss was not promptly addressed, and there was no documentation of family notification regarding the weight loss. The physician's progress note indicated that the resident's weight loss was due to multiple factors, including respiratory failure, advanced Parkinson's disease, and severe gastroparesis, and that the resident was receiving the maximum amount of nutrition tolerable.
Failure to Ensure Timely Pain Medication Delivery
Penalty
Summary
The facility failed to ensure timely delivery of narcotic pain medications and did not offer additional non-pharmacy interventions for a resident with chronic pain, resulting in multiple missed doses and unresolved pain. The facility's policy on medication administration did not address the ordering process for controlled substances or procedures for pharmacy delivery issues. The resident, who was cognitively intact and had a history of chronic pain, polyneuropathy, anxiety disorder, major depression, and post-traumatic stress disorder, reported frequent lapses in receiving pain medication and was not provided with alternative pain management options during these lapses. The resident's care plan included administering analgesia as per orders and evaluating the effectiveness of pain interventions but failed to include non-pharmacy interventions. The resident experienced multiple instances where pain medication was not administered, and alternative medications like Tylenol or Ibuprofen were not offered. The resident reported severe pain and anxiety due to the lack of timely pain management, which was exacerbated by a rare lung disease and an abscessed tooth. Interviews with staff revealed issues with insurance coverage for the medications and a lack of awareness about the pharmacy's delivery cutoff time. The pharmacy director confirmed that orders placed after 1:00 PM would be delivered the following day, contributing to the delays. The resident's pain management was further compromised by the facility's failure to reorder medications promptly and the pharmacy's practice of sending limited quantities of pain medication at a time.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to ensure that trauma survivors received trauma-informed, culturally competent care, which led to potential re-traumatization for two residents. Resident 63, who was admitted with diagnoses including type two diabetes mellitus, Parkinson's disease, and PTSD, had a care plan that did not identify any specific triggers related to PTSD or how to address them. The care plan also failed to address the effects of trauma on the resident's mental, physical, social, emotional, and spiritual well-being. Despite being cognitively intact, as indicated by a BIMS score of 15 out of 15, the resident's care plan lacked a trauma-informed care approach. Similarly, Resident 110, who was admitted with diagnoses including aphasia, cognitive communication deficit, and PTSD, had a care plan that did not identify any specific triggers related to trauma or how to address them. The resident, who was severely cognitively impaired with a BIMS score of zero out of 15, also had a care plan that failed to address the effects of trauma on their well-being. The Director of Nursing confirmed that the care plans for both residents were inadequate as they did not identify the triggers for either resident, despite the facility's policy to provide trauma-informed care.
Failure to Ensure Timely Delivery of Pain Medications
Penalty
Summary
The facility failed to ensure timely delivery of pain medications for a resident (R73) with chronic pain, resulting in unresolved pain. The facility did not have a policy on ordering medications, specifically controlled substances, and did not collaborate effectively with the pharmacy to ensure a process was in place for ordering these medications. This led to multiple missed doses of Oxycodone for R73, as documented in the Medication Administration Record (MAR) and confirmed by interviews with the resident and staff. R73, who was cognitively intact with a BIMS score of 15 out of 15, reported frequently going without pain medications because the nurses did not order them in a timely manner. The resident's electronic medical record (EMR) showed multiple one-time orders for Oxycodone, but there were several instances where the medication was not administered as prescribed. The resident expressed that the facility staff told her the issue was due to insurance not paying for the medication, which was contradicted by the Director of Nursing (DON). Interviews with various staff members, including LPNs and the Director of Quality at the pharmacy provider, revealed inconsistencies in the process of ordering and delivering controlled substances. The pharmacy had a cutoff time for same-day delivery, which was not communicated effectively to the nursing staff. Additionally, there were issues with obtaining new prescriptions and accessing the onsite locked supply of narcotics. These communication and procedural failures contributed to the resident's unresolved pain and distress.
Latest citations in Delaware
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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