Cadia Rehabilitation Silverside
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, Delaware.
- Location
- 3322 Silverside Road, Wilmington, Delaware 19810
- CMS Provider Number
- 085056
- Inspections on file
- 20
- Latest survey
- December 1, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Cadia Rehabilitation Silverside during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was subjected to alleged abuse by a CNA, who stuck her tongue out and threw wipes at the resident during care. The incident was witnessed and reported to an LPN, but not escalated to the Abuse Coordinator as required. The accused CNA continued working for several days before the incident was formally reported, in violation of facility policy and reporting requirements.
Staff failed to consistently follow infection prevention and control protocols, including proper use of PPE, hand hygiene, and adherence to transmission-based precautions. Multiple staff members, including nursing, housekeeping, and leadership, were observed entering rooms on enhanced barrier or contact precautions without appropriate PPE or hand hygiene, and performing resident care tasks without changing gloves or sanitizing equipment. These actions were contrary to facility policy and involved residents with conditions such as ESBL, MRSA, and those under COVID-19 precautions.
The facility did not ensure medications were administered as ordered, resulting in a medication error rate of 10%. Two residents received medications after meals that were prescribed to be given before eating, with nursing staff acknowledging the timing errors. The DON confirmed that medications are expected to be administered according to orders and packaging instructions.
The facility did not properly maintain the outdoor garbage area, as a large dumpster without a lid was left on site containing ripped garbage bags with exposed food waste, and garbage was observed scattered on the ground. Staff confirmed the lack of a policy for dumpster area maintenance and acknowledged that the area was not kept clean or secured against pests.
The facility did not properly inform residents about its grievance policy or the process for filing complaints, with several residents unaware of how to voice concerns or who to contact. In multiple cases, grievances related to housekeeping and personal property were not fully investigated or resolved, and staff interviews revealed inconsistent application of the grievance process.
Multiple residents experienced abuse or mistreatment, including a resident with severe cognitive impairment who was subjected to inappropriate behavior by a CNA, a resident who was struck by another resident, and a cognitively intact resident who reported rude and rough treatment by a CNA. In each case, there were failures in timely reporting, intervention, or prevention of abuse, as well as lapses in staff conduct and adherence to facility policy.
A resident with multiple diagnoses and intact cognition developed a swollen, bruised thumb after an altercation with a CNA. While the facility investigated and ruled out staff-to-resident abuse, no further investigation was conducted to determine the cause of the injury once abuse was unsubstantiated, contrary to facility policy regarding injuries of unknown origin.
A resident with hypertension was prescribed Propranolol HCl with instructions to hold the dose if the heart rate was below 50. On multiple occasions, staff failed to document the required heart rate before administering the medication, as confirmed by the DON.
A resident with cognitive impairment and a history of falls was not provided with required fall prevention measures, including a low bed and bilateral floor mats, as outlined in the care plan and physician orders. Multiple observations confirmed the absence of these interventions, and facility leadership acknowledged the deficiency.
A resident with severe cognitive impairment and an indwelling urinary catheter was repeatedly observed with the catheter bag and tubing in contact with the floor, contrary to facility policy and staff knowledge. Despite staff awareness that the resident frequently removed the bag from its proper position, no care plan was initiated or revised to address this ongoing issue.
The facility failed to notify the responsible party of a resident with severe cognitive impairment about an ulceration on the resident's left shoulder blade. Despite the facility's policy requiring such notifications, there was no documentation indicating that the responsible party was informed. The wound care nurse and the facility administrator confirmed the lapse in communication.
A resident's room was not properly cleaned, with observations confirming dirt, debris, and heavy dust buildup. The resident, who was cognitively intact and had chronic conditions, reported inadequate cleaning. The Housekeeping Director acknowledged the issue and cited a lack of training for a new employee.
The facility failed to protect two residents from physical abuse by CNAs. One resident with dementia reported being roughly handled by two CNAs, and another resident with functional quadriplegia reported similar rough treatment. Both incidents were substantiated through investigations, and the involved CNAs were terminated.
A resident reported that a CNA was rough with her during care, but the facility delayed reporting the incident to the State Agency by five days. The delay occurred because the DON initially considered it a customer service issue rather than an abuse allegation.
The facility failed to conduct thorough investigations into allegations of potential abuse involving two residents. In one case, a resident reported being injured by another resident, but the investigation was limited to interviews with the involved parties and a physical assessment. In another case, a resident reported rough handling by a CNA, but no additional interviews were conducted. Both investigations were deemed incomplete by the facility's administration.
The facility failed to complete a smoking assessment and secure smoking materials for a resident identified as a smoker. Despite the facility's non-smoking policy, the resident had smoking materials in his room and admitted to smoking off the property. Staff members were unaware of the resident's smoking activities and possession of smoking materials, leading to the deficiency.
The facility did not provide the required 30 days for a resident or their responsible party to rescind the Binding Arbitration Agreement, instead allowing only 21 days. This was confirmed by the Admission Coordinator, who noted that no arbitration cases had been pursued.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of staff-to-resident abuse involving a resident with severe cognitive impairment. The incident occurred when a Certified Nursing Assistant (CNA) stuck her tongue out at a resident and threw three wipes toward the resident's head during care. Another CNA witnessed the event and reported it to a Licensed Practical Nurse (LPN), but the incident was not reported to the facility's Abuse Coordinator until several days later. During this period, the accused CNA continued to work scheduled shifts in the facility. The resident involved had a history of cerebral infarction, unspecified dementia with agitation, and major depressive disorder, and was assessed as severely cognitively impaired. The incident was witnessed by a second CNA, who reported it to the LPN. The LPN did not escalate the report, believing that keeping the CNA away from the resident was sufficient. Additionally, a Unit Clerk learned of the incident but failed to report it immediately, only recalling to do so days later. The facility's policy required immediate reporting of suspected abuse to the appropriate authorities and immediate suspension of the accused staff member pending investigation. However, the delay in reporting allowed the accused CNA to remain on duty and interact with other residents. The deficiency was identified during a survey, which found that the facility did not follow its own policy or regulatory requirements for timely reporting of abuse allegations.
Removal Plan
- Implemented a Removal Plan to address the deficient practice
- Developed a Performance Improvement Plan (PIP) in response to the incident
- Reviewed the Performance Improvement Plan (PIP)
- Selected residents randomly for review regarding abuse
- Provided re-education to all staff for abuse and the proper reporting of abuse
Failure to Follow Infection Prevention and Control Protocols
Penalty
Summary
Multiple breaches in infection prevention and control protocols were observed throughout the facility, involving both nursing and non-nursing staff. Staff failed to follow established policies for transmission-based precautions, hand hygiene, and the use of personal protective equipment (PPE) during resident care. For example, an LPN entered a resident's room on enhanced barrier precautions without PPE, handled tube feeding equipment that had fallen on the floor without sanitizing it, and administered medications without proper hand hygiene. A CNA performed incontinent care and changed linens without changing gloves between dirty and clean tasks, and both the LPN and CNA failed to use PPE appropriately during these activities. Additionally, staff were observed entering and exiting rooms on enhanced barrier precautions without washing or sanitizing their hands, and in some cases, without donning required gowns or gloves. Housekeeping staff also failed to adhere to contact precaution protocols. One housekeeper entered a resident's room, which was under contact precautions for ESBL in urine, without wearing a gown or gloves and used the same cleaning equipment in multiple rooms. The housekeeper was unaware of the need to use PPE, and the infection preventionist confirmed that housekeeping staff should have been using PPE in such situations. Nursing staff were also observed entering the same resident's room without donning a gown, despite clear signage and available PPE supplies, and incorrectly believed that PPE was only necessary if direct contact with bodily fluids occurred. Further deficiencies were noted in medication administration practices, with a nurse observed popping medications into their hand before placing them in a medication cup, contrary to facility policy. Leadership staff, including the ADON and LPN supervisors, were observed entering and exiting rooms on enhanced barrier precautions without proper hand hygiene or PPE use. In one instance, linen was picked up from the floor without appropriate PPE. The facility's policies for COVID-19 precautions were also not consistently followed, with some staff uncertain about the requirements for droplet and contact precautions and the use of PPE for residents under quarantine.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration Timing
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required. During a medication pass observation, three errors were identified out of 30 opportunities, resulting in a 10% error rate. Specifically, one resident with attention deficit disorder and gastroesophageal reflux disease was administered ritalin and omeprazole after having already eaten breakfast, despite both medications being ordered to be given before meals. The nurse administering the medications acknowledged awareness of the timing requirements but cited other responsibilities as a reason for not adhering to the prescribed schedule. Another resident with diabetes was prescribed glipizide to be given 30 minutes before meals on specific days. However, the medication was administered after the resident had already received her breakfast tray. The nurse involved confirmed the timing of administration and did not provide further explanation when questioned about the correct timing. The Director of Nursing stated that medications are expected to be given as ordered and according to blister package instructions.
Improper Disposal and Maintenance of Outdoor Garbage Area
Penalty
Summary
The facility failed to maintain the outdoor garbage and dumpster area in a manner that would prevent pests from accessing garbage. Observations over several days revealed a large dumpster without a lid, filled with garbage bags, some of which were ripped or torn, exposing food scraps and containers. Garbage, including cigarette butts, paper, and cardboard, was also found scattered on the ground around the compactor area. The Dietary Manager confirmed the presence of garbage on the ground and acknowledged that maintenance was responsible for cleaning the area. The large dumpster had been used while the compactor was being repaired, but even after the compactor was returned, the dumpster remained on site, still uncovered and containing exposed waste. Interviews with facility staff indicated that there was no policy in place regarding the maintenance of the dumpster area. The Maintenance Director stated that the dumpster had been present for a couple of weeks and that waste management did not provide dumpsters with lids. Maintenance staff typically cleaned the area twice a week. The Registered Dietitian reported that her sanitation inspections included checking the dumpster area to ensure it was not overfilled, the lid was closed, and there was no garbage on the ground, but the large dumpster did not have a lid. The Administrator confirmed the absence of a facility policy for dumpster area maintenance and acknowledged that the dumpster should have been covered.
Failure to Inform Residents of Grievance Policy and Inadequate Grievance Resolution
Penalty
Summary
The facility failed to adequately inform residents about its grievance policy and the process for filing complaints, as well as the identity and contact information of the grievance official. Seven residents interviewed during a resident council meeting stated they were unaware of any formal complaint process or postings about grievances, and none knew who the designated grievance officer was, except for the social worker. The facility's grievance policy was posted in a location that was difficult to read, and there was no evidence that the grievance process was discussed in resident council meetings or communicated to residents who did not attend. In the case of one resident, a family member reported multiple grievances regarding poor housekeeping, including unclean rooms and bathrooms, and inadequate cleaning of public areas. While some grievances were documented and investigated, at least one concern related to housekeeping was not addressed or responded to, despite being reported on a Resident Concern Form. Interviews with staff confirmed that the grievance process was inconsistently followed, with some concerns not being investigated or resolved as required by policy. Two additional residents experienced issues related to personal property. One resident had a small refrigerator removed from her room without explanation, and there was no documentation or policy provided to justify the removal. Another resident reported a missing electric razor, which was not documented as a grievance or thoroughly investigated, despite the resident's dependence on the item for personal care and his report that previous razors had been broken during care. Staff interviews revealed a lack of clarity about whether these incidents should have been treated as grievances and how they should have been addressed according to facility policy.
Failure to Protect Residents from Abuse and Timely Reporting
Penalty
Summary
The facility failed to protect residents from abuse and did not ensure timely reporting and intervention in multiple incidents involving both staff-to-resident and resident-to-resident abuse. In one case, a resident with severe cognitive impairment experienced an incident where a CNA threw wipes at her head and made inappropriate gestures during care. The incident was witnessed by another CNA, who reported it to an LPN, but the event was not reported to the Abuse Coordinator until four days later. This delay allowed the CNA involved to continue working scheduled shifts after the incident. Another incident involved resident-to-resident aggression, where a resident with moderate cognitive impairment reported being struck in the face by another resident during the night. The incident was unwitnessed and only reported the following day. The care plans for both residents indicated a history or risk of behavioral issues, but the incident still occurred, and the facility's response included room changes and psychiatric evaluations after the fact. Interviews with staff and residents confirmed the event and the subsequent interventions, but the initial failure to prevent or immediately address the aggression was noted. A third incident involved a cognitively intact resident who, along with a family member, reported being treated rudely and roughly by a CNA during care, including being told to clean his room and experiencing pain when his brief was handled. The resident and family member reported the events to nursing staff, who then involved the social worker and ADON. The CNA involved admitted to making inappropriate comments, and the investigation could not identify a second staff member involved in the alleged rough handling. The facility's documentation and interviews confirmed that the resident experienced distress and pain as a result of the CNA's actions.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that an injury of unknown origin was properly investigated for one resident. The resident, who had diagnoses including cerebral palsy, major depressive disorder, and anxiety disorder, was cognitively intact at the time of the incident. The resident reported that a CNA pinched his thumb after he threw a soda can at her, resulting in a 1.5 cm by 1.5 cm purple area with swelling on his thumb. An initial investigation was conducted to determine if staff-to-resident abuse had occurred. The CNA involved was suspended, witnesses were interviewed, and video footage was reviewed, all of which led to the conclusion that the allegation of abuse was unsubstantiated. The emergency room records from the same day did not document the thumb injury, and the facility's investigation focused solely on the abuse allegation. After ruling out staff abuse as the cause, the facility did not pursue further investigation into the origin of the resident's thumb injury, despite facility policy requiring all injuries of unknown source to be investigated. Interviews with facility leadership confirmed that the injury should have been considered of unknown origin and investigated accordingly, but no additional documentation or follow-up was completed to determine how the injury occurred.
Failure to Document Heart Rate Prior to Propranolol Administration
Penalty
Summary
A deficiency occurred when the facility failed to follow physician's orders for a resident who was readmitted for hypertension. The physician's order required administration of Propranolol HCl 40 mg orally twice daily, with instructions to hold the medication if the resident's heart rate (HR) was less than 50. Review of the Medication Administration Record (MAR) showed that on several occasions, the required HR was not documented prior to medication administration: specifically, the morning dose on one date and the bedtime dose on four separate dates. The Director of Nursing (DON) confirmed that the HR was not taken as ordered on these dates.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
A deficiency was identified when staff failed to implement and follow fall prevention interventions for a resident with a history of falls and cognitive impairment. The resident, who had been readmitted with fractures to the right pelvis and shoulder, was assessed as being at high risk for falls due to impaired cognition, deconditioning, and gait/balance problems. The care plan included interventions such as bilateral fall mats, but did not reflect a physician's order for a low bed issued on a later date. Multiple observations over several days showed the resident in a standard-height bed without bilateral floor mats in place, contrary to the documented care plan and physician orders. Interviews and record reviews confirmed that the required fall interventions were not consistently implemented. The Assistant Director of Nursing (ADON) acknowledged that the resident did not have the prescribed bilateral floor mats and that the bed remained at standard height. This lack of adherence to the care plan and physician orders for fall precautions constituted a failure to ensure the environment was free from accident hazards and that adequate supervision and interventions were provided to prevent accidents.
Failure to Maintain Proper Catheter Bag Positioning and Care Planning
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was repeatedly observed with the catheter bag and tubing in direct contact with the floor while in bed. Multiple observations over several days documented the catheter bag hanging from the side of the bed, uncovered and either skimming or resting completely on the floor. Facility policy requires catheter bags to be positioned below the bladder but off the floor, and to be covered for privacy. Staff interviews confirmed knowledge of the correct procedure, but also acknowledged that the resident frequently removed the bag from its hook, resulting in improper placement. Record review revealed that there was no care plan initiated or revised to address the resident's non-compliance with catheter care management, despite the ongoing issue. The resident had severe cognitive impairment and a history of urinary tract infection, and required a catheter per physician orders. Staff, including CNAs and an LPN, confirmed the improper placement of the catheter bag and stated that the resident often pulled the bag off the hook. The DON stated that staff should monitor catheter placement and report any issues, and that care planning should occur if a resident repeatedly interferes with catheter management.
Failure to Notify Responsible Party of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure the responsible party for a resident with pressure ulcers was notified of the resident's change in condition. The facility's policy required staff to notify the provider and applicable POA/responsible parties of significant changes in the resident's condition. However, in the case of a resident with severe cognitive impairment, there was no documentation indicating that the responsible party was informed about an ulceration on the resident's left shoulder blade, which was identified during care and documented in an incident report and progress notes. The wound care nurse confirmed that the family was not notified of the abrasion on the shoulder, despite the facility's policy and the expectation that the staff would complete the incident report and notify the responsible party. The resident's medical history included Parkinson's disease, dementia, abnormal posture, muscle weakness, and acute embolism and thrombosis of the left iliac vein. The incident report and progress notes documented the presence of an abrasion on the resident's left posterior shoulder, which was attributed to a screw on the wheelchair. A physical therapy consult was recommended to evaluate the wheelchair and address the source of the abrasion. Despite these findings, there was no documentation of notification to the resident's responsible party, which was confirmed by both the wound care nurse and the facility administrator.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a resident's room was properly cleaned to maintain a homelike environment. The resident, who was cognitively intact and had multiple chronic conditions including respiratory failure and COPD, reported that their room was not being cleaned adequately. Observations confirmed the presence of dirt and debris around the bed, a heavy buildup of dust on the bed frame, air mattress pump frame, and bedside table. The resident expressed dissatisfaction with the cleaning, stating that the housekeeping staff had not been properly trained on how to clean the room effectively. Further observations revealed that the room remained in the same unclean condition over several days. The Housekeeping Director confirmed the heavy buildup of dust and dirt and acknowledged that a new employee might not have been adequately trained. The facility's housekeeping procedure outlined a five-step cleaning process, which included disinfecting horizontal surfaces and dusting hard-to-reach areas, but these steps were not followed in the resident's room.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to ensure that two residents remained free from physical abuse. Resident 86, who has dementia with mood and behavior disturbances, reported being roughly handled by two CNAs. The incident was substantiated through an investigation that included witness statements from another staff member and a resident. Both CNAs involved were suspended during the investigation and subsequently terminated for their actions. Resident 62, who has functional quadriplegia and cognitive communication deficits, reported being roughly handled by a CNA while being turned in bed. The resident's account was corroborated by another CNA who witnessed the incident and observed the resident visibly upset and crying. The CNA involved was terminated following an investigation that included interviews with the resident and the witnessing CNA. Both incidents were confirmed by the facility's Director of Nursing and Administrator, who were not employed at the time of the initial investigation but reviewed the substantiated reports. The facility's policy on abuse, neglect, and mistreatment was not adhered to, resulting in physical abuse of the residents.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure that an allegation of staff-to-resident abuse was reported timely to the State Agency. The incident involved a resident who reported that a Certified Nursing Assistant (CNA) had been rough with her while providing care and turning her in bed. The resident, who had a BIMS score indicating intact cognition, reported the incident to the administration on the same day it occurred. However, the Facility Reported Incident (FRI) was not submitted until five days later, despite the facility's policy requiring immediate reporting of such incidents. During an interview, the Administrator confirmed that the facility was aware of the allegations on the day they occurred but did not report the incident until five days later. The delay was attributed to the Director of Nursing (DON) initially considering the issue to be a customer service matter rather than an abuse allegation. This failure to report the incident in a timely manner had the potential to place the resident at risk for further abuse.
Incomplete Investigations into Allegations of Potential Abuse
Penalty
Summary
The facility failed to ensure a thorough investigation was completed related to allegations of potential abuse for two residents. In the first case, a resident with rheumatoid arthritis and moderate cognitive impairment reported that another resident, who was severely cognitively impaired, threw a wheelchair leg rest on her foot. The facility's investigation was limited to interviews with the two involved residents and a physical assessment of the injured resident, which showed no significant injury. No additional staff or resident interviews were conducted, and the investigation was deemed incomplete by the Director of Nursing (DON) and the Administrator during a follow-up interview with surveyors. In the second case, a resident with functional quadriplegia and intact cognition reported that a Certified Nursing Assistant (CNA) was rough during care. The facility's investigation did not include interviews with other residents or staff members. The Administrator admitted that she did not feel it was necessary to conduct additional interviews because the resident was alert and oriented. Upon further review, the Administrator confirmed that the investigation was incomplete. Both incidents highlight the facility's failure to adhere to its own policy, which mandates thorough investigations involving interviews with all persons identified as involved or with knowledge of the occurrence. The lack of comprehensive investigations into these allegations of potential abuse resulted in deficiencies in ensuring resident safety and compliance with regulatory requirements.
Failure to Complete Smoking Assessment and Secure Smoking Materials
Penalty
Summary
The facility failed to complete a smoking assessment and secure smoking materials for a resident identified as a smoker. Despite the facility's policy prohibiting smoking on the premises, the resident was found to have smoking materials in his room and admitted to smoking off the property. The resident's electronic medical record did not contain a smoking assessment, and staff members, including the Administrator and the Director of Nursing, were unaware of the resident's smoking activities and possession of smoking materials. Interviews with various staff members revealed that the resident had been smoking for some time, and smoking materials such as lighters and vapes had been repeatedly confiscated from his room. The resident confirmed that he smoked occasionally and did not inform the staff about his smoking activities or possession of smoking materials. The facility's failure to adhere to its smoking policy and properly assess and monitor the resident's smoking behavior led to the deficiency identified in the report.
Failure to Allow 30-Day Rescission Period for Arbitration Agreement
Penalty
Summary
The facility failed to allow 30 days for a resident or their responsible party to rescind the voluntary Binding Arbitration Agreement after it was signed. The facility's Attachment #3: Binding Arbitration Agreement stated that the agreement could be rescinded within twenty-one (21) days of the date upon which it was signed, instead of the required 30 days. This discrepancy was confirmed during an interview with the Admission Coordinator, who acknowledged that the form allowed only 21 days for rescission. No instances of arbitration being pursued were reported.
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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