Cadia Rehabilitation Renaissance
Inspection history, citations, penalties and survey trends for this long-term care facility in Millsboro, Delaware.
- Location
- 26002 John J Williams Highway, Millsboro, Delaware 19966
- CMS Provider Number
- 085052
- Inspections on file
- 27
- Latest survey
- August 25, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Cadia Rehabilitation Renaissance during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain sanitary dishwashing and food storage practices. The dish machine repeatedly operated below the required 150°F wash temperature on multiple documented dates, with the digital display alarming and the FSD confirming the substandard temperatures. In addition, a container of rice and broccoli was stored in a unit refrigerator without a label or date, and a fuzzy, black spotted substance was observed on the wall around the dry storage room light switch. These issues were confirmed by facility staff and reviewed with facility leadership.
Two residents experienced transfers or discharges for which the facility did not provide required notification to the Ombudsman. One resident with complete intestinal obstruction and acute kidney failure was transferred to the hospital without Ombudsman notification, and another resident with a lower back stress fracture and left rib fracture was discharged home without such notification. The SW reported that Ombudsman notifications had shifted from monthly to quarterly and were not sent during the SW’s medical leave, and the CNO confirmed that the required notifications for these residents were not submitted.
A resident's medication was found missing, and although the LPN and RN supervisor promptly notified the DON, the incident was not reported to the state agency within the required timeframe. The DON delayed reporting while conducting an investigation, resulting in a nineteen-day gap between the incident and state notification.
A controlled drug administration record for a resident showed a five-capsule discrepancy in morphine reconciliation, with staff unable to account for the missing doses. Interviews with an LPN, RN, and CNO confirmed the documentation error, which was attributed to a clerical or typographical mistake, and no clarification was found in the records.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
A deficiency was identified when a resident with a mental health disability, admitted with PTSD and anxiety, remained in the facility beyond the authorized PASARR convalescent categorical period without a required PASARR Level I and II rescreening. The original PASARR outcome authorized only a 60‑day stay and specified that rescreening must occur by or before 60 days if the resident was expected to remain longer, but staff did not submit the rescreening. During interview, a SW confirmed the rescreening had not been submitted and reported they had mistakenly believed the approval period was 90 days.
A resident with a history of stroke, right-side weakness, and right spastic hemiplegia had physician orders for a right hand/wrist splint and a care plan intervention for a resting hand splint to address contractures and risk of further contractures. However, staff interviews revealed the resident consistently refused to wear the splint and was never observed using it, and the care plan did not document this refusal or address it. This showed the facility did not develop and implement a comprehensive, person-centered care plan that reflected the resident’s actual response to the ordered splint.
A resident with a history of stroke and right-side weakness, care planned to receive assistance with daily hygiene and grooming and assessed as needing moderate assistance for personal hygiene, was repeatedly observed over several days with very long fingernails and dark, encrusted debris under each nail, indicating that nail grooming had not been provided. A CNA confirmed that nail care was scheduled during a prior shift per the shower record, and an LPN acknowledged that the resident’s nails needed to be cut, filed, and cleaned, demonstrating a failure to provide necessary nail care as part of ADL support.
A resident with a history of stroke, right-sided weakness, and documented contractures had a care plan and ROM assessment indicating the need for a resting right hand/wrist splint to be applied on all shifts. Surveyors repeatedly observed the resident in bed without the splint, which was consistently found on the wheelchair instead. A CNA stated they had never seen the resident with a brace, despite documenting in the RNP task sheet that the splint had been applied, and an LPN reported the resident does not wear the splint and always refuses it. These observations showed that the ordered splint was not consistently applied as planned for contracture management.
Surveyors found that providers did not consistently document rationales when disagreeing with or not clearly responding to pharmacist monthly MRR recommendations for two residents. For one resident, multiple pharmacist suggestions related to psychotropic GDRs, monitoring for ASA/Clopidogrel effects, and evaluating medication tolerability with documented allergies were either marked as “disagree” without rationale or left without a clear agree/disagree response. For another resident, a pharmacist recommendation to consider a lorazepam GDR lacked any documented provider rationale. The NP, DON, and CNO confirmed that MRRs are reviewed and discussed with the pharmacist, psychiatric NP, and medical director, and acknowledged that required rationales for disagreement were not documented.
A resident developed dysuria and had an in-house urine dipstick positive for blood and leukocytes, leading to an order for UA and C&S. The outside lab later uploaded a urine culture showing a UTI with significant E. coli growth, but there was no documentation that the abnormal result was addressed or that the provider was notified for several days. An antibiotic was not ordered until multiple days after the positive culture, and administration was further delayed due to pharmacy processing issues related to an allergy and the need to obtain doses from a local pharmacy. Staff interviews indicated that lab results are auto-uploaded into the chart, that staff must monitor and notify providers, and that the lab generally does not call for positive urine cultures, contributing to the delay in provider notification and treatment.
A resident with severe cognitive impairment was allegedly pushed by a CNA, as witnessed by two CNAs who reported the incident to an LPN. The LPN instructed them to write statements but did not report the allegation to the state agency, and the accused CNA continued working. The DON began investigating the next day but was unaware the incident had not been reported, and there was no evidence of timely reporting as required by policy.
A resident was allegedly pushed by a CNA, and although the facility's policy required immediate suspension of any staff member accused of abuse pending investigation, the accused CNA was not suspended and continued working. The DON and LPN supervisor confirmed that the staff member remained on duty during the investigation, which found no injuries or evidence of abuse.
The facility failed to provide a homelike dining environment, maintain privacy for a resident with a catheter, and protect privacy with shower schedules. Meals were served on trays, and a resident's catheter bag was visible from the hallway. A whiteboard in a common area displayed residents' shower schedules, compromising privacy.
The facility did not adequately explain the binding arbitration agreement to residents or their representatives, and the agreement lacked a 30-day rescission period and a clause for communication with officials. Three residents were affected, including one with intact cognition who was unaware of signing, another who did not understand the agreement, and a third with severely impaired cognition. The Admissions Coordinator provided only a brief explanation, and the administrator acknowledged the deficiencies.
The facility's arbitration agreement did not allow for the selection of a neutral arbitrator or a convenient venue, affecting three residents. The agreement required arbitrators to be retired judges or experienced attorneys, without mentioning venue selection. Staff interviews revealed a lack of awareness about these requirements, with the Admissions Coordinator not discussing these rights with residents and the Administrator acknowledging the issue but providing an unchanged agreement.
The facility failed to maintain proper infection control in a secured unit, with missing PPE and improper doffing procedures, affecting all residents. A resident was seen handling soiled PPE, and staff were unclear on PPE requirements. Additionally, an LPN did not change gloves during wound care for a resident, risking infection. The DON confirmed the need for proper glove changes and tool use during wound care.
The facility failed to honor the self-determination rights of two residents. One resident, who was cognitively intact, was not allowed to choose their preferred transfer method, despite expressing fear of the mechanical lift. Another resident, also cognitively intact, was restricted from going outside as desired due to staff time constraints and supervision requirements. These actions placed the residents at risk for psychosocial harm by limiting their independence and choice.
A resident, who was cognitively intact and his own decision-maker, was restrained by facility staff using a Wanderguard and physical force. The resident, who had bilateral leg amputations, was pulled back into the facility against his will while in his wheelchair after going outside to calm down. The following day, a Wanderguard was attached to his wheelchair, restricting his movement. Staff interviews confirmed these actions met the definition of a physical restraint, violating the facility's policy.
The facility failed to develop comprehensive care plans for two residents, one with side rails and another with no weight monitoring due to palliative care. The absence of care plans for these specific needs was confirmed by staff, placing residents at risk for decreased quality of life and care.
A resident with chronic gout, diabetes, and a pressure ulcer on the left heel had an inadequate care plan that failed to include specific interventions for off-loading pressure. The care plan used a pre-set template rather than a resident-specific approach, leading to the resident's heel not being properly elevated, as confirmed by interviews with the resident's representative and an LPN.
A resident with Alzheimer's disease was not provided adequate dining assistance, despite being dependent on staff for eating. Observations showed the resident was left alone during meals, resulting in minimal food intake. Staff confirmed the need for direct engagement, but the facility lacked a policy for assistance with eating.
A resident with a self-care deficit was found to have an unsafe toilet environment, with a wobbly commode and exposed rusted metal, posing a risk of injury. The resident, cognitively intact, required assistance with hygiene and toileting. Facility staff confirmed the unsafe condition, and the administrator acknowledged the absence of a policy for maintaining a safe environment.
A facility failed to assess the need for side rails and obtain informed consent for a resident with moderately impaired cognition and mobility assistance needs. Despite the resident's use of padded side rails, there was no documented evaluation or care plan addressing their use. Interviews with staff revealed confusion about responsibility for assessments and informed consent, with no clear process in place.
A facility failed to provide appropriate trauma-informed care for a resident with PTSD, who was admitted with a stroke and Parkinson's disease. The resident exhibited symptoms such as depression and visual hallucinations, and a positive trauma screening identified the recent death of his twin brother as a traumatic event. However, the care plan lacked specific interventions or identification of triggers, and staff were not adequately trained to address the resident's trauma-related needs.
A resident with Parkinson's and hemiplegia did not receive prescribed medications consistently due to the facility's failure to ensure availability and administration. Despite having a Pyxis system and multiple pharmacy deliveries, the resident missed several doses of Cyanocobalamin and Lubricating Eye Drops. Staff interviews revealed communication breakdowns and inadequate follow-up on medication availability, leading to the deficiency.
A resident with a tooth abscess and moderate protein-calorie malnutrition did not receive prescribed antibiotics due to unavailability from the pharmacy. Despite having a system in place to manage medication shortages, the facility failed to administer the medication on several occasions. Staff interviews confirmed the oversight and acknowledged the importance of antibiotics as significant medications.
A facility failed to ensure an insulin pen was not expired before use, leading to a resident receiving expired Humalog insulin at least five times. An LPN confirmed the administration of the expired insulin, and the DON acknowledged that expired insulin should not be administered, highlighting a breach in the facility's medication storage policy.
A resident with severe cognitive impairment and a finger food diet order was not provided with appropriate menu extensions, leading to potential weight loss. The facility's dietary staff were unaware of the resident's specific needs, and the menus lacked finger food options. Observations showed the resident struggled to eat certain foods with her fingers, and staff interviews revealed a lack of communication and understanding of the dietary requirements.
Dishwashing Temperatures and Food Storage Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure dishes and utensils were cleaned under sanitary conditions and that food storage areas were maintained in a clean and orderly manner. During a follow-up kitchen visit, surveyors observed the dishwashing machine operating with a wash cycle temperature of 135°F, below the required minimum of 150°F, with the digital display flashing red to indicate the low temperature. The Food Service Director (FSD) confirmed that the wash cycle temperature did not meet the minimum requirement and acknowledged seeing the alarm. Review of the facility’s dish machine temperature logs showed multiple dates in June, July, and August when dishwashing temperatures failed to meet the minimum 150°F standard, despite a contractor having serviced the machine on one of those dates. Surveyors also identified additional sanitation and storage issues in food service areas. In a unit refrigerator, a plastic food storage container holding rice and broccoli was found unlabeled and undated, and this was immediately confirmed by the unit clerk. During a follow-up visit to the kitchen, surveyors observed an area of fuzzy, black spotted substance on the wall surrounding the light switch in the dry storage room, which the FSD also immediately confirmed. These findings were later reviewed with the Nursing Home Administrator, Chief Operating Officer, and Chief Nursing Officer during the exit conference.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide required notifications to the Ombudsman for resident transfers and discharges. One resident admitted with complete intestinal obstruction and acute kidney failure was transferred to the hospital, as documented in a progress note, but there was no corresponding documentation that the Ombudsman was notified of this transfer. During interview, the social worker stated that Ombudsman notifications were being sent quarterly and acknowledged that while on medical leave, the assistant had not been sending them, and that prior to the leave they had been sent monthly. The Chief Nursing Officer later confirmed that the required notification of this resident’s hospital transfer had not been submitted to the Ombudsman. Another resident admitted with a lower back stress fracture and left rib fracture was discharged home, with the clinical record documenting the discharge, but there was no notification sent to the Ombudsman regarding this planned discharge. In interview, the social worker confirmed that no Ombudsman notification had been made for this resident’s discharge home, and the Chief Nursing Officer also confirmed that the required notification had not been sent. These findings were reviewed with the Nursing Home Administrator, Chief Operating Officer, and Chief Nursing Officer during the exit conference.
Delayed Reporting of Suspected Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the state agency within the required timeframe for one resident. According to the facility's abuse policy, all alleged incidents involving misappropriation must be reported to the NHA or designee immediately, and to the state agency within eight hours, or within two hours if serious bodily harm is involved. In this case, a nurse identified that six purple tablets were missing from a resident's medication count and immediately notified the nursing supervisor, who then informed the Director of Nursing (DON). Despite recognizing the incident as an allegation of misappropriation, the DON delayed reporting the incident to the state agency, citing the ongoing investigation as the reason for the delay. The incident, which occurred on July 19, was not reported to the state agency until August 7, nineteen days after the event. Interviews with staff confirmed the delay in reporting, and the deficiency was acknowledged by facility leadership during the exit conference.
Failure to Accurately Document Controlled Drug Reconciliation
Penalty
Summary
The facility failed to ensure the accuracy of medication reconciliation documentation for a controlled drug prescribed to a resident. According to the controlled drug administration record, thirty morphine capsules were received from the pharmacy. Subsequently, one capsule was administered to the resident, and the record indicated that twenty-nine capsules remained. However, the record later showed that twenty-four capsules were destroyed, which did not account for five capsules, resulting in a discrepancy. There was no documentation or clarification in the clinical or drug administration records to explain the missing five capsules. Interviews with facility staff, including the LPN and RN involved, revealed that neither could account for the five-capsule deficit. The LPN confirmed witnessing the destruction of the medications but did not recall any error, while the RN suggested the discrepancy might be a typographical error. The Chief Nursing Officer also acknowledged the discrepancy and referred to it as a clerical error. The issue was reviewed with facility leadership during the exit conference.
Improper Labeling and Storage of Drugs and Biologicals
Penalty
Summary
Drugs and biologicals in the facility were not labeled according to currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in noncompliance with regulations regarding the proper labeling and secure storage of medications and biologicals within the facility.
Failure to Complete Timely PASARR Rescreening for Resident With Mental Health Disability
Penalty
Summary
A deficiency occurred when the facility failed to ensure a timely PASARR Level I and II rescreening for one resident with a mental health disability whose initial PASARR determination authorized only a 60‑day convalescent categorical stay. The resident’s Notice of PASARR Level I Screen Outcome, dated 6/5/25, documented a convalescence categorical approval period of 60 days with a suspected or confirmed mental health (MH) disability and specified that a 60‑day or less NF stay was authorized and that rescreening must occur by or before 60 days if the individual was expected to remain beyond that timeframe. The resident was admitted on 6/12/25 with diagnoses including post‑traumatic stress disorder and anxiety and remained in the facility beyond the 60‑day authorization period without a new PASARR rescreening being submitted. During an interview on 8/22/25, the social worker acknowledged that the PASARR rescreening had not been submitted and stated they believed the approval period was 90 days, confirming that the required rescreening had not been initiated within the mandated timeframe.
Failure to Care Plan Resident’s Refusal of Hand Splint
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing a resident’s refusal to wear a prescribed right hand/wrist splint for contractures. The resident was admitted with diagnoses including stroke and right-side weakness, and orders dated 1/3/24 documented use of a splint/brace/device. The care plan initiated an intervention for a resting right hand splint on 2/19/24 for actual contractures and risk of further contractures related to decreased mobility and right spastic hemiplegia following stroke, but the care plan did not document that the resident refused to wear the splint. During interviews, a CNA reported never seeing the resident wear a splint, and an LPN stated the resident does not wear the splint and always refuses it, further confirming that the resident’s refusal had not been incorporated into the care plan. These observations and record reviews showed that the care plan was not updated to reflect the resident’s ongoing refusal of the splint.
Failure to Provide Required Nail Care for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of activities of daily living (ADL) care related to nail hygiene for one resident (R37). R37 was admitted on 1/2/24 with diagnoses including a stroke and right-side weakness, and a care plan dated 4/1/25 documented the need for assistance with daily hygiene, grooming, and other self-care tasks, with no evidence that the resident refused nail care. A quarterly MDS assessment dated 6/25/25 showed that R37 required moderate assistance for personal hygiene and grooming. Despite this, multiple observations from 8/18/25 through 8/21/25 showed that the resident’s fingernails on both hands were very long with dark, encrusted debris underneath each nail, and that no nail grooming had been provided over this period. During an interview on 8/21/25 at 10:16 AM, a CNA (E19) confirmed that, according to the shower record, R37 should have received nail care on 8/17/25 during the 3:00 PM to 11:00 PM shift. Later that day at 2:05 PM, an LPN (E18) observed and confirmed that R37’s nails needed to be cut, filed, and cleaned. These observations and interviews demonstrated that the facility failed to provide necessary nail care to a resident who required assistance with personal hygiene and grooming as outlined in the care plan and MDS assessment.
Failure to Ensure Use of Prescribed Wrist Splint for Contracture Management
Penalty
Summary
The deficiency involves the facility’s failure to provide and ensure use of a prescribed right wrist/hand splint for a resident with a history of stroke and right-sided weakness, despite facility policy on range of motion and contracture management. The resident was admitted with diagnoses including stroke and right-side weakness, and the care plan identified actual contractures and risk for further contractures related to decreased mobility and right spastic hemiplegia, with an intervention for a resting right hand splint initiated. The resident’s range of motion assessment documented severely reduced right wrist ROM attributed to actual contracture and tone. The resident’s record and RNP task sheet specified that the splint was to be applied on all three shifts. Multiple observations over several days showed the resident in bed without the splint in place, while the splint was repeatedly seen lying on the resident’s wheelchair. A CNA reported never having seen the resident wear a brace, despite knowing the resident’s right arm was weak, and documentation by this CNA indicated the splint had been applied at a time when the resident was observed not wearing it. An LPN stated that the resident does not wear the splint and always refuses it, yet the splint continued to be observed off the resident and on the wheelchair. These observations and interviews demonstrated that the ordered splint was not consistently applied as care-planned and as required by the facility’s ROM/contracture management policy.
Failure to Document Provider Rationales for Disagreeing With Monthly MRR Recommendations
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling of monthly medication regimen review (MRR) recommendations, specifically the failure of providers to document rationales when disagreeing with or not clearly responding to pharmacist recommendations for two residents. For one resident admitted on 7/6/25, multiple MRRs contained pharmacist recommendations regarding psychotropic medications, potential gradual dose reductions (GDRs), monitoring for adverse effects, and evaluation of medication tolerability in the context of documented allergies. On 12/31/24, the pharmacist recommended considering a Trazodone GDR for insomnia; the provider marked “disagree” but did not document a rationale. On 3/30/25, the pharmacist recommended considering a clozapine GDR; again, “disagree” was checked without a rationale. On 4/28/25, the pharmacist suggested monitoring for bruising/bleeding with ASA/Clopidogrel, and “disagree” was checked with no rationale. On 5/4/25, the pharmacist requested evaluation of tolerability to Amoxicillin and Aspirin given penicillin and Excedrin allergies, and documentation was noted but neither “agree” nor “disagree” was selected. On 7/6/25, the pharmacist requested evaluation of Aspirin use with an Excedrin allergy and clarification of a “psych disorder” diagnosis per CMS, but there was no provider response. On 7/25/25, the pharmacist noted that an olanzapine “psych disorder” diagnosis would trigger an MDS quality indicator and recommended review of diagnosis and usage for possible GDR, as well as a risk vs. benefit analysis for methocarbamol per Beers criteria; neither “agree” nor “disagree” was selected and no rationale was documented. The NP (E7) confirmed she reviews pharmacist recommendations, consults with the pharmacist and psychiatric NP for psychotropic changes, and acknowledged that a rationale should be documented when a provider disagrees. The CNO (E11) confirmed that the attending physician failed to document actions taken or not taken in response to identified irregularities. For a second resident admitted on 10/13/23, the clinical record showed a 7/1/25 MRR in which the pharmacist recommended that lorazepam 0.5 mg twice daily be considered for GDR. There was no rationale documented by the provider in response to this recommendation. The NP (E7) stated she reviews monthly GDR recommendations, discusses findings with the psychiatric NP, and then documents her rationale on the pharmacy GDR form and in the electronic medical record. The DON (E3) reported that quarterly reviews of MRRs are conducted and findings are discussed with the medical director, and confirmed that the medical director did not include a rationale for the lorazepam recommendation. These interviews and record reviews demonstrated that the facility did not consistently ensure that providers documented rationales when disagreeing with or failing to clearly respond to pharmacist-identified medication irregularities during the MRR process.
Delay in Provider Notification and Treatment of Positive Urine Culture
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify the ordering practitioner of abnormal urine culture results for one resident. The resident was admitted to the facility and later complained of burning with urination. A nursing progress note documented that a urine sample was collected, an in-house dipstick was positive for blood and leukocytes, and a urinalysis and culture and sensitivity were ordered. The nurse documented that the NP was notified in the book, and a physician progress note confirmed that the urine had been picked up by the lab and that they were awaiting culture and sensitivity results. When the urine culture results became available, they showed a positive urinary tract infection with greater than 100,000 CFU of E. coli. The clinical record lacked evidence that the positive urine culture and resulting UTI were addressed for three days after the results were available. A physician’s order for an oral antibiotic (cefuroxime axetil) was not written until several days after the positive culture result. The medication administration record then showed that the antibiotic was initially not available and was not administered until the following day. A nursing progress note indicated that the pharmacy did not process the cefuroxime due to a documented allergy and that doses were obtained from a local pharmacy, resulting in an additional one-day delay. Interviews with nursing staff and the unit manager revealed that outside lab urine culture results are automatically uploaded into the resident’s chart, that staff are expected to monitor the chart and notify the provider when results appear, and that the outside lab generally does not call for positive urine culture results. The unit manager confirmed there was a delay in notifying the provider about the culture results for this resident.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with Alzheimer's disease and severe cognitive impairment. On the evening of the incident, a CNA witnessed another CNA allegedly push the resident and reported this to the supervising LPN, who instructed the witness to write a statement and leave it under the DON's door. Another CNA also witnessed the event and followed the same instructions. The supervising LPN did not read the statements or report the allegation to the state agency, and the accused staff member continued working on the unit. The DON became aware of the incident the following day and began an investigation but was unaware that the incident had not been reported as required by facility policy. There was no evidence that the facility reported the allegation of abuse to the appropriate state regulatory authority within the required timeframe. The findings were reviewed with facility leadership during the exit conference.
Failure to Suspend Accused Staff Member During Abuse Investigation
Penalty
Summary
The facility failed to follow its abuse policy by not suspending a staff member accused of abuse pending the outcome of an investigation. According to the facility's policy, any staff member accused of abuse should be immediately suspended while the investigation is conducted. On the evening of 5/16/25, a CNA reported to an LPN supervisor that another CNA had pushed a resident. The supervisor instructed the reporting CNA to write a statement and leave it for the DON. The following day, the DON was made aware of the incident and initiated an investigation, which included statements from involved staff and a head-to-toe assessment of the resident, with no injuries noted. Despite the policy requirement, the accused CNA was not suspended and continued to work their scheduled shifts during and after the investigation. This was confirmed by both the DON and the LPN supervisor during interviews. The investigation concluded that there was no evidence of abuse, but the failure to suspend the accused staff member during the investigation constituted noncompliance with the facility's own abuse prevention policy.
Deficiencies in Dining Environment, Privacy, and Shower Schedule Documentation
Penalty
Summary
The facility failed to provide a homelike dining environment for eight residents during meals. Observations revealed that meals were served on trays with plate warmers, and desserts were served in Styrofoam containers, which was not considered homelike. Interviews with staff confirmed that this practice was not in line with providing a dignified dining experience. Additionally, one resident was observed to have unclean hands during meals and was not routinely offered a washcloth or hand wipe, despite expressing a desire for clean hands. The facility also failed to maintain privacy for a resident with an indwelling catheter. The resident's catheter drainage bag was visible from the hallway, and staff did not use privacy bags to cover the urine-filled bag. Interviews with staff indicated a misunderstanding of the facility's requirements for using privacy bags, leading to the resident's privacy being compromised. Furthermore, the facility did not maintain privacy with shower schedules. A whiteboard in a common area displayed a list of residents scheduled for showers, along with notes indicating whether they had refused or completed their showers. This practice was deemed inappropriate as it exposed personal information in a public area, violating residents' rights to privacy.
Failure to Properly Explain Arbitration Agreement
Penalty
Summary
The facility failed to adequately explain the binding arbitration agreement to residents or their representatives, and did not provide an agreement that allowed for rescission within 30 days of signing. The arbitration agreement also lacked a clause permitting communication with federal, state, local officials, and the ombudsman. This deficiency was identified in three residents out of a sample of 34. The facility's arbitration agreement required rescission within 21 days, contrary to the 30-day period stipulated by regulations. Additionally, the agreement did not inform residents or their representatives of their right to communicate with relevant authorities. Resident 11, with intact cognition, was unaware of signing the arbitration agreement and did not recall it being explained. Resident 43, also with intact cognition, confirmed signing the agreement but stated it was not explained in a way that was understandable. Resident 89, with severely impaired cognition, had signed the agreement despite their condition. The Admissions Coordinator admitted to providing only a brief explanation of the agreement and was unaware of the 30-day rescission period. The facility's administrator acknowledged the missing components in the agreement and provided an updated version that still contained the same deficiencies.
Facility Fails to Provide Neutral Arbitration Process
Penalty
Summary
The facility failed to ensure that its arbitration agreement allowed for the selection of a neutral arbitrator and a convenient venue for arbitration, affecting three residents out of a sample of 34. The arbitration agreement, dated 01/01/24, required that all arbitrators be either a retired state or federal court judge or a member of the state bar with at least ten years of experience as an attorney, without mentioning the selection of a venue. This stipulation was found in the agreements signed by Residents 11, 43, and 89, with no provision for a neutral arbitrator or a mutually agreed-upon venue. Interviews with facility staff revealed a lack of awareness and understanding of the arbitration agreement's requirements. The Admissions Coordinator admitted to not discussing the right to a neutral arbitrator or an agreed-upon venue with residents and had not read the facility's arbitration agreement herself. The Administrator, when questioned about the missing components in the arbitration agreement, stated she would look into it but later provided an agreement that contained the same stipulations as the original. This oversight placed residents at risk of not having the opportunity to choose an arbitrator or venue.
Inadequate Infection Control and Wound Care Practices
Penalty
Summary
The facility failed to implement effective infection control protocols, particularly in the secured 300-unit, where COVID-19 precautions were not adequately followed. Observations revealed that isolation carts lacked necessary eye protection, and doffing bins were without lids, allowing residents to access soiled PPE. Staff were observed not wearing full PPE, such as goggles, and there was confusion about PPE requirements. Additionally, meal and laundry carts were not cleaned before exiting the unit, and there was no established process for cleaning and storing eye protection after use. Resident 89 was observed handling doffed gowns from open bins without hand sanitizing afterward, indicating a lapse in infection control measures. The Infection Preventionist confirmed the absence of lids on doffing bins and the lack of eye protection in isolation carts, acknowledging the need for clearer PPE guidelines. The Staff Development Coordinator also noted that isolation carts should be fully stocked and that doffing bins should have lids to prevent resident access. In a separate incident, during wound care for Resident 104, an LPN failed to change gloves after cleaning fecal material before applying ointment to a wound, which could lead to infection. The LPN acknowledged the mistake and noted that a Q-tip could have been used instead of fingers to apply the ointment. The Director of Nursing confirmed that the LPN should have changed gloves and used a tool to apply the ointment to prevent infection.
Failure to Honor Resident Self-Determination
Penalty
Summary
The facility failed to honor a resident's right to choose their preferred method of transferring, impacting Resident 43. Despite being cognitively intact and expressing fear of using a mechanical lift, the facility did not assist the resident with alternative transfer methods. The resident had a transfer board brought in by a family member, but it was removed by the facility for safety reasons. The Certified Occupational Therapy Assistant and the Director of Nursing acknowledged the resident's preference and the need for safety, but the facility's protocol did not allow for the use of the transfer board independently. The Social Service Director and the Administrator recognized the resident's right to make decisions, even if deemed unsafe, but the facility's actions did not reflect this understanding. Another deficiency involved Resident 42, who was not allowed to go outside as desired, despite being cognitively intact and expressing a preference for outdoor activities. The resident reported limited opportunities to go outside, with staff citing time constraints and supervision requirements as barriers. Interviews with staff confirmed that the resident was not permitted to go outside without supervision, and the Activity Coordinator acknowledged the resident's right to outdoor access. The Administrator also stated that the resident could go outside with supervision, indicating a need for staff education on resident rights. These deficiencies highlight the facility's failure to promote and facilitate resident self-determination, as required by resident rights. Both residents were at risk for psychosocial harm due to the facility's actions, which diminished their independence and ability to make choices about their daily lives. The facility's protocols and staff actions did not align with the residents' rights to make personal decisions, impacting their quality of life.
Resident Restrained with Wanderguard and Physical Force
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by the application of a Wanderguard to prevent the resident from leaving the facility. The resident, identified as R43, was cognitively intact and his own decision-maker, as indicated by a BIMS score of 13 out of 15. Despite this, the facility staff physically pulled him back into the building against his will while he was in his wheelchair, which was considered a physical restraint according to the facility's policy. The incident occurred when R43, who had a history of bilateral leg amputation below the knee, went outside to calm down after being upset. The staff followed him outside and eventually pulled him back into the facility when he refused to return on his own. The following day, a Wanderguard was attached to his wheelchair, which locked the doors when he approached them, further restricting his freedom of movement. Interviews with various staff members, including the Director of Nursing, Certified Occupational Therapy Assistant, and Social Service Director, confirmed that the actions taken by the staff met the definition of a physical restraint. The facility's policy clearly stated that restraints should not be used for coercion, discipline, convenience, or retaliation, yet the staff's actions contradicted this policy. The resident expressed his frustration, stating that he felt his freedom was being denied, which was contrary to his rights as a resident.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans for two residents, which placed them at risk for decreased quality of life and care. Resident 62, who had a moderately impaired cognition due to conditions such as cerebrovascular accident, dementia, and chronic obstructive pulmonary disease, was observed with padded side rails in an oversized bed. However, there was no care plan addressing the use of side rails or enabler devices, and no informed consent for their use was found in the resident's records. The MDS Coordinator admitted to being unaware of the side rails and acknowledged that they should have been included in the care plan. Resident 51, with severely impaired cognition and diagnoses including Alzheimer's disease, dementia, congestive heart failure, malnutrition, and dysphagia, had a physician order indicating no weight monitoring due to palliative care wishes. Despite this, there was no care plan reflecting the decision to forego weight monitoring. The Registered Dietitian and MDS Coordinator both confirmed the absence of a care plan for this aspect of the resident's care, with the RD stating she did not complete the nutritional assessment and the MDSC indicating it was the RD's responsibility.
Inadequate Care Plan for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure the Comprehensive Care Plan was accurate and updated for a resident with chronic gout and diabetes, who was admitted with a moderately impaired cognitive status and an unstageable pressure ulcer on the left heel. The care plan, which was supposed to be developed and revised by a team of health professionals, included interventions such as keeping the skin clean and dry, using lotion on dry skin, consulting a wound care provider, and using barrier cream and enhanced barrier protection. However, the care plan did not include specific interventions to off-load pressure from the resident's heel, which was observed to have a necrotic ulcer and was not elevated as required. Interviews with the resident's representative and a Licensed Practical Nurse revealed that the resident's heel was not being properly off-loaded, as there was no pillow or wedge to elevate the foot. The MDS Coordinator confirmed that the care plan interventions were not specific and acknowledged the use of a pre-set template rather than a resident-specific custom plan. This lack of specificity and failure to update the care plan placed the resident at risk for unmet care needs and a diminished quality of life.
Failure to Provide Dining Assistance for Resident with Alzheimer's
Penalty
Summary
The facility failed to provide adequate assistance with dining for a resident diagnosed with Alzheimer's disease, who was dependent on staff for eating. The resident, identified as having significant cognitive impairment, was observed during multiple lunch services where she was not adequately assisted or cued by staff. Despite being served meals, the resident was left alone for extended periods, resulting in minimal food intake. Staff interactions were limited to pointing at the food and occasionally pushing the table closer to the resident, without providing the necessary supervision or assistance. The resident's care plan indicated a need for assistance with activities of daily living, including eating, due to dementia and activity intolerance. Observations revealed that the resident was not consistently engaged or assisted during meals, which was contrary to the care plan's interventions. Interviews with staff, including the Director of Nursing and a Licensed Practical Nurse, confirmed that the resident required direct engagement and feeding assistance to eat effectively, especially given her dementia. The facility lacked a policy regarding assistance with eating, which contributed to the deficiency. Interviews with staff highlighted that the resident ate better with direct engagement, such as when her husband or certain staff members were present. Despite these insights, the facility did not ensure consistent one-on-one supervision or engagement during meals, leading to the resident's inadequate food intake.
Unsafe Toilet Environment for Resident
Penalty
Summary
The facility failed to provide a safe toilet environment for a resident, identified as R42, which created the potential for falls or skin injuries. R42, who was cognitively intact with a BIMS score of 14 out of 15, had a self-care deficit related to deconditioned status and weakness. The care plan indicated that R42 required assistance with daily hygiene and toileting. During an observation, the toilet in R42's bathroom was found to be black inside, and the commode placed over it was wobbly. The commode seat was too small for the frame, exposing cross bars and a rusted metal bar, which posed a risk of injury. Interviews with R42 and facility staff confirmed the unsafe condition of the commode. R42 mentioned that the commode had always been wobbly. The Director of Rehabilitation acknowledged that the seat was too small, and the Environmental Services Supervisor noted that the toilet was stained and would need replacement. The facility administrator admitted there was no policy for ensuring a safe, clean, comfortable, and homelike environment, highlighting a lack of oversight in maintaining resident safety.
Failure to Assess and Obtain Consent for Side Rail Use
Penalty
Summary
The facility failed to assess the need for side rails and obtain informed consent for a resident, identified as R62, who was reviewed for side rail use. R62 had a moderately impaired cognition with a BIMS score of eight out of 15 and was diagnosed with cerebrovascular disease, dementia, and dependence on supplemental oxygen. The resident required partial to moderate assistance for mobility, including rolling and transitioning from lying to sitting. Despite these needs, there was no documented order, evaluation, or assessment related to the use of side rails in R62's electronic medical record. Additionally, the care plan did not address the use of side rails or enabler devices, even though R62 was observed using padded side rails in an oversized bed. Interviews with facility staff revealed a lack of clarity and responsibility regarding the assessment and informed consent for side rail use. The Director of Nursing and the Administrator referred to the side rails as enablers, while a Licensed Practical Nurse indicated that occupational or physical therapy would handle such assessments. However, a Certified Occupational Therapy Assistant stated that no evaluation was conducted because the side rails were part of the bed, and informed consent was assumed to be the responsibility of physical therapy. The MDS Coordinator confirmed that side rails should be included in care plans but was unaware of R62's use of side rails, highlighting a communication gap within the interdisciplinary team.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with post-traumatic stress disorder (PTSD), which was identified during a survey. The resident, who was admitted with diagnoses including a stroke and Parkinson's disease, had a severely impaired cognitive status and exhibited symptoms such as depression, decreased energy, mood swings, and visual hallucinations. Despite a positive trauma screening indicating the recent death of the resident's twin brother as a traumatic event, the facility's care plan lacked specific interventions or identification of triggers to address the resident's trauma. Observations and interviews revealed that the facility's staff, including the Social Services Director (SSD) and the MDS Coordinator (MDSC), did not effectively communicate or implement trauma-informed care practices. The SSD acknowledged the lack of specific guidelines or education for staff on handling residents with PTSD, and the MDSC confirmed that the trauma care plan was not detailed enough to assist staff in managing the resident's trauma-related behaviors. This deficiency placed the resident at risk of unmet needs and a diminished quality of life.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure the availability and administration of medications for a resident, identified as R92, who was admitted with diagnoses including Parkinson's disease and hemiplegia following a stroke. The facility's policy on using an electronic interim box for emergency and non-emergency medication dosing was not effectively implemented, resulting in missed doses of prescribed medications. Specifically, R92 did not receive the Cyanocobalamin Oral Tablet 50 MCG on 18 of 24 opportunities in August and 11 of 18 opportunities in September. Additionally, the resident missed several doses of Lubricating Eye Drops, with eight missed opportunities in September alone. Interviews with staff revealed a lack of communication and follow-up regarding the unavailability of medications. RN2 acknowledged that the facility had a Pyxis system and that medications could be obtained from a local pharmacy if necessary, yet R92 still went without his prescribed medications. LPN5 confirmed that the resident missed doses and expressed uncertainty about why medications were not automatically refilled. The Nurse Practitioner was unaware of the medication lapses, indicating a breakdown in communication and escalation procedures within the facility. The Director of Nursing confirmed that the pharmacy made multiple daily deliveries and could expedite medication requests, emphasizing that residents should not miss medications. Despite these resources, the facility did not take adequate steps to ensure R92 received his medications as prescribed, highlighting a deficiency in the facility's pharmaceutical services and medication management processes.
Failure to Administer Prescribed Antibiotics
Penalty
Summary
The facility failed to ensure that a resident received necessary antibiotics for a diagnosed tooth abscess and moderate protein-calorie malnutrition. The resident, who was cognitively intact with a BIMS score of 14, was prescribed Amoxicillin to be administered four times daily. However, the medication was not administered on several occasions due to unavailability from the pharmacy, as documented in the resident's Medication Administration Record (MAR) and progress notes. The facility's policy on utilizing an electronic interim box for emergency and non-emergency dosing was not effectively implemented, leading to missed doses on specific dates. Interviews with facility staff, including a registered nurse, a nurse practitioner, and the Director of Nursing, revealed that antibiotics are considered significant medications, and the resident should not have missed multiple doses. The staff acknowledged the oversight and indicated that the medication should have been retrieved from the Pyxis system, which was equipped to handle such situations. The nurse practitioner was unaware of the missed doses and stated that she would have extended the order if informed. The Director of Nursing emphasized that residents should not go multiple days without medication, highlighting a lapse in communication and medication management within the facility.
Expired Insulin Pen Administered to Resident
Penalty
Summary
The facility failed to ensure that an insulin pen used for a resident was not expired, which increased the risk of the insulin not being effective. During an observation of a medication cart, a Humalog Kwik pen with approximately 61 units remaining was found to be expired. The Licensed Practical Nurse (LPN) confirmed that the resident had received the expired insulin at least five times. The Director of Nursing (DON) stated that expired insulin should not be administered, indicating a lapse in adherence to the facility's medication storage policy.
Failure to Provide Finger Food Diet for Resident with Dementia
Penalty
Summary
The facility failed to provide menu extensions for finger foods for a resident with severe cognitive impairment, which could potentially lead to weight loss due to difficulty in eating. The resident, identified as R89, was on a finger food diet due to dementia and was receiving hospice care. Despite the diet order specifying finger foods, the facility's menu extensions did not include this option, and the resident was served meals that were not conducive to self-feeding with fingers, such as mashed potatoes and canned pears. Observations revealed that R89 struggled to eat certain foods with her fingers, such as mandarin oranges and peas, which were not suitable for a finger food diet. The facility's Registered Dietitian (RD) and Dietary Manager (DM) were unaware of the specific dietary needs of R89, and the corporate Registered Dietitian (CRD) confirmed that the menus did not include finger food extensions. The lack of communication and coordination between the dietary staff and nursing staff contributed to the oversight in providing appropriate meals for R89. Interviews with facility staff indicated a lack of awareness and understanding of the resident's dietary needs. The Licensed Practical Nurse (LPN) acknowledged the finger food alert on R89's meal ticket but considered it a recommendation rather than a requirement. The CRD admitted that oatmeal, which was served to R89, was not a suitable finger food, highlighting the inconsistency in meal preparation and delivery for residents with specific dietary orders.
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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