Complete Care At Hillside Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, Delaware.
- Location
- 810 South Broom Street, Wilmington, Delaware 19805
- CMS Provider Number
- 085013
- Inspections on file
- 17
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Complete Care At Hillside Llc during CMS and state inspections, most recent first.
Surveyors found that shower rooms on multiple floors had cracked and broken tiles, standing water, dripping shower heads, discolored walls, and clutter that blocked access to handwashing sinks, as confirmed by CNAs who reported difficulty washing hands due to equipment stored in these areas. Hallway carpets and several residents’ room floors were repeatedly observed to be visibly soiled, and the ESD acknowledged there was no established carpet-cleaning schedule. Additionally, a shower bed cushion with multiple surface openings exposing permeable foam was left in use for an extended period, with staff confirming its damaged condition and the inability to properly disinfect it.
A cognitively intact resident with orthostatic hypotension and heart failure reported that a male CNA entered the room without knocking or announcing himself and attempted to remove the resident’s underwear while the resident was asleep in order to check for incontinence. The resident described feeling tugging at the hip and being told he had to take his underwear off, though he denied any sexual touching. Surveyors determined that staff attempted to provide incontinence care without first waking the resident or obtaining permission, resulting in a failure to maintain the resident’s dignity and right to self-determination.
The facility failed to follow professional standards and state scope-of-practice requirements by allowing LPNs to complete admission assessments and initial post-fall assessments that must be performed by an RN, and by not ensuring RN involvement in discharge education. In two separate admissions, an LPN completed the full admission nursing assessment and related evaluations instead of an RN. For another resident, the discharge plan was documented by non-licensed staff, and there was no evidence in the record that an RN provided or documented discharge teaching. In a fall event involving a resident with dementia and cancer, an LPN completed the initial neurological and post-fall assessment, with no RN assessment documented.
A resident who was totally dependent on staff for ADLs due to a stroke was care planned to receive regular showers or bed baths according to his preferences and to follow a twice-weekly bathing schedule. Review of documentation showed that, over multiple scheduled opportunities, the resident was bathed only twice, refused once, and on two scheduled days no bath or shower was provided and no reason was documented in the record for the missed care. Progress notes lacked any explanation for these missed bathing events, and facility leadership confirmed the documentation gaps during the survey.
A facility failed to implement timely Transmission Based Precautions for residents with respiratory symptoms, leading to potential infection spread. One resident with End Stage Renal Disease and a history of stroke tested positive for influenza but was not immediately isolated. Another resident with a leg fracture showed symptoms but lacked TBP signage and PPE. A third resident with chronic conditions was not isolated until after testing positive for COVID-19. The DON and IP confirmed the delay in isolation, acknowledging the risk of infection spread.
The facility failed to ensure medications were not left at the bedside for two residents who were not assessed to self-administer medications. One resident had two inhalers left by a nurse without orders for self-administration, while another resident had an inhaler on the bedside table despite not being care planned for self-administration. Staff were aware of the medications but did not take appropriate action.
A resident with multiple health conditions was found with the call light out of reach, compromising their ability to maintain independence and dignity. Despite being cognitively intact, the resident was observed multiple times with the call light clipped to the wall behind them. Facility staff, including an LPN and the Administrator, confirmed that call lights should be within reach, indicating a lapse in standard care practices.
The facility failed to investigate allegations of misappropriation of property involving two residents. A resident reported that a CNA took cigarettes and money from them, but the Facility Reported Incident lacked evidence of interviews with other residents or staff. The Administrator could not recall how the CNA accessed a secured drawer and admitted that interviews are typically conducted during investigations, but no further information was provided.
A facility failed to develop a comprehensive care plan for a resident requiring nebulizer treatment. The resident, with diagnoses of heart failure, diabetes, and breast cancer, had an order for Ipratropium-Albuterol Solution via nebulizer twice daily for wheezing and coughing. However, the care plan for this treatment was not documented in the electronic medical record. The ADON acknowledged the oversight but could not explain the absence of the care plan.
The facility failed to provide adequate personal hygiene services to two residents who were unable to perform activities of daily living. One resident, who preferred showers, did not receive them on multiple assigned days, while another resident was bathed only once over a month despite requiring assistance. Staff interviews confirmed these deficiencies, and the Administrator emphasized the need for proper documentation.
A resident with a history of diabetes and other conditions was not provided with an air mattress as recommended by the wound care team, despite being at risk for pressure ulcers. Observations confirmed the resident was on a regular mattress, and there was a discrepancy in the application of Santyl ointment for a stage three wound. Staff interviews revealed communication lapses and failure to implement recommended interventions.
A resident with a Foley catheter was observed with the catheter bag improperly positioned, lying on the floor and unsupported, contrary to the facility's policy. Staff interviews confirmed that catheter bags should be kept off the floor and supported, yet observations showed repeated non-compliance, indicating a failure in maintaining appropriate catheter care.
A resident with heart failure, diabetes, and breast cancer did not receive proper respiratory care as per facility policy. The resident's nebulizer was found dirty and improperly stored, with the mouthpiece wrapped in paper towels. The resident reported that nursing staff did not turn off the nebulizer after use. The DON confirmed the nebulizer's poor condition, and an LPN admitted to not following proper procedures during treatment.
The facility failed to attempt alternative measures before installing bed rails for two residents, despite assessments indicating that bed rails should not be used. Both residents had cognitive scores indicating no impairment, and their care plans included bed rails without exploring alternatives. Interviews revealed that staff were unaware of the assessments' recommendations and did not discuss alternatives with residents. The facility's policy requires a person-centered approach and consideration of alternatives, which was not adhered to.
A facility failed to obtain informed consent for psychotropic medications for a resident with severe cognitive impairment and depression. The resident was receiving Trazadone and hydroxyzine without documented discussions of risks and benefits with the resident or representative. The Director of Nursing and Administrator confirmed the absence of informed consent documentation, contrary to facility policy.
A resident with type 2 diabetes received insulin improperly due to an LPN removing the needle too quickly, contrary to facility policy. The LPN was unaware of the requirement to keep the needle in the skin for the specified duration, as confirmed by the facility's Infection Preventionist and Educator.
The facility failed to label insulin pens with open dates, as required by their procedure, for three residents. Observations revealed that insulin pens in medication carts lacked open or discard dates, which was confirmed by the LPNs and the Infection Preventionist. This oversight could lead to the administration of expired medications.
A facility failed to document the education and consent process for a resident receiving the pneumococcal vaccine. The policy requires that residents or their representatives be informed of the risks and benefits before vaccination, with this information recorded in the clinical record. However, a review of the resident's EMR showed no evidence of such documentation prior to administering the Prevnar 20 vaccine. This oversight was confirmed by the Infection Preventionist.
A resident with moderate cognitive impairment and chronic health conditions was unable to use a malfunctioning call light to request assistance during an episode of wheezing and coughing. The facility's policy mandates immediate reporting and repair of non-functioning call lights, but this issue was not addressed promptly.
The facility failed to ensure the activities program was directed by a qualified professional, as the current Activities Director, previously an Activity Assistant, was not yet certified. The Administrator noted the previous director's unexpected passing and recruitment challenges, allowing the acting director to complete her training.
The facility failed to implement a care plan for a resident's continuous use of oxygen, despite physician's orders for oxygen therapy due to acute respiratory failure with hypoxia. This deficiency was identified during a record review and discussed with facility staff.
A resident with multiple diagnoses became unresponsive, and the facility failed to perform a nursing assessment, including vital signs, before transporting the resident to a hospital. The RN Supervisor encountered errors with the blood pressure machine and did not use the available Emergency Cart equipment.
The facility failed to provide competent nursing care for a resident with acute respiratory failure, as the RN on duty did not perform a manual blood pressure assessment or use available emergency respiratory supplies. The RN had not received hands-on training for the emergency cart and was the only RN on duty, with no policy for RN Supervisors in place.
Failure to Maintain Clean, Accessible Shower Rooms and Resident Care Equipment
Penalty
Summary
Surveyors identified that the facility failed to maintain clean, sanitary, and home-like shower rooms and resident areas on the second, third, and fourth floors. During multiple tours, the second-floor shower room was observed with cracked tiles, standing water on the floor, discolored walls, and water dripping from the shower head. The handwashing sink in this room was inaccessible due to multiple pieces of equipment, including wheelchairs and mechanical lifts, and a large amount of black debris was seen in an area between the wall and window where a heater had previously been located. CNAs reported that they were not able to access the handwashing sinks in the shower rooms because of the amount of equipment stored there. Similar conditions were observed in the third- and fourth-floor shower rooms, including broken tiles, dripping shower heads, discolored walls, and inaccessible handwashing sinks due to wheelchairs and other equipment. Across all three units, hallway carpets and multiple residents’ room floors were repeatedly observed to be visibly soiled over several days, and the environmental services director stated there was no schedule for carpet cleaning. The shower rooms on all three units continued to be cluttered on repeated observations. In addition, a plastic cushion on a shower bed in the fourth-floor shower room was found with five to six surface openings exposing the underlying permeable foam. Staff interviews confirmed that the cushion had been in that condition for some time and that the openings were present, raising questions about how it could be disinfected. These findings regarding environmental cleanliness, clutter, and damaged resident care equipment were confirmed with facility leadership during the survey.
Failure to Maintain Resident Dignity During Incontinence Care
Penalty
Summary
The deficiency involves a failure to ensure a resident’s right to dignity and self-determination during incontinence care. The resident was admitted with orthostatic hypotension and heart failure and had an admission MDS BIMS score of 15, indicating intact cognition. According to a facility incident report, the resident reported that a male CNA entered his room and pulled down his underwear or pants while he was in bed, with the resident later clarifying that he was woken up by the CNA attempting to pull his underwear down. The resident stated that the CNA did not announce himself, did not knock on the door, and that he felt tugging at his hip while he was asleep. The resident reported that the CNA told him he had to take his underwear off and that the CNA was trying to remove his underwear to check for incontinence, but the resident denied being touched in a sexual manner. The incident reports and subsequent interview with the resident consistently described that the CNA attempted to provide incontinence care without first waking the resident or obtaining his permission, and without announcing his presence or knocking before entering the room. These actions failed to honor the resident’s right to be treated with dignity and to exercise control over his personal care.
Failure to Use RNs for Required Admission, Discharge Teaching, and Post-Fall Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services were provided in accordance with Delaware State Board of Nursing scope of practice requirements and professional standards. For one resident admitted on 11/22/25, an LPN completed the Nursing Admission/Readmission/Annual/Significant Change Assessment, as well as the lift/transfer/reposition evaluation, AIMS assessment, PHQ-9 evaluation, and bedrail evaluation in the EMR, despite state regulations specifying that admission assessments must be completed by an RN. For another resident admitted on 6/27/25 with diagnoses including breast cancer and dementia, an LPN completed the Nursing Admission/Readmission/Annual/Significant Change Assessment and documented completion of the admission nursing assessment, with no evidence in the EMR that an RN performed the required admission assessment. The deficiency also includes failures related to discharge education and post-fall assessment. One resident admitted on 11/11/25 and discharged on 11/19/25 had a discharge plan documented entirely by a social work assistant and a nursing clerical assistant, with no evidence that any licensed nursing personnel reviewed the discharge plan documentation. EMR progress notes for this resident contained no evidence that an RN provided discharge education prior to discharge; instead, a social worker documented that the resident chose to discharge and was educated on the risks of not completing rehab. For the resident with breast cancer and dementia who experienced a fall on 7/8/25, a fall incident report and neurological evaluation flow sheet showed that an LPN completed the initial post-fall neurological assessment and documentation, even though state regulations require an RN to complete the initial post-fall assessment. Review of the EMR confirmed there was no RN post-fall assessment documented for this resident.
Failure to Provide Scheduled Bathing for Dependent Resident
Penalty
Summary
A dependent resident with an ADL self-care performance deficit related to a stroke was care planned on admission to be totally dependent on staff for bathing or showering, with an intervention specifying that it was very important for him to choose how he was bathed and that he preferred a shower or bed bath. The resident’s care plan also emphasized the importance of engaging in daily routines meaningful to his preferences. Documentation from admission through early September showed he was scheduled to receive a shower or bath twice weekly on the evening shift and as needed. Out of five scheduled bathing opportunities during the review period, the resident received bathing on two occasions and refused once, but there was no documentation explaining why bathing was not provided on two other scheduled dates. Review of the progress notes confirmed the lack of documented reasons for missed bathing on those dates, and the NE/IP later confirmed these findings during the surveyor interview.
Failure to Implement Timely Isolation Precautions
Penalty
Summary
The facility failed to adhere to its infection control procedures concerning Transmission Based Precautions (TBP) for several residents, leading to a potential risk of infection spread. Resident R48, who was admitted with diagnoses including End Stage Renal Disease and a history of stroke, exhibited respiratory symptoms such as a constant coarse cough. Despite testing positive for influenza, there was a delay in placing her on isolation, as confirmed by the Infection Preventionist (IP). The Licensed Practical Nurse (LPN) acknowledged the resident's symptoms and advised precautionary measures, but no isolation signage was present on the resident's door at the time of observation. Resident R93, admitted with a fracture of the right lower leg, also showed respiratory symptoms, including a wet cough and congestion. Although the resident was symptomatic and had been tested for COVID-19, which returned negative, there was no TBP signage or personal protective equipment (PPE) available near her room. The Director of Nursing (DON) and the IP later confirmed that R93 should have been placed on isolation earlier due to her symptoms and the presence of confirmed influenza and COVID-19 cases in the facility. Similarly, Resident R199, with chronic kidney disease and colon cancer, experienced a frequent wet cough and was not placed on TBP until later, despite having symptoms for two days. The IP confirmed that R199 tested positive for COVID-19 after a second test. The DON stated that respiratory screening and testing for COVID-19 and influenza were initiated for all residents with symptoms after the survey team raised concerns. The delay in implementing isolation precautions for these residents was acknowledged by the DON and the facility administrator, highlighting a lapse in following the facility's infection control policy, which increased the potential for infection spread.
Failure to Ensure Proper Medication Administration Procedures
Penalty
Summary
The facility failed to ensure medications were not left at the bedside for residents who were not assessed to self-administer medications. In the case of Resident 24, two inhalation aerosols were observed on the bedside table, which the resident stated had been left there since the previous night by a nurse. The resident had a BIMS score indicating no cognitive impairment and was diagnosed with stroke and asthma. However, there were no orders for self-administration of the inhalers, and the Director of Nursing confirmed that the resident did not have authorization for bedside medication storage. Similarly, Resident 298, who was readmitted with diagnoses including muscle weakness and polyneuropathy, was found with an inhaler on the bedside table. The resident had a BIMS score indicating no cognitive impairment and was not care planned for self-administration of medications. Despite this, the resident stated that staff were aware of the inhaler. A registered nurse initially claimed the resident was assessed to self-administer but later corrected herself, acknowledging the resident should not have the inhaler. The Infection Preventionist was informed of the situation but did not document the conversation with the resident.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for a resident, identified as R85, which compromised the resident's ability to maintain independent functioning, dignity, and well-being. R85, who was admitted with diagnoses including diabetes mellitus type two, polyneuropathy, epilepsy, and an acquired absence of the left leg below the knee, was observed multiple times with the call light out of reach. Despite being cognitively intact and able to use the call light, R85 was found in bed with the call light clipped to the wall behind him, making it inaccessible. Interviews with facility staff, including an LPN and the Administrator, confirmed that call lights should be within reach of residents when they are in their rooms. The LPN acknowledged the oversight and moved the call light within R85's reach, while the Administrator emphasized the importance of residents having access to their call lights. The Infection Preventionist/Educator Nurse Practice also stated that call lights should always be accessible to residents, highlighting a lapse in ensuring this standard was met for R85.
Failure to Investigate Misappropriation of Property
Penalty
Summary
The facility failed to investigate allegations of misappropriation of property involving two residents, R84 and R108. According to the facility's policy on abuse, neglect, and exploitation, all allegations should be thoroughly investigated, including interviews with potential witnesses. However, the Facility Reported Incident (FRI) dated 05/01/24 revealed that R84 reported to the Administrator that a Certified Nurse Aide (CNA1) took cigarettes from him and money from R108. The FRI lacked evidence of interviews with other residents or staff who might have witnessed the incidents. During an interview, the Administrator could not recall how CNA1 accessed R108's secured drawer and admitted that she typically conducts interviews with other residents and staff during investigations, but no additional information was provided by the end of the survey.
Failure to Develop Comprehensive Care Plan for Nebulizer Treatment
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as R12, who required nebulizer treatment. The resident was admitted with diagnoses of heart failure, diabetes, and cancer of the left breast. Despite having an order for Ipratropium-Albuterol Solution to be administered via nebulizer twice daily for wheezing and coughing, the care plan for this treatment was not documented in the resident's electronic medical record. The Assistant Director of Nursing acknowledged the oversight, stating that care plans are typically documented by nursing staff but could not explain why this particular care plan was missing.
Failure to Provide Adequate Personal Hygiene Services
Penalty
Summary
The facility failed to ensure that two residents, who were unable to perform activities of daily living, received the necessary services to maintain good personal hygiene. Resident 31, who was admitted following a stroke affecting the right side, was cognitively intact and expressed a preference for showers over bed baths. However, the facility's records showed that the resident did not receive showers on multiple assigned days in December and January. Interviews with the resident and staff confirmed the lack of showers, and the Resource Nurse acknowledged gaps in documentation. Resident 200, admitted with spinal stenosis and type 2 diabetes, required partial assistance for bathing. The care plan specified twice-weekly baths or showers, but records indicated the resident was bathed only once over a month-long period. Interviews with the resident and staff confirmed the infrequency of bathing, and the Administrator stated that bathing should be documented in the electronic medical records, including any refusals.
Failure to Implement Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for a resident, identified as R85, who was at risk for skin breakdown. R85 had a history of diabetes mellitus type two, polyneuropathy, epilepsy, and an acquired absence of the left leg below the knee. The resident was dependent on staff for various activities of daily living and had a pressure injury that required specific interventions, including the use of an air mattress for pressure redistribution. Despite recommendations from the wound care team, R85 was observed lying on a regular mattress multiple times, indicating a failure to implement the recommended interventions. The facility's policy on pressure injury prevention and management emphasized the importance of evidence-based interventions for residents at risk of pressure injuries. However, the facility did not adhere to these guidelines for R85. The wound care nurse practitioner had recommended an alternating air/low air loss mattress, but this was not provided to the resident. Interviews with staff revealed a lack of communication and follow-through regarding the implementation of the air mattress, despite its availability in the facility. Additionally, there was a discrepancy in the application of Santyl ointment for R85's stage three wound. The treatment order specified applying the ointment to the posterior scrotum, but during an observation, the ointment was applied to the entire scrotum. This indicates a deviation from the prescribed treatment plan. The facility's process for tracking and implementing wound care orders was not effectively executed, contributing to the deficiency in care for R85.
Improper Catheter Care Leading to Potential Contamination
Penalty
Summary
The facility failed to ensure proper care for a resident with a urinary catheter, leading to potential contamination and risk of urinary tract infections. The resident, who was cognitively intact and dependent on toileting hygiene, had a Foley catheter in place for wound healing. Observations revealed that the catheter bag was improperly positioned, lying directly on the floor beside the resident's bed and hanging freely without support when the resident was in a Broda chair. This improper positioning was contrary to the facility's policy, which mandates that catheter bags should be kept off the floor and supported to prevent backflow and contamination. Interviews with staff, including LPNs, the Administrator, and the Infection Preventionist/Educator Nurse Practice, confirmed that the catheter bag should not be placed on the floor and should be properly supported. Despite these guidelines, the catheter bag was repeatedly observed in contact with the floor, indicating a failure in adhering to the facility's catheter care policy. This deficiency was identified during a survey, highlighting a lapse in maintaining appropriate catheter care for the resident.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services to a resident, identified as R12, in accordance with professional standards. R12, who was admitted with diagnoses of heart failure, diabetes, and breast cancer, was observed with a nebulizer that was improperly maintained. The nebulizer was found on the resident's nightstand, with the mouthpiece wrapped in paper towels, and the unit was dirty with white, crusty debris. The tubing was wet, and neither the tubing nor the mouthpiece was stored in a plastic bag as required by the facility's policy. R12, who was cognitively intact, reported that nursing staff did not turn off the nebulizer after use, and the resident was unaware of when the tubing or mouthpiece was last changed. Interviews with the Director of Nursing (DON) and Licensed Practical Nurse (LPN)3 revealed further lapses in care. The DON acknowledged the nebulizer's filthy condition and the improper storage of its components. LPN3 admitted to administering a treatment to R12 without noticing the dirty condition of the nebulizer and did not remain in the room during the treatment. LPN3 also failed to turn off the machine or clean it properly, only wiping the mouthpiece. The facility's policy required nebulizer treatments to be administered using proper technique and standard precautions, which were not followed in this instance.
Failure to Attempt Alternatives Before Bed Rail Use
Penalty
Summary
The facility failed to ensure that alternative measures were attempted before the installation of bed rails for two residents. Resident 83, who was readmitted with paraplegia and a complete traumatic amputation of the right shoulder and upper arm, had a care plan that included bed rails as an enabler. However, the bed rail evaluation indicated that no alternatives were attempted prior to the placement of the side rails, and the determination was that no bed rails should be used. Similarly, Resident 298, who was readmitted with muscle weakness and polyneuropathy, had a care plan that included 1/4 side rails to assist with bed mobility. The bed rail evaluation for this resident also revealed that no alternatives were attempted before the placement of the side rails, and the determination was that no bed rails should be used. Interviews with staff revealed a lack of awareness and adherence to the facility's policy on bed rail use. An LPN stated that all residents are provided with a bed rail use consent form upon admission, and bed rails are used unless residents refuse. The LPN also mentioned that alternatives are not discussed or explored prior to bed rail use, and ongoing reassessment for continued bed rail use is not conducted. The Director of Education confirmed that bed rail assessments should be completed on admission and annually, and that alternatives should be considered before using bed rails. However, she was unaware that the assessments for both residents indicated that bed rails should not be used. The facility's policy emphasizes a person-centered approach and the use of appropriate alternatives before installing bed rails, which was not followed in these cases.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure the medical necessity of psychotropic medication administration for a resident, identified as R48, who was part of a sample of 47 residents reviewed for psychotropic medication administration. The deficiency was identified through record reviews and staff interviews, which revealed that informed consent was not obtained from the resident or the resident's representative for the administration of psychotropic medications. This oversight created the potential for the resident to receive unwanted medications. The facility's policy on the use of psychotropic medications, revised in July 2024, mandates that residents and/or their representatives be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments and non-pharmacological interventions. R48 was admitted to the facility with diagnoses including End Stage Renal Disease, depression, and anxiety. The resident's annual Minimum Data Set assessment indicated severe cognitive impairment and signs of depression nearly every day during the assessment period. Despite this, there was no documentation in R48's comprehensive record showing that the risks and benefits of Trazadone or hydroxyzine were discussed with the resident or her representative, nor was there evidence of informed consent for these medications. Interviews with the Director of Nursing and the Administrator confirmed the absence of informed consent documentation in the resident's record, which was against the facility's expectations and policy.
Improper Insulin Administration Procedure
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors during a medication pass observation. The deficiency involved the improper administration of insulin to a resident diagnosed with type 2 diabetes. The facility's policy required that the insulin pen needle remain in the resident's skin for six to ten seconds after injection. However, during an observation, an LPN administered the insulin and removed the needle after only two seconds, contrary to the facility's policy. The resident involved had a BIMS score indicating mild cognitive impairment and was receiving Humulin Insulin as per physician's orders. The LPN responsible for administering the insulin stated that he was unaware of the requirement to keep the needle in the skin for the specified duration. The facility's Infection Preventionist and Educator confirmed the expectation that the needle should remain in the skin for ten seconds post-administration, highlighting a gap in staff training or communication regarding the insulin administration procedure.
Failure to Label Insulin Pens with Open Dates
Penalty
Summary
The facility failed to ensure that resident medications stored in medication carts were appropriately labeled with open dates, leading to a potential risk of administering expired or out-of-date medications. Specifically, insulin pens for three residents were found without open or discard dates. The facility's procedure for insulin pen management requires that insulin pens be clearly labeled with the resident's name, physician's name, date dispensed, type of insulin, amount to be given, frequency, and expiration date, and that they should be disposed of after 28 days or according to the manufacturer's recommendation. During observations, open insulin glargine pens for two residents were found in the medication cart on the third floor without open or discard dates. Similarly, an open Lantus insulin pen for another resident was found in the medication cart on the fourth floor without the required labeling. Interviews with the LPNs responsible for these carts confirmed the absence of the necessary labeling and acknowledged that the pens should have been dated. The Infection Preventionist and Educator also confirmed that insulin pens are expected to be labeled with the date they were opened to ensure proper disposal timing.
Failure to Document Vaccine Education and Consent
Penalty
Summary
The facility failed to ensure that a resident was provided with information regarding the risks and benefits of the pneumococcal vaccine prior to its administration. The facility's policy, dated 08/02/24, mandates that residents or their representatives receive education about the benefits and potential side effects of the pneumococcal immunization, with documentation of this education in the clinical record. However, a review of the electronic medical records (EMR) for a resident, who was over the age of [AGE] and admitted to the facility on [DATE], revealed that there was no evidence of such education or consent documented before the administration of the pneumococcal 20-valent (Prevnar 20) vaccine. This deficiency was confirmed during an interview with the Infection Preventionist, who acknowledged the absence of documented risks versus benefits or consent for the vaccine in the resident's records.
Deficiency in Call Light Functionality for Resident
Penalty
Summary
The facility failed to ensure that a resident's room was equipped with a functioning call light, which is a critical component for residents to request assistance. The deficiency was identified during an observation where the call light in the resident's room was not operational. The resident, who was moderately cognitively impaired and had a history of heart failure, chronic bronchitis, and chronic kidney disease, was unable to summon help due to the malfunctioning call light. The resident was experiencing wheezing and coughing at the time, highlighting the importance of a working call system. The Director of Nursing was notified and confirmed the malfunction by attempting to use the call light, which failed to operate correctly. The facility's policy requires staff to report any issues with call lights immediately, but it appears this was not done in a timely manner. The facility's administrator mentioned that call lights are checked monthly, and any non-functioning lights should be reported and fixed immediately, though it was unclear why this particular issue was not addressed sooner.
Unqualified Activities Director in Facility
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, which could potentially affect the quality of life for the 96 residents residing in the facility. The Activities Director position was filled by an individual who was previously an Activity Assistant and was not yet qualified as per the facility's job description requirements. The job description specified that the Activities Director must be a qualified therapeutic recreation specialist or an activities professional with specific credentials or experience. The current Activities Director was working towards her certification, expected to be completed in March 2025, and had not yet sat for the federal exam. The Administrator acknowledged the deficiency, explaining that the previous Activities Director had unexpectedly passed away, and despite recruitment efforts, the current acting Activities Director was given the opportunity to complete her training to become qualified.
Failure to Implement Oxygen Use Care Plan
Penalty
Summary
The facility failed to implement a care plan for a resident's continuous use of oxygen. The resident was admitted with diagnoses including acute respiratory failure with hypoxia and had physician's orders for oxygen at 2-3 liters continuously every shift via nasal cannula. However, a review of the resident's care plans revealed no evidence of a care plan for the use of oxygen. This deficiency was identified during a record review and discussed with the Nursing Home Administrator, Director of Nursing, Staff Educator, and Regional Clinical Consultant.
Failure to Provide Appropriate Treatment and Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and physician orders. The resident, who had multiple diagnoses including acute respiratory failure with hypoxia, anemia, high blood pressure, diabetes, and congestive heart failure, became unresponsive on the evening of 11/14/23. Despite a physician's order for a low blood sugar protocol and continuous oxygen via nasal cannula, the resident was transported to an acute care hospital without a nursing assessment, including vital signs. The RN Supervisor attempted to get the resident's blood pressure but encountered errors with the machine and did not utilize the facility's Emergency Cart, which contained manual blood pressure equipment and oxygen delivery supplies. The clinical record review revealed that the resident's vital signs were within normal limits earlier in the day. However, later that evening, the resident was found unresponsive, and the RN Supervisor's attempts to assess the resident's condition were unsuccessful. The facility documentation lacked assessments for blood pressure, pulse, blood sugar, temperature, and lung sounds after the resident was found unresponsive. This deficiency was discussed with the Nursing Home Administrator, Director of Nursing, Staff Educator, and Regional Clinical Consultant on 11/17/23.
Failure to Provide Competent Nursing Care for Resident with Respiratory Condition
Penalty
Summary
The facility failed to provide competent nursing care for a resident (R1) who experienced a change in respiratory condition. R1 was admitted with multiple diagnoses, including acute respiratory failure with hypoxia, anemia, and congestive heart failure. On the night of the incident, a CNA reported that R1 was not waking up, and the RN (E3) found R1 unresponsive. E3 attempted to measure R1's blood pressure but received an error from the machine and did not use the manual blood pressure equipment available on the emergency cart. E3 called 911 for additional support but did not utilize the emergency respiratory supplies available in the facility. E3 had been a nurse for only three months and did not receive hands-on training for the emergency cart during her orientation. The facility's staffing schedule revealed that E3 was the only RN on duty during the 3-11 shift, and there was no policy for the role of RN Supervisor. The facility's nursing orientation process lacked a hands-on practical review of the emergency cart and its equipment. The facility documentation showed no evidence that R1 received additional assessments or respiratory interventions, such as a manual blood pressure assessment or the use of a non-rebreather mask, which could have supported R1's respiratory comfort. Interviews with the staff confirmed the lack of complete training and the absence of a policy for RN Supervisors.
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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