Complete Care At Silver Lake Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Dover, Delaware.
- Location
- 1080 Silver Lake Blvd, Dover, Delaware 19904
- CMS Provider Number
- 085027
- Inspections on file
- 18
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Complete Care At Silver Lake Llc during CMS and state inspections, most recent first.
Surveyors found that chicken salad sandwiches were not maintained at proper cold holding temperatures during meal service. A pan of approximately 20 sandwiches was observed on the counter near the steam table and used on the tray line, and temperature checks by the Dietary District Manager showed the chicken salad at 54°F. A second tray of sandwiches taken from the refrigerator measured 57°F. The chicken salad, made from diced cooked chicken, mayonnaise, and pepper, was required by facility policy to be held below 41°F. This deficient practice had the potential to affect most residents in the facility.
Surveyors found that the facility failed to maintain an effective pest control program and kitchen sanitation, resulting in a significant fruit fly presence around a three-compartment sink. Initial observation with dietary staff revealed numerous fruit flies, multiple bait boxes, food-related debris, and an acknowledged ongoing pest problem. A later observation showed an increased number of fruit flies and fewer bait boxes in place, despite pest control recommendations. Maintenance staff confirmed pest control visits occurred weekly and that additional visits could be requested, but no interim contact was made despite the increased insect activity, contrary to the facility’s written pest control policy.
The facility failed to report an allegation of resident-to-resident abuse to the state agency as required by its abuse policy. A cognitively intact resident, as shown by a high BIMS score on a recent MDS, struck a severely cognitively impaired resident in the face while lying in bed, as documented in progress notes and risk management records and confirmed by an LPN. The cognitively impaired resident had a very low BIMS score on a recent MDS and was attempting to calm or comfort the other resident at the bedside when struck. The DON and a regional corporate consultant confirmed the incident was not reported to the state agency, and the Administrator stated he believed the event was accidental, despite the written policy requiring all alleged violations and substantiated incidents to be reported.
The facility failed to thoroughly investigate an allegation of potential abuse when a cognitively intact resident struck a severely cognitively impaired resident in the face while that resident was attempting to provide comfort at the bedside. Documentation showed the incident was reviewed through internal risk management and deemed not state reportable, and the DON was notified, but there was no documentation of interviews with residents or staff as part of the investigation. This lack of investigative documentation did not follow the facility’s abuse policy, which requires a focused investigation into whether abuse occurred, assessment for injury, identification of causative factors, and interventions to prevent further injury.
A cognitively intact but fully ADL-dependent resident with schizophrenia and intellectual disabilities used a breath-activated call light that required precise positioning near the mouth. The care plan and facility policy required that the call light be kept within reach, yet observations found the resident repeatedly calling out for help while the device was positioned several inches away and not usable. Multiple staff, including a CNA, LPN, RN, and the DON, acknowledged that the call light needed to be near the resident’s mouth and within reach, but it was not consistently placed correctly, leaving the resident at times unable to activate it.
A resident on hospice had a PRN lorazepam order for agitation and restlessness that was repeatedly administered over an extended period without a 14-day stop date or documented prescriber reassessment and justification for continued use. The consultant pharmacist indicated that PRN psychotropic orders require a 14-day limit and documented evaluation for extension, including for hospice residents, while the DON believed the 14-day limit did not apply due to hospice status. Review of facility policy confirmed that PRN psychotropic medications must be limited to 14 days unless the prescriber documents the rationale and specific duration for extending the order, which was not present in this case.
A resident admitted with ESRD, cellulitis, difficulty walking, terminal lung cancer, two Stage 3 pressure ulcers, and MASD did not have an individualized, person-centered care plan addressing actual wound care needs. The MDS showed risk for PU/PI and existing Stage 3 ulcers, but the comprehensive care plan only addressed risk for skin impairment and lacked specific objectives, measurable interventions, and time frames for the existing wounds and MASD. The MDSC confirmed the plan was based on a triggered CAA but did not include goals and services for the actual wounds, the UM reported reviewing care plans for specific care needs, and the DON could not identify appropriate wound care interventions in the plan, contrary to facility policy requiring comprehensive services based on triggered CAAs.
Two residents with intact cognition and identified ADL self-care deficits did not consistently receive scheduled showers and associated weekly skin assessments as outlined in their care plans. One resident, who required set-up/clean-up assistance, reported not getting twice-weekly showers on her designated days despite preparing for them, and documentation showed multiple dates marked as not applicable for shower/personal care without recorded refusals. Another resident, care planned for potential skin impairment and documented as independent with bathing, stated she was not getting showers even when requested, and her records also showed missed shower/personal care entries marked as not applicable. CNAs, an RN, and the DON described a process for offering showers, reapproaching after refusals, notifying nurses, and documenting refusals, but the chart lacked corresponding refusal documentation, contrary to the facility’s ADL policy requiring documentation of provided care and/or refusals.
A resident with dementia, limited mobility, and dependence on staff for bathing was care planned for scheduled showers twice weekly, but task records showed repeated shower refusals while the resident reported wanting a shower and only receiving sponge baths. CNAs documented refusals in the task system and stated they notified nurses, yet there was no corresponding nursing documentation of re-approach or refusal in the EMR, and the resident was observed with oily, pungent hair. This demonstrated a failure to provide and properly document necessary ADL hygiene care in accordance with the facility’s ADL policy.
A resident with diabetes, CKD, hemiplegia, PVD, and multiple non-pressure ulcers had a care plan and physician order specifying a low air loss (LAL) mattress setting of 150 to address impaired skin integrity and existing foot and heel breakdown. Surveyors found the LAL mattress pump set between 200 and 240 instead of the ordered setting, despite facility policy requiring licensed nurses to check powered support surfaces each shift and staff reports that nurses and CNAs verify LAL mattress function during rounds.
A resident with morbid obesity, paraplegia, and an unhealed Stage 4 pressure ulcer had a physician order and care plan directing use of a low air loss (LAL) mattress set at 250, with settings checked every shift. Surveyors observed the LAL pump set between 300 and 350 with the static mode activated, contrary to the order and care plan. The IP and an LPN confirmed the incorrect settings during interviews, despite the LPN stating she checked the pump each shift. Facility policy required powered support surfaces to be used per evidence-based practice and checked each shift for proper function. The report states this failure placed the resident at risk of worsening pressure wounds, new wound development, and unmet care needs and goals.
A resident with an indwelling catheter for urinary retention and obstructive uropathy was repeatedly observed with catheter tubing hanging from the bedframe and the drainage bag resting on the floor, without a securement strap in place as required by the care plan. An LPN, who stated she was responsible for ensuring CNAs provided catheter care, had not assessed for the presence of a securement device and did not replace it when she noted it was missing. Later, an RN replaced the strap but found the catheter tubing positioned under the resident’s thigh and had to reposition it. The IP stated that a drainage bag resting on the floor placed the resident at risk of bacterial contamination, and records showed the LPN lacked a documented annual competency check-off for indwelling catheter care, despite a facility policy requiring proper use of catheter straps.
Two residents with confirmed influenza were placed on Contact/Droplet precautions with signage requiring staff to don a gown, N95 mask, face shield, and gloves before room entry, but an LPN was observed entering each resident’s room to administer medications without any PPE. The LPN stated PPE was only used when making direct contact with residents, despite the posted isolation instructions and the facility’s Influenza Exposure Control policy requiring adherence to transmission-based precautions for residents with respiratory viruses.
Three residents in a facility suffered significant injuries due to inadequate supervision and failure to follow care plans. One resident, requiring two staff for bed mobility, was repositioned by one CNA, resulting in bilateral femur fractures. Another resident suffered second-degree burns from hot water spilled by a CNA who did not follow microwave safety protocols. A third resident, at high risk for falls, fell and fractured a femur due to obstructed fall mats and insufficient safety measures.
The facility failed to maintain proper sanitation and food safety standards in its kitchen, affecting 107 residents. Observations revealed dirty and damaged kitchen walls and floors, lack of temperature gauges in cold storage units, and improper cooling of leftovers. The Dietary Manager acknowledged the issues, and the Registered Dietitian emphasized the importance of proper cooling practices.
The facility failed to implement its Antibiotic Stewardship Program effectively, as evidenced by incomplete documentation of antibiotic use and lack of data analysis. Interviews with the IP and DON revealed gaps in tracking infection locations and summarizing antibiotic data, placing all residents at risk for adverse events related to antibiotic administration.
A facility failed to prevent cross-contamination during wound care for a resident with a sacral wound and did not adhere to proper PPE protocols for a COVID-positive resident. An RN used the same gauze for the entire wound bed and improperly handled medical grade honey, while a housekeeper entered a COVID-positive room without a gown or face shield, ignoring posted droplet precautions.
A Spanish-speaking resident with cognitive impairment was not communicated with in their preferred language, despite the facility's policy for Limited English Proficiency (LEP) residents. Staff interacted with the resident in English, leading to potential unmet care needs. The facility had procedures for translation services, but these were not consistently used.
A facility failed to protect two residents from physical abuse by another resident, leading to injuries. One resident, moderately cognitively impaired, was punched, resulting in a skin tear and bruising. Another resident, cognitively intact, was assaulted over a television dispute, sustaining facial injuries. The aggressive resident had a care plan for one-to-one supervision, which was inconsistently applied, leading to these incidents.
A resident with severe cognitive impairment alleged that a nurse made an inappropriate gesture after he refused medication. The incident was not reported to the state agency within the required two-hour timeframe, as the RN involved did not consider it abuse due to the resident's history. The facility's policy requires immediate reporting of all abuse allegations, regardless of circumstances.
A resident with intact cognition and multiple diagnoses was transferred to the hospital without receiving the required written notification of the transfer. The facility's policy mandates written notice to residents and their representatives, but in this case, the notice was only included in the transfer packet given to EMS, with no verification that the resident received it.
A facility failed to provide a resident with a written bed hold notice during a hospital transfer, as required by policy. The resident, with intact cognition and multiple diagnoses, was transferred to a hospital, but there was no evidence she received the notice. Interviews revealed discrepancies in documentation, with the ADON unable to find the notice in the EMR and the DON unable to confirm the resident received a copy.
The facility failed to create and implement discharge care plans for two residents, one with type two diabetes and an acquired absence of the right leg, and another with dehydration and type two diabetes. Both residents expressed concerns about their discharge process, and the Social Services Director admitted to not documenting or developing discharge plans. The DON confirmed the need for the Social Services Director's involvement in discharge planning.
A resident with bipolar disorder and a history of abuse did not receive necessary psychosocial support from the Social Services Director (SSD), despite expressing feelings of depression and being under constant supervision. The SSD acknowledged the potential impact of the supervision on the resident's mental state but did not take action to address these needs, as confirmed by the Director of Nursing.
The facility failed to serve food at the appropriate temperature for three residents, leading to complaints of cold and unappetizing meals. Meals were often served in disposable foam trays, which are not insulated, contributing to the issue. Residents reported dissatisfaction with the food, and observations confirmed that meals were served cold. A test tray also revealed lukewarm food despite registering at a higher temperature.
Improper Cold Holding of Chicken Salad Sandwiches
Penalty
Summary
Surveyors identified a deficiency related to improper cold holding of chicken salad sandwiches prepared and served by the facility’s dietary department. During a kitchen observation with the Dietary District Manager (DDM), a steam table pan containing approximately 20 chicken salad sandwiches was seen on the counter at the left end of the steam table, with sandwiches stacked on top of one another. At that time, the sandwiches were being used on the tray line for room trays. A review of the lunch meal temperature log showed the chicken salad sandwiches had previously been documented within a safe temperature range. However, when the DDM checked the temperature of the chicken salad on a sandwich at 12:15 PM, it measured 54°F, which did not meet the facility’s policy requirement for cold food holding at less than 41°F. The DDM then obtained another tray of chicken salad sandwiches from the refrigerator and checked their temperature, which measured 57°F, also above the required cold holding temperature. The chicken salad recipe consisted of diced cooked chicken, mayonnaise, and pepper. During an interview, the Administrator stated that all food should be served at the right temperature to avoid any residents getting sick. The facility’s written policy titled “Food: Preparation,” revised 02/2025, specified that all foods will be held at appropriate temperatures, including less than 41°F for cold food holding. The deficient practice had the potential to affect 112 of 114 residents who could have been served these sandwiches.
Failure to Maintain Effective Pest Control and Sanitation in Kitchen Area
Penalty
Summary
The facility failed to maintain an effective pest control program and keep the kitchen area free from fruit flies as required by its pest control policy, affecting all 114 residents. During an initial kitchen observation with the Dietary Manager, surveyors observed approximately 15–20 fruit flies near the floor by a smaller three-compartment sink located near a hand-washing sink. On the floor near this sink, there were multiple bait boxes on both sides, an empty one-ounce plastic coffee creamer container, and black debris. The Dietary Manager acknowledged that the area needed cleaning, confirmed there was an ongoing and past problem with fruit flies, and stated that pest control came weekly and sprayed the area. In a subsequent kitchen observation with the Dietary District Manager, surveyors observed an increased number of fruit flies, approximately 50–75, near the floor at each end of the same three-compartment sink. At that time, only one bait box was observed on the floor on the left side of the sink, and no other bait boxes were present, despite prior recommendations from the pest control provider that bait boxes remain under the sink. The Dietary District Manager stated that pest control treated fruit flies weekly and that the area should be clean with food and debris removed, and further stated that the Dietary Manager had only recently added cleaning this area to his weekly cleaning schedule. The Maintenance Director reported that pest control visited weekly and that staff could contact pest control between visits if there was an increase in bugs, but confirmed that pest control had not been contacted despite the increased fruit fly activity, and they were waiting for the regular weekly treatment. The facility’s written Pest Control Program policy stated it was the facility’s policy to maintain an effective pest control program that eradicates and contains common household pests and rodents.
Failure to Report Resident-to-Resident Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving one resident to the state agency as required by its abuse, neglect, and exploitation policy. One cognitively intact resident, with a Brief Interview for Mental Status (BIMS) score of 13 out of 15 on a quarterly MDS dated 04/21/25, struck another resident on 06/30/25. Progress notes and risk management documentation for that date indicated that this resident struck another resident with an open hand while lying in bed. The other resident involved had severe cognitive impairment, with a BIMS score of 4 out of 15 on an annual MDS dated 04/21/25, and was standing next to the first resident’s bedside attempting to calm or comfort her when the strike occurred. Progress notes and risk management notes for the cognitively impaired resident documented that the resident was slapped on the cheek or hit in the face with the back of the hand while trying to comfort the other resident. During interviews, an LPN confirmed that the cognitively intact resident smacked the cognitively impaired resident on the face with her left hand while in bed. The DON and the Regional Corporate Consultant both confirmed that this incident was not reported to the state agency. The Administrator stated that he believed the incident was accidental. The facility’s abuse, neglect, and exploitation policy dated 09/12/24 stated that the facility will report all alleged violations and all substantiated incidents to the state agency and other required agencies, but this allegation was not reported as required.
Failure to Thoroughly Investigate Allegation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of potential abuse involving one cognitively intact resident and one severely cognitively impaired resident. The cognitively intact resident had an admission history dating back several years and a recent BIMS score of 13/15, indicating intact cognition. A progress note documented that this resident struck another resident with an open hand. The other resident, who had severe cognitive impairment with a BIMS score of 4/15, was documented as standing next to the first resident’s bedside and attempting to calm the resident when the slap to the cheek occurred. Internal risk management notes described that the cognitively intact resident hit the cognitively impaired resident in the face with the back of the hand while the latter was trying to comfort the former, and that the incident was determined by the facility not to be state reportable. The cognitively impaired resident was assessed for injury, with none noted, and the DON was notified. During interview, the DON acknowledged there was no documentation of resident and staff interviews included in the investigation. This was inconsistent with the facility’s Abuse, Neglect, Exploitation policy, which required that all allegations and incidents be investigated with a focus on whether abuse or neglect occurred, the extent of any occurrence, clinical evaluation for signs of injury, causative factors, and interventions to prevent further injury.
Failure to Maintain Accessible Breath-Activated Call Light
Penalty
Summary
The facility failed to ensure a resident’s specialized call light was consistently within reach and usable as care planned. The resident was admitted with schizophrenia and intellectual disabilities and had an admission MDS showing a BIMS score of 14/15, indicating intact cognition, but was dependent on staff for all ADLs. The care plan directed staff to keep the call light within reach and encourage its use for assistance, with prompt response to all requests. The resident used a breath-activated call light attached to a malleable black tube with a white end that needed to be positioned near her mouth to function. During one observation, the resident was in bed repeatedly calling out for help while the call light was positioned approximately six inches above her head, not in a position she could use. Subsequent observations and interviews with staff confirmed that the call light was not consistently placed where the resident could activate it. A CNA stated the resident required total care and that the call light needed to be near her mouth to work, agreeing it was not in place. On another occasion, the resident again had the call light about six inches from her face and stated she could not use it. An LPN acknowledged the importance of the call light being within reach and had to repeatedly adjust and bend the device before the resident could successfully use it, after which the resident confirmed she could locate and use it. Nursing staff, including an RN and the DON, stated that the call light should always be within reach and that all staff working with the resident should know how to position it, but observations showed this was not consistently done, resulting in the resident at times being unable to use the call light when needed.
Failure to Limit and Reassess PRN Psychotropic Medication Use Beyond 14 Days
Penalty
Summary
The facility failed to ensure that a resident receiving hospice services did not continue to receive a PRN psychotropic medication beyond 14 days without appropriate evaluation and documentation. The resident was admitted on 11/04/24 and had an order dated 12/23/25 for lorazepam 0.5 mg, with instructions to administer 0.25 mg every four hours PRN for agitation and restlessness. Review of the Medication Administration Record showed multiple administrations of lorazepam from late December through January, including doses on 12/24/25, 12/26/25, 12/29/25, and 12/30/25, and frequent administrations throughout January. There was no documented reassessment by the prescriber or documentation of clinical indications to justify extending the PRN psychotropic medication order beyond 14 days. During interviews, the Consultant Pharmacist stated that any PRN psychotropic medication order must include a 14-day stop date, after which the medical provider must reassess the need for continued use and document justification in the clinical record, and that this requirement also applies to residents on hospice. In contrast, the DON stated that the PRN lorazepam order did not require a 14-day end date because the resident was receiving hospice services. Review of the facility’s “Use of Psychotropic Medications” policy dated 02/18/25 indicated that PRN orders for psychotropic medications, excluding antipsychotics, are limited to 14 days unless the prescriber documents the rationale and specific duration for extending the order, which was not done in this case.
Failure to Develop Person-Centered Comprehensive Wound Care Plan
Penalty
Summary
Surveyors identified a deficiency in the development of a person-centered, comprehensive care plan for a resident receiving wound care. The resident was admitted with diagnoses including cellulitis, ESRD, dependence on renal dialysis, difficulty in walking, and had a terminal prognosis related to lung cancer. The admission MDS showed the resident was at risk for pressure ulcers/injuries and had two Stage 3 pressure ulcers and moisture associated skin damage (MASD) on admission. The care plan, initiated shortly after admission and later revised, documented potential impairment to skin integrity related to multiple comorbidities and noted actual skin breakdown to the right gluteal fold and coccyx. Record review and staff interviews revealed that the care plan was not individualized or person-centered regarding treatment and services for the resident’s two Stage 3 pressure ulcers and MASD. The MDS Coordinator confirmed that the comprehensive care plan, developed from a triggered CAA for pressure ulcers, only addressed risk for pressure ulcers and did not include specific objectives, interventions, or time frames for the actual wounds. The Unit Manager stated she reviewed care plans weekly for specific care needs and appropriate interventions, and the DON was unable to identify appropriate interventions in the care plan for the two Stage 3 wounds or MASD. Review of the facility’s Comprehensive Care Plans policy showed that all triggered CAAs were to be considered in developing the plan of care and that the comprehensive care plan should describe the services to be furnished to attain or maintain the resident’s highest practicable well-being, which was not reflected in this resident’s wound care plan.
Failure to Provide and Document Scheduled Showers and Hygiene Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents maintained good hygiene and received scheduled bathing and skin assessments as care planned. One resident, R20, was admitted with diagnoses including major depressive disorder, Parkinson’s disease, dizziness, anxiety, and difficulty walking. Her care plan documented an ADL self-care performance deficit due to activity intolerance and identified potential for skin impairment related to decreased mobility, hypertension, fragile skin, and poor safety awareness, with an intervention that her skin would be assessed weekly on her scheduled bath day. Her quarterly MDS showed intact cognition with a BIMS score of 15 and indicated she required set-up or clean-up assistance with showers and bathing. However, documentation reports for December 2025 and January 2026 showed “NA” for Shower/Bathing/Personal Care on her scheduled Wednesday and Saturday bath days. During a Resident Council meeting, R20 reported she should be receiving showers twice a week but was not, stating there were times she gathered her shower items and placed them on her overbed table, then fell asleep and woke up the next morning realizing no one had come to get her for her shower. She identified Wednesday and Saturday as her shower days. In a follow-up interview the next day, she stated she still had not received a shower, no one had come to talk to her about it, and she had not refused the shower. These statements, combined with the “NA” entries in the shower/bathing documentation, show that scheduled showers and associated weekly skin assessments on bath days were not consistently provided or documented for this resident as planned. A second resident, R75, was admitted with diagnoses including seizures, major depressive disorder, and difficulty walking. Her care plan identified an ADL self-care performance deficit due to disease process, general body weakness, impaired balance, limited mobility, and limited ROM, and noted potential for skin impairment related to hypothyroidism, polyneuropathy, and anticoagulant use, with an intervention that her skin would be assessed weekly on her scheduled bath day. Her quarterly MDS showed intact cognition with a BIMS score of 14 and indicated she was independent with showers and bathing. Documentation reports showed “NA” for Shower/Bathing/Personal Care on multiple dates in December 2025 and January 2026. During the Resident Council meeting, she stated she was not getting showers all the time and that even when she asked for them, she still did not receive them. CNAs and an RN described a process of reapproaching residents who refuse showers, notifying the nurse, and documenting refusals, and the DON stated CNAs are expected to ask residents about showers and notify nurses of refusals, with both nurses and CNAs documenting refusals. However, the record lacked documentation of refusals corresponding to the “NA” entries, despite the facility’s ADL policy requiring documentation of ADL care and/or refusals of care.
Failure to Provide and Document Necessary ADL Hygiene Care
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received necessary services to maintain good personal hygiene. The resident, admitted with dementia with agitation and care planned for an ADL self-care performance deficit related to limited mobility, was documented on the quarterly MDS as being dependent on staff for baths and showers. The plan of care specified scheduled shower/bathing/personal care on Mondays and Thursdays during the day shift. Task documentation showed repeated entries that the resident refused showers on multiple dates, while the resident reported wanting a shower but only receiving sponge baths. On observation, the resident stated she had not had a shower in the last few days, and her hair appeared oily and pungent. Interviews with CNAs, RNs, the Unit Manager, and the DON revealed that CNAs were expected to notify nurses when a resident refused a shower so the nurse could re-approach and document the refusal. CNA staff reported they would ask residents about showers and notify the nurse if the resident refused. Nursing staff stated they would educate residents, document refusals, and inform families, using the shower schedule to identify who needed showers. However, the Unit Manager confirmed that although CNAs had documented multiple shower refusals in the task system, there was no corresponding nursing documentation in the EMR indicating that nurses were aware of the refusals or had spoken with the resident. This pattern showed that the facility did not follow its ADL policy, which required providing necessary services to maintain good grooming for residents unable to perform ADLs.
Failure to Follow Ordered Low Air Loss Mattress Settings for Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow a care plan intervention for a resident who required a low air loss (LAL) mattress to be set at 150. The resident was admitted with multiple diagnoses including Type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcers of both heels, midfoot, and right ankle, chronic kidney disease, hemiplegia following cerebral infarction, limited mobility, peripheral vascular disease, anemia, and hypertension. The resident’s care plan, initiated and later revised in the EMR, identified potential for impaired skin integrity and actual skin breakdown of the right medial foot and right heel, with an intervention specifying that the LAL mattress be set at 150. Surveyor review of an order listing provided by the DON showed that the physician-ordered LAL mattress setting for this resident was 150. However, during observation, the resident’s LAL mattress pump was found set between 200 and 240 instead of the ordered setting. The IP stated that LAL pump settings were based on resident weight unless otherwise specified in physician orders and that improper settings could affect wound healing. The UM reported that nurses and nurse aides were responsible for checking LAL mattresses during rounds to ensure they functioned appropriately. Facility policy on support surfaces required that powered devices be checked each shift and as needed for proper functioning and inflation, but the observed mattress setting did not match the physician order or care plan intervention.
Failure to Follow Ordered Low Air Loss Mattress Settings for Pressure Ulcer Management
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order and care plan interventions for a resident requiring a low air loss (LAL) mattress setting of 250. Surveyor observation showed the resident’s LAL pump was set above 300, with the static setting turned on. The resident’s medical record documented morbid obesity, cellulitis of the left lower limb, and paraplegia, and the quarterly MDS indicated the resident was at risk for pressure ulcers and had at least one unhealed Stage 4 pressure ulcer present on admission. A verbal physician order dated 07/26/25 directed that the LAL mattress be set at 250 every shift for wound care, with settings and function checked each shift. The resident’s care plan, initiated in 2022 and revised in 2026, also specified that the LAL mattress setting be kept at 250 as part of interventions for actual skin breakdown to the gluteal areas and excoriation to the buttocks. During interviews, the Infection Preventionist stated that LAL pump settings were based on resident weight unless otherwise ordered and confirmed that the pump was set between 300 and 350 with the static mode activated, which she said should only be used briefly for transfers and should not be on for this resident. An LPN reported that she checked the LAL pump each shift and believed it was set correctly at 250, referencing tape on the pump marked “250,” but upon inspection she confirmed the setting was between 300 and 350 with static mode on. After reviewing the physician orders, the LPN acknowledged the setting should have been at 250. The facility’s policy on support surfaces required licensed nurses to check powered devices each shift and as needed for proper functioning and inflation, and stated that support surfaces would be used in accordance with evidence-based practice for residents with or at risk for pressure injuries. The observed pump setting and static mode use were inconsistent with the physician order, care plan, and facility policy, and the report states this placed the resident at risk of worsening pressure wounds, new wound development, and unmet care needs and goals.
Failure to Maintain Proper Indwelling Catheter Positioning and Securement
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate indwelling urinary catheter care for one resident, specifically by allowing the catheter tubing and drainage bag to rest on the floor and by not ensuring use of a catheter securement device as care-planned. On multiple observations over two days, the resident’s indwelling urinary catheter was seen hanging from the right side of the bedframe with the drainage bag resting on the floor, and no securement strap was present on either thigh. The resident had been admitted with benign prostatic hyperplasia with lower urinary tract symptoms, obstructive and reflux uropathy, unspecified hydronephrosis, and urinary retention, and the quarterly MDS documented an indwelling urinary catheter. The resident’s care plan, initiated and later revised, specified a 16F coude indwelling catheter with interventions including use of a catheter strap, weekly strap changes, and checking strap placement every shift. During interview and observation, an LPN stated she was responsible for ensuring CNAs provided catheter care but acknowledged she had not assessed the resident for a securement strap; when she observed the resident, there was no strap in place and the drainage bag was on the floor, and she did not replace the strap at that time. Later, an RN reported being informed at shift change that the resident did not have a securement strap and showed that she had replaced the strap on the left thigh; however, the catheter tubing was found positioned under the resident’s right thigh and had to be repositioned. The Infection Preventionist stated that resting an indwelling catheter drainage bag on the floor placed the resident at risk of bacterial contamination. Review of training records showed the LPN lacked an annual competency skill check-off for indwelling catheters, and the facility’s indwelling catheter care policy required ensuring straps were snug but not tight.
Failure to Follow PPE and Isolation Precautions for Residents on Contact/Droplet Isolation
Penalty
Summary
Surveyors identified that the facility did not implement its infection prevention and control program for residents on Contact/Droplet precautions. One resident, identified as R2, had a positive influenza diagnosis, and signage at the room entrance directed staff to don a gown, N95 mask, face shield, and gloves before entering. On 01/23/26 at 9:04 AM, LPN6 was observed preparing R2’s medications and entering R2’s room without putting on any PPE, despite the posted Contact/Droplet Precautions. In an interview, LPN8 confirmed that R2 was positive for flu. The facility’s written Influenza Exposure Control policy dated 2024 required that Contact/Droplet Precautions be implemented for residents with suspected or confirmed respiratory virus and that staff follow the facility’s transmission-based procedures while such precautions were in effect. A similar failure was observed for another resident, R91, who was also positive for influenza. On 01/23/26 at 9:20 AM, LPN6 prepared R91’s medications and entered R91’s room without donning PPE, even though Contact/Droplet Precautions signage was posted at the room entrance. In an interview, LPN8 confirmed that R91 was positive for flu. During an interview at the time of the observation, LPN6 stated he only used PPE when making contact with residents and believed he did not make contact when administering medications. The Infection Preventionist later stated that LPN6 should have donned an N95 mask, face shield, gown, and gloves before entering the rooms and removed the PPE before exiting, consistent with the facility’s policy and the posted isolation precautions.
Inadequate Supervision Leads to Resident Injuries
Penalty
Summary
The facility failed to provide adequate supervision and prevent accidents for three residents, leading to significant injuries. One resident, who required assistance from two staff members for bed mobility, was repositioned by only one CNA, resulting in the resident sliding out of bed and sustaining bilateral femur fractures. The resident was cognitively intact and had been holding onto the side rail when the incident occurred. The CNA attempted to prevent the fall but was unsuccessful, and the resident fell from a high bed position. Another resident suffered second-degree burns when a CNA accidentally spilled hot water on her. The CNA had heated the water in the microwave for three minutes, contrary to the facility's policy of heating in 30-second increments. The hot water spilled on the resident's hand, abdomen, breast, and thigh, causing significant burns. The resident was cognitively intact and had requested the hot water for coffee, but the CNA's actions led to the accident. A third resident, who was at high risk for falls due to severe cognitive impairment, experienced a fall that resulted in a fractured femur. The resident was found on the floor with a fall mat in place, but the overbed table and wheelchair were obstructing the mat, reducing its effectiveness. The resident was known to be fidgety and impulsive, with poor safety awareness, and the facility failed to implement adequate interventions to prevent further falls and injuries.
Deficiencies in Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in its kitchen, as observed during a survey. The kitchen walls and floors were found to be dirty and in disrepair, with dried splatters, food debris, and dust accumulation noted in various areas, including around the coffee and tea station, the range, and the hand sink. The wall strips were broken, and a dark substance was observed at the wall tile and floor junctures. Additionally, the door frames were gouged, exposing raw wood. The Dietary Manager (DM) acknowledged the responsibility for cleaning the walls but indicated that housekeeping and maintenance were responsible for the tile and floors. The facility also failed to ensure that cold storage units contained interior temperature gauges, which is essential for monitoring food safety. Four cold storage units, including refrigerators and freezers storing produce, ice cream, vegetables, and milk, were found without temperature gauges. This lack of monitoring could potentially lead to improper food storage temperatures, increasing the risk of foodborne illness among the 107 residents receiving meals from the facility. Furthermore, the facility did not adhere to proper cooling procedures for leftovers, as required by the United States Food & Drug Administration Food Code. On two separate occasions, leftovers from breakfast were not cooled to the required temperature within the specified time frame. The DM admitted that ice baths, typically used to cool foods, were not utilized due to short staffing. The Registered Dietitian (RD) was unaware of the improper cooling practices and emphasized the importance of using shallow pans for faster cooling. These deficiencies in food handling and sanitation practices had the potential to affect the health and safety of all residents receiving meals from the facility.
Inadequate Implementation of Antibiotic Stewardship Program
Penalty
Summary
The facility failed to consistently implement its Antibiotic Stewardship Program, which is designed to monitor and manage the use of antibiotics among residents. The program's protocols require documentation of criteria for antibiotic use, the specific antibiotics administered, and the results of culture and sensitivity testing. However, the facility did not maintain complete records of these elements, as evidenced by missing data in the Monthly Infection Surveillance Logs (MISL) and Monthly Infection Surveillance Summary Reports (MISSR) from September 2024 through January 2025. This lack of documentation prevented the facility from effectively analyzing antibiotic use and identifying trends or areas for improvement. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) revealed that the facility did not have a system in place to track the location of infections to observe for clusters or trends. The IP, who was new to the role, was not fully aware of the procedures for receiving and summarizing antibiotic use data. The DON confirmed that monthly summaries were completed but did not provide evidence of data analysis or process improvements. This deficiency placed all 111 residents at risk for adverse events related to antibiotic administration, as the facility did not ensure the appropriateness and effectiveness of antibiotic treatments.
Infection Control Failures in Wound Care and PPE Usage
Penalty
Summary
The facility failed to complete wound care in a manner that prevents cross-contamination for a resident with a sacral wound. The resident, who was severely cognitively impaired and at risk for pressure ulcers, was observed receiving wound care from an RN who did not adhere to proper infection control protocols. The RN used the same gauze pad to clean all areas of the wound bed, applied medical grade honey with a Q-tip, and pushed honey from intact skin into the wound. Additionally, the RN's gown was improperly fastened, exposing her uniform, and she failed to clean the saline wound cleanser bottle before returning it to the wound cart, despite the resident being in contact isolation due to COVID-19. In another incident, a housekeeper entered a COVID-positive resident's room without wearing the required PPE, including a gown and face shield, as indicated by the droplet precautions sign. The housekeeper wore only an N95 mask and gloves, and exited the room twice without discarding the PPE or performing hand hygiene before handling cleaning supplies. These actions were contrary to the posted guidelines and increased the risk of spreading infections within the facility.
Failure to Communicate with Spanish-Speaking Resident
Penalty
Summary
The facility failed to ensure effective communication with a Spanish-speaking resident, identified as R113, who was unable to understand English. R113 was admitted with diagnoses including an unspecified fracture of the right femur, repeated falls, and dementia, and was noted to be severely cognitively impaired. Despite the facility's policy to provide meaningful communication for residents with Limited English Proficiency (LEP), staff members were observed interacting with R113 in English, which the resident could not understand. This lack of communication in the resident's preferred language could potentially lead to frustration and unmet care needs. During observations, R113 was seen sitting in a Geri-chair at the nurses' station, appearing restless and speaking in Spanish. Staff members, including a Registered Nurse (RN) and a Certified Nurse Aide (CNA), interacted with R113 in English, despite the availability of a language line and Spanish-speaking staff. Interviews with staff revealed that while there were procedures in place to use translation services, these were not consistently utilized. The Director of Nursing (DON) and the Administrator acknowledged that the care plan, which included using the language line, was not followed during the incident.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, leading to a deficiency in ensuring resident safety. Resident 24, who was moderately cognitively impaired, was punched by Resident 90 in the courtyard, resulting in a skin tear and bruising. Despite the incident, Resident 24 refused to discuss the event further. Resident 82, who was cognitively intact, was also assaulted by Resident 90 after a disagreement over a television. This altercation resulted in Resident 82 sustaining facial injuries, including an orbital contusion and a conjunctival hemorrhage, requiring evaluation in the emergency room. Resident 90, who was cognitively intact but had a history of physical aggression related to poor impulse control, was involved in both incidents. The care plan for Resident 90 included one-to-one supervision from 7:00 AM to 11:00 PM and a motion sensor alarm at night. However, the supervision was inconsistent, as noted by staff interviews, and Resident 90 was able to assault both residents. The facility's policy on abuse prevention was not effectively implemented, as Resident 90 was not adequately supervised to prevent these incidents. Interviews with staff, including a CNA and RN, revealed that Resident 90's supervision was not consistently maintained, and there were lapses in monitoring. The Administrator and Director of Nursing confirmed that Resident 90 should have been under constant supervision during the day and monitored by a motion sensor at night. Despite these measures, the facility failed to prevent the physical abuse of Residents 24 and 82, highlighting a significant deficiency in resident protection and supervision protocols.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe to the state agency for a resident who was severely cognitively impaired. The resident, who had a history of agitation and false accusations, reported that a nurse had given him the middle finger after he refused medication. This incident was initially reported to a registered nurse (RN5) by the resident, but RN5 did not report it to the Director of Nursing (DON) or any other supervisor immediately, as required by the facility's policy. Instead, RN5 only communicated the incident to the DON after being asked about it later. The DON confirmed that the incident was reported to her by the resident the following day, and an investigation revealed that the nurse and a certified nursing assistant (CNA) present during the incident denied the resident's claim. Despite the resident's history of verbal abuse and refusal of medication, the facility's policy mandates immediate reporting of any abuse allegations, regardless of the circumstances. The failure to report the incident promptly to the state agency was a deficiency in the facility's adherence to its abuse reporting policy.
Failure to Provide Written Notification of Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of a hospital transfer to a resident and their responsible party. This deficiency was identified for one of the five residents reviewed for hospitalization. The facility's policy requires that residents and/or their representatives be notified in writing of the reason for transfer or discharge. However, in the case of the resident in question, there was no documentation indicating that a written notice was provided to either the resident or their family member. The resident, who had intact cognition and was diagnosed with diabetes mellitus, hypertension, and chronic obstructive pulmonary disease, was transferred to the hospital due to low potassium levels. Although a verbal notification was attempted via a phone call to the family member, the written notice was not directly provided to the resident or their representative. The Director of Nursing confirmed that the notice was included in the transfer packet given to EMS, but there was no verification that the resident received it. The resident confirmed during an interview that they did not receive any transfer papers.
Failure to Provide Bed Hold Notice to Resident
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to a resident and their responsible party during a hospitalization event. The facility's policy requires that residents or their representatives be informed in writing of the bed-hold and return policy prior to transfers and therapeutic leaves. However, for one resident, identified as R62, this procedure was not followed. R62, who had intact cognition and was diagnosed with diabetes mellitus, hypertension, and chronic obstructive pulmonary disease, was transferred to a hospital. Although a bed hold notice was reportedly signed by R62 and sent with the patient, there was no evidence that R62 received a copy of this notice. Interviews conducted during the investigation revealed discrepancies in the facility's documentation and communication processes. R62 stated that she had not received any bed hold papers during her recent hospitalization. The Assistant Director of Nursing (ADON) initially claimed that the notice was uploaded to the electronic medical record (EMR), but upon review, no such notice was found. The Director of Nursing (DON) later provided a hard copy of the notice with R62's signature, indicating it was included in the transfer packet given to emergency medical services (EMS) for the hospital. However, the DON could not confirm that R62 received a written copy of the notice, highlighting a failure in ensuring the resident was properly informed as per the facility's policy.
Failure to Implement Discharge Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement an effective discharge care plan for two residents, leading to potential confusion and unmet care needs. Resident 46, who was admitted with type two diabetes and an acquired absence of the right leg below the knee, required setup assistance with eating and oral hygiene and was dependent on staff for all other activities of daily living. Despite attending a care conference, Resident 46 expressed concerns about not knowing what to do once she received her prosthetic leg, as there was no discharge care plan in place. The Social Services Director admitted to discussing discharge plans with Resident 46 but failed to document this in the electronic medical record. Similarly, Resident 82, who was readmitted with dehydration and type two diabetes, required moderate assistance with all activities of daily living and had a BIMS score indicating cognitive intactness. Resident 82 expressed a desire to discharge to an Assisted Living Facility but needed assistance with the process. The Social Services Director acknowledged that she had only recently started working with Resident 82 and had not developed a discharge care plan. The Director of Nursing confirmed that the Social Services Director should have been involved in discharge planning for both residents.
Failure to Address Resident's Psychosocial Needs
Penalty
Summary
The facility failed to provide necessary medically related social services to a resident diagnosed with bipolar disorder, who also expressed feelings of depression and hopelessness. The Social Services Director (SSD) did not address the resident's psychosocial needs, despite the resident's cognitive intactness and self-reported depression. The resident, identified as R90, was under constant one-to-one supervision, which the SSD acknowledged could contribute to the resident's distress, yet no action was taken to address these concerns. Interviews revealed that the SSD had not engaged with the resident regarding his psychosocial needs, despite the resident's history of abuse and current supervision status. The Director of Nursing (DON) confirmed that the SSD should have been involved in addressing the resident's psychosocial needs. This lack of action resulted in the resident not receiving the expected care and support from the Social Services Department, as outlined in the SSD's job description.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to serve food that was palatable and at the appropriate temperature for three residents, which could potentially lead to weight loss and decreased quality of life. The facility's policy on food quality and palatability, revised in February 2023, mandates that food should be prepared to conserve nutritive value, flavor, and appearance, and be served at a safe and appetizing temperature. However, observations and interviews revealed that residents were served cold food, often in disposable foam trays, which are not insulated and contribute to the food cooling rapidly. Resident 62, who has intact cognition and multiple health conditions including diabetes and hypertension, reported being served cold meals on several occasions. The resident's meals were served in disposable foam trays due to COVID-19 precautions, and the Dietary Manager acknowledged the use of these trays for COVID-positive residents. The Dietary Manager also mentioned a recent change in the delivery service to help keep food warm, but was unaware of the latest CDC guidance regarding the use of regular utensils for COVID-positive residents. Resident 46, who is cognitively intact and has a history of type two diabetes and a leg amputation, expressed dissatisfaction with the food, describing it as cold and unappetizing. Similarly, Resident 11, who has moderate cognitive impairment and multiple sclerosis, reported that the food was not good and was often cold. Observations confirmed that Resident 11's meal was served in Styrofoam dishes and was the last tray to be served from the cart, contributing to the food being cold. A test tray conducted by the Dietary Manager also revealed that the oatmeal was lukewarm, despite registering at 135 degrees Fahrenheit.
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Multiple cognitively impaired residents with known behavioral issues, including wandering, agitation, and physical aggression, were not adequately protected from resident‑to‑resident abuse. In one case, a resident with dementia and PTSD was pushed to the floor by another resident who had a history of combative behavior, resulting in multiple fractures and facial lacerations after staff initially documented the event as an unwitnessed fall. In another case, two residents with dementia and psychotic features engaged in a physical altercation in a dayroom after one placed his hand on the other’s chest, leading to mutual punching. A separate incident occurred when a resident with dementia and behavioral disturbances entered another resident’s room, pulled at the bedcovers, yelled that the room was his house, and allegedly struck the other resident, who was later noted with puffiness around one eye. In all incidents, the involved residents had documented behavioral care plans and significant cognitive impairment, yet physical confrontations still occurred.
A resident with dementia, spinal stenosis, and total dependence for transfers, care-planned for Hoyer lift use with two-person assist, was being transferred from a shower bed to a Geri-chair when the Hoyer lift tipped sideways. Staff reported the lift’s legs had been widened and that one CNA manually pushed the feet apart instead of using the control, and straps may have been unevenly positioned. The resident was lowered to the floor while still in the sling and sustained a small skin tear to the elbow; imaging later showed no fractures. The DON stated that three CNAs were involved, including one on light duty who was not supposed to be using the lift, and that no mechanical defect was found with the lift.
The facility failed to thoroughly investigate several allegations of verbal and potential physical abuse involving four cognitively intact residents with conditions including hemiplegia, rheumatoid arthritis, type 2 DM, epilepsy, and heart disease. In each case, the facility’s investigations were limited, often including only the directly involved resident and omitting interviews with other potentially knowledgeable residents or staff. One resident reported a verbal altercation with a CNA after a fall to the floor, another reported being verbally abused by a roommate’s family member, a third reported a male CNA was too rough and upset while changing linens, and a fourth reported a staff member insulted her and refused brief care. Investigation files lacked broader resident and staff interviews, timely physical and psychosocial assessments, and review of the accused staff member’s employee record, contrary to the facility’s abuse policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
A resident with rectal cancer and intact cognition reported that an RN on night shift confronted him when he returned from smoking off campus, spoke to him loudly about his smoking, used profanity, and threatened to have staff refuse to buzz him back into the building. A CNA corroborated that the RN was upset about being called in to work and used curse words toward the resident, but did not report the incident at the time because the RN was the night supervisor. The resident reported the event to the Social Services Director the next day, yet the facility initially treated it as a grievance rather than abuse and delayed submitting a report to the State Survey Agency until weeks later, after determining it was a reportable abuse incident.
Two residents did not receive required ADL and hygiene care as care planned. One resident with dementia and osteoarthritis, dependent for toileting and personal hygiene, was not toileted during an evening shift, with CNA documentation showing no toileting and the oncoming CNA finding the resident’s clothing, linens, and mattress saturated with urine; the assigned CNA reported care resistance but did not notify an RN or LPN. Another resident with dementia and stroke, requiring assistance with dressing and personal hygiene, remained in bed in pajamas into the afternoon without having received morning care, despite CNA documentation indicating dressing was completed; the CNA later confirmed that care was only provided after being questioned by an RN supervisor following a family complaint.
A resident with left-sided weakness after a stroke, high fall risk, and total dependence for ADLs and bed mobility was being turned onto their side for peri care by an aide when they fell from the bed to the floor, sustaining head trauma and a scalp laceration while on blood thinners. The care plan required extensive to total assistance with two-person support for bed mobility, but the fall occurred during care without documentation of the required level of assistance, indicating the facility did not provide adequate supervision and assistance to prevent accidents as outlined in its own fall prevention practices.
A resident with significant upper extremity weakness and recent surgery was discharged home to a multi-story residence without confirmed DME delivery, home health services, or caregiver support. Although referrals for home health, skilled nursing, and DME were made and family attended a discharge care plan meeting, staff did not verify that services were active, did not set or confirm a start-of-care date with the agency, and did not confirm delivery of a hospital bed. The resident, who lived alone and could not manage fine motor tasks, arrived home without in-home assistance, reported difficulty with eating and self-care, and was later found by an HHA RN in unsafe conditions, unable to access food or medications, leading to emergency transport back to the hospital.
A resident with dementia, Parkinson’s disease, CHF, and a history of AKI had documented fluid goals and was identified as at risk for dehydration and malnutrition, yet daily intake records repeatedly showed fluid consumption well below the recommended amounts. Despite severely impaired cognition, poor oral intake, and documented changes in mentation, lethargy, falls, and restlessness, the facility did not consistently implement or document enhanced monitoring, assistive feeding measures, or timely provider consultation focused on hydration. The resident was hospitalized twice with AKI, dehydration, hypotension, and anemia, and staff interviews confirmed that while expectations existed to encourage fluids and notify providers when goals were not met, there was no clear evidence that these expectations were carried out for this resident.
A resident with cardiac conditions was discharged home with a documented post-discharge plan for home health aide, home health RN/LPN, and PT/OT, but the facility did not complete the home health referral before discharge. The resident went home with a family member and, according to a complaint, did not receive PT, OT, or a nursing wellness check for about a week. The SW later confirmed the referral for home health and therapy services was not requested until several days after discharge, and services did not begin until even later, despite therapy recommendations that are typically communicated to social services to arrange home care.
The facility failed to consistently revise care plans to reflect residents’ current needs and behaviors and did not ensure a cognitively intact resident was involved in ongoing care planning. One resident participated in an initial care conference but was not included in later care plan updates. Another resident with an order for a palm protector was frequently observed without it and often refused it, yet the care plan did not address refusals. Two cognitively impaired residents whose MDS assessments showed dependence for bathing had care plans that still listed only setup or one‑person assist. A cognitively impaired resident with combative behaviors and an incident of striking another resident had a behavior care plan that was not updated to include attempts to hit other residents or the risk of resident‑to‑resident altercations.
Failure to Prevent Resident‑to‑Resident Physical Abuse Among Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from resident‑to‑resident physical abuse. One resident with dementia, agitation, depression, anxiety, and PTSD, and a BIMS score indicating moderate cognitive impairment, was pushed to the floor by another resident after that resident entered his room and followed him into the hallway. Staff initially documented the event as an unwitnessed fall after hearing loud screaming and finding the resident on the floor with complaints of right shoulder and left wrist pain, active bleeding from facial lacerations, and clamminess. Subsequent review of surveillance footage showed that another resident walked into the victim’s room, then followed him out and pushed him, causing the fall that resulted in multiple fractures, including a closed left distal radius fracture, a closed, displaced comminuted right proximal humerus fracture, and a closed, displaced distal clavicle fracture. The resident who pushed him had dementia with mood disturbances, bipolar disorder with psychotic features, PTSD, insomnia, and depression, and a BIMS score indicating severe cognitive impairment. His care plan identified a behavior problem related to bipolar disorder and dementia, including wandering, refusal of care, and physical aggression toward staff and others, such as biting a CNA and swinging a walker at a CNA. The care plan directed staff to anticipate and meet his needs, divert him with alternative objects or activities, intervene to protect the rights and safety of others, and conduct safety checks. Despite these identified risks and interventions, he was able to enter another resident’s room and subsequently push that resident in the hallway, resulting in serious injury. Another incident involved two residents with significant cognitive impairment and behavioral symptoms, including delusions, physical behaviors toward others, agitation, and a tendency to invade others’ personal space. One resident, who was described as aggressive toward others, easily agitated, and prone to getting into others’ personal space, walked next to another resident sitting in a dayroom chair and placed his hand on that resident’s chest. The seated resident responded by punching him in the face with the back of his fist, and the first resident then punched back. Staff and psychiatric documentation noted this altercation and ongoing behavioral concerns such as combativeness with care, agitation, and wandering, but the record contained no additional progress notes describing the incident itself beyond the brief psychiatric follow‑up entry. A further incident occurred when a resident with anxiety, major depressive disorder, dementia with behavioral disturbances, agitation, and severe cognitive impairment entered another resident’s room on the memory care unit. The resident in the room, who had depression, anxiety, dementia without behavioral disturbances, PTSD, insomnia, hallucinations, verbal behaviors toward others, other behavioral symptoms, and wandering, reported that he was hit in the face. Staff heard yelling and found the intruding resident pulling covers at the foot of the bed and yelling that the room was his house, while the other resident sat on the side of the bed and stated that he had been hit and told staff to get a gun and shoot the other resident. Slight puffiness was noted around the reporting resident’s left eye. The intruding resident’s care plan documented compulsiveness, invading others’ personal space, yelling, restlessness, physical aggression, and attempts to assist other residents he believed needed help, with interventions to divert him, familiarize him with his surroundings, and intervene to protect the rights and safety of others. Despite these identified behaviors and interventions, he was able to enter another resident’s room, engage in a confrontation, and allegedly strike the resident.
Resident Injury from Improper Hoyer Lift Operation During Transfer
Penalty
Summary
The deficiency involves the facility’s failure to prevent an accident during a Hoyer lift transfer, resulting in a fall and skin tear injury to a resident. The resident had diagnoses including spinal stenosis, Alzheimer’s disease, vascular dementia with behavioral disturbance, bipolar disorder, and pain, and was documented on the MDS as dependent on staff for transfers from bed to chair. The care plan and physician orders specified that the resident required a Hoyer lift with assistance of two staff for transfers. On the day of the incident, the resident was being transferred via Hoyer lift after a shower, from a shower bed back to a Geri-chair. Progress notes and the post-fall evaluation documented that the fall occurred in the bathroom during a Hoyer transfer with staff assistance of two, and that the Hoyer lift tipped sideways. The resident was found on the floor in the sling, with staff reporting that the Hoyer lift’s legs were widened and that as the resident was being positioned over the chair, the lift tipped to the side. Staff held the sling on each side of the resident’s head and lowered the resident to the floor, after which a skin tear measuring 1.0 cm x 0.1 cm was noted on the elbow. The facility’s investigation determined that the Hoyer tipped because one CNA pushed the lift’s feet apart manually instead of using the designated button to open the legs. Interviews indicated that the manual mechanical lift used at the time was considered less steady and required manual operation of a foot pedal to open the legs, and that the straps may have been more to one side than the other. The DON reported that three CNAs were involved with operating the lift at the time of the incident, including one CNA on light duty who was not supposed to be using the Hoyer lift, and that the lift itself was later found to have no mechanical problems. As a result of the tipping incident, the resident sustained a skin tear to the elbow and required diagnostic imaging to rule out fractures.
Incomplete Investigations of Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of verbal or potential physical abuse as required by its abuse, neglect, and exploitation policy. One cognitively intact resident with hemiplegia following a stroke reported a verbal altercation with a CNA after sliding to the floor while being assisted back to bed. The resident requested use of a Hoyer lift, the CNA told him he could get himself up, and an argument ensued in which the CNA told the resident it was not his room and did not leave until directed by an LPN. The facility’s investigation file for this incident contained only the resident’s interview and no interviews with other residents on the unit who might have had knowledge of similar verbal abuse by the CNA. Another cognitively intact resident with rheumatoid arthritis, hypertension, and peripheral vascular disease reported that her roommate’s daughter came into her room and verbally abused her after the roommate had been relocated due to aggression. The daughter allegedly cursed at the resident, calling her an offensive name and telling her she was going to hell. The investigation file for this incident contained no interviews with other residents on the unit to determine whether they had experienced verbal abuse by this family member or had knowledge of the event. The DON acknowledged that no such interviews were conducted. A third cognitively intact resident with type 2 diabetes and epilepsy reported, through her daughter, that a male CNA wearing a red shirt was too rough with her and appeared upset about having to change her linens. The facility’s investigation into this potential staff-to-resident abuse included an interview with the resident but did not include interviews with other interviewable residents in the same area who might have had knowledge of the incident. A fourth cognitively intact resident with type 2 diabetes and heart disease, later discharged, reported that a staff member entered her room, called her a poor excuse for a human being, and refused to assist with changing her brief. The investigation documentation for this allegation lacked interviews with additional residents or staff, did not show that the resident was promptly assessed physically and psychosocially in relation to the allegation, and did not include a review of the accused staff member’s employee record, resulting in an incomplete investigation contrary to facility policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
Failure to Protect Resident From Verbal Abuse and Delay in Reporting Incident
Penalty
Summary
The facility failed to protect a cognitively intact resident from verbal abuse by a staff member. The resident, admitted with rectal cancer and independently ambulatory with a rolling walker, reported that during an overnight shift he left the campus to smoke and, upon returning and walking toward the nursing station, was confronted by an RN. According to the resident’s report, the RN told him that when she was on the night shift he was not allowed to go outside, using profanity toward him, and further stated that if he went out the door she would instruct staff not to buzz him back into the building. A CNA later confirmed that the RN had been upset about being called in to work, spoke loudly to the resident about his smoking, and used curse words when he responded to her. The incident was not promptly reported to facility administration despite occurring during the night shift, with the CNA stating that the RN involved was the supervisor at the time. The resident reported the incident the following day to the Social Services Director, but the facility did not immediately recognize or treat the allegation as reportable abuse. Instead, the administration initially considered it a grievance and investigated it in that manner. The incident report was not submitted to the State Survey Agency until several weeks after the resident’s report, and only after the facility later determined that the event constituted a reportable abuse incident.
Failure to Provide Required ADL and Hygiene Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL assistance to maintain grooming and personal hygiene for two dependent residents. One resident with dementia, osteoarthritis, and moderately impaired cognition was care planned to receive partial to substantial assistance with personal and oral care, scheduled toileting every two hours, and assistance with toilet transfers. CNA documentation for an evening shift showed “N/A” for all scheduled toileting times, and a facility incident report stated that the CNA assigned to this resident failed to provide incontinence care during that shift. The oncoming night-shift CNA later found the resident’s clothing, linens, and mattress saturated and soaked with urine and provided the needed care, with the prior-shift LPN confirming the condition when notified. The assigned CNA reported the resident was resistant to care but did not notify the LPN or RN for assistance or document the issue. The second resident, with dementia, stroke, weakness, and moderately impaired cognition, was care planned for an ADL self-care deficit requiring setup or cleanup assistance with eating, partial to substantial assistance with personal hygiene and oral care, and substantial assistance with toileting, showering/bathing, and lower body dressing. On a morning shift, the resident’s daughter-in-law reported to the LSW that she did not believe the resident had received morning care because he was still in bed wearing pajamas and had not yet received his lunch tray. A CNA statement indicated the resident had eaten breakfast and was later found asleep in bed, and CNA documentation for that shift showed the dressing task as completed. However, the facility’s follow-up summary documented that the CNA confirmed care had not been provided to the resident prior to being questioned by the RN supervisor, and the LSW confirmed that the CNA changed the resident only after the family reported the concern and nursing was notified.
Failure to Provide Adequate Supervision and Assistance During Bed Mobility for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for a resident with significant functional and cognitive impairments. The resident was admitted with left-sided weakness after a stroke and was care planned as extensively to totally dependent for bed mobility, requiring the support of two persons. A fall risk evaluation documented a score of 10, indicating high fall risk, and a quarterly MDS assessment showed the resident was unable to participate in a cognitive assessment and was completely dependent on staff for all ADLs. Despite these identified needs and risks, the resident was being turned onto their side for peri care by an aide when they fell from the bed to the floor. During this incident, the resident sustained head trauma and a small scalp laceration, and was on blood thinners at the time of the fall. The fall occurred while the aide was providing peri care and turning the resident, but the report does not document the presence of a second staff member, despite the care plan indicating the need for two-person assistance for bed mobility. The facility’s own policy on falls emphasized instituting individualized practices to minimize fall risk and maximize safety for residents identified as high risk, but the resident’s documented high fall risk and total dependence were not adequately addressed in the supervision and assistance provided at the time of the fall.
Failure to Ensure Safe Discharge with Confirmed Home Services and Support
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s discharge home included confirmed durable medical equipment (DME), home health services, and adequate caregiver support. The resident was admitted with spinal stenosis, cervical disc disorder, muscle weakness, carpal tunnel syndrome, and a recent post-fasciotomy to the right arm, and was documented as cognitively intact with a BIMS score of 14/15. Despite these physical limitations, the facility discharged the resident home in the evening via medical transport to a three-story residence, where no caregiver support was present. The facility’s own policy required a post-discharge plan of care developed with the resident and representative, and orientation to ensure a safe and orderly transfer or discharge, but the record lacked evidence that services were confirmed as in place prior to discharge. Prior to discharge, the social worker documented that the resident would have a safe discharge home with services and supports in place, and that referrals for home health care, skilled nursing services, and DME had been made, with family members in attendance at the discharge care plan. However, the clinical record did not contain confirmation that these services were actually arranged and active before the resident left the facility. The resident was discharged with medications called to the pharmacy for home delivery, but there was no documentation that the hospital bed had been delivered or that home health nursing, therapy, or home health aide services were scheduled to start at the time of discharge. The social worker later acknowledged not informing the agency of a specific start-of-care date, assuming the agency and VA would contact the resident, and confirmed not calling to verify delivery of the hospital bed. After discharge, it was discovered that the hospital bed ordered days earlier was not delivered until the morning after the resident arrived home, and that therapy, RN, and HHA services had not yet begun or contacted the resident by the time the facility followed up. The resident reported living alone, being unable to use their hands, needing a caretaker, and having to rely on a sister-in-law for limited assistance with hygiene, meals, and rearranging furniture for the bed that arrived later. The significant other confirmed that no one lived with the resident, that they had their own health issues, and that neither they nor their son stayed with the resident after discharge. When a home health RN eventually visited, the resident was found sitting on a couch in minimal clothing, reporting not having eaten adequately for two days, having little or no accessible food, and being unable to open medications or bottles due to impaired fine motor skills. The RN observed the resident’s inability to grip or perform fine motor tasks, assisted with toileting, and then contacted the agency director and emergency services due to the unsafe conditions in which the resident had been left. These events led surveyors to determine that the facility failed to ensure services and caregiver support were in place prior to discharge, resulting in an immediate jeopardy situation.
Removal Plan
- Audited discharge documentation related to home health services, appropriate caregiver/family support, and any necessary services to meet residents' care needs to determine if any residents were affected.
- Reviewed planned discharges by the Administrator, DON, Director of Social Services, and Director of Rehabilitation to ensure home health services, appropriate caregiver/family support, and necessary services to meet the resident's care needs are in place before discharge.
- Completed a root cause analysis identifying failure to have a robust discharge care plan meeting with the interdisciplinary team (IDT), resident, and resident representative.
- Reviewed the procedure for safe and effective discharge planning with the IDT.
- Re-educated the discharge planning IDT on the discharge policy and procedure to ensure sufficient preparation and orientation for a safe discharge.
- Implemented review of residents scheduled to be discharged to ensure appropriate discharge planning is in place.
- Implemented review of residents scheduled for discharge to ensure ADL support is in place, durable medical equipment is available prior to or on the discharge date, medications are available upon discharge, and identified needs/support are available.
- Implemented review of residents scheduled for discharge to ensure safe discharge planning is in place and to address any issues identified.
- Implemented oversight during utilization review by the NHA/designee to ensure discharge planning preparation and services are in place prior to discharge.
- Initiated audits and educational in-services to the IDT team and conducted staff interviews to confirm education received regarding discharge to the community and/or transfers to other facilities.
Failure to Maintain Adequate Hydration Resulting in Recurrent AKI and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate hydration for a resident with significant medical conditions, including acute kidney injury (AKI), congestive heart failure (CHF), dementia, and Parkinson’s disease. Upon admission, the resident’s care plan identified potential for altered nutrition and included interventions such as assisting at meals, encouraging oral fluids, and monitoring for additional nutrition interventions. A nutrition assessment established an initial fluid goal of 1943–2098 mL/day and documented that the resident was at risk for dehydration and malnutrition, with early labs showing a BUN of 29, creatinine of 1.4, and eGFR of 53. The admission MDS documented that the resident was severely cognitively impaired and required setup assistance for feeding and hydration. Daily fluid intake records from CNA task flow sheets and the MAR showed that the resident’s intake frequently fell below the recommended fluid goals, with multiple days of intake under 1200 mL and some days as low as 360–720 mL. A malnutrition risk assessment identified the resident as at risk for malnutrition due to severe dementia and tremors. A subsequent nutrition note on 5/12/25 documented that the resident’s average fluid intake was 330 mL/day, recommended discontinuing a prescribed hydration pass due to CHF, and set a new fluid goal of 1635–1766 mL/day, while continuing to recommend encouraging oral fluids. Despite these documented risks and low intakes, there is no evidence in the record of intensified monitoring or additional interventions to ensure the resident met the revised fluid goals. The resident experienced multiple clinical deteriorations associated with poor intake and changes in condition. On 6/1/25, after a day with only 360 mL of recorded intake, the resident was transferred to the hospital following falls, hypotension, and confusion, and was admitted with AKI and dehydration. After readmission to the facility, nursing documentation noted low oral intake and a plan to discuss adding the resident to an assist-to-feeding list, but the record lacked evidence that this occurred. Subsequent notes documented lethargy, increased confusion, agitation, restlessness, and continued poor intake, yet a physician progress note following two unwitnessed falls did not include an assessment of hydration status or interventions to improve hydration. On 6/19/25, labs showed a BUN of 62 mg/dL and creatinine of 1.7 mg/dL, and the resident was again sent to the hospital and admitted with AKI, hypotension, and anemia, requiring IV fluid resuscitation. Staff interviews confirmed expectations to monitor intake, encourage fluids, and notify providers when fluid goals were not met, but there was no documentation that the provider was consistently notified or that appropriate interventions were implemented in response to the resident’s ongoing inadequate fluid intake and changes in condition.
Failure to Arrange Timely Home Health Services Prior to Discharge
Penalty
Summary
The facility failed to ensure a timely referral for home health care services prior to discharge for one resident. Facility policy dated 5/1/25 required sufficient preparation and orientation to residents to ensure an orderly transfer or discharge. The resident was admitted on 7/28/25 with diagnoses including aortic valve replacement, aortic regurgitation, and congestive heart failure. A discharge summary dated 8/11/25 documented a post-discharge plan for home health aide, home health RN/LPN, and occupational and physical therapy. The resident was discharged home with a family member on 8/12/25. A complaint received by the Division on 9/30/25 stated that the resident was discharged to a family member's home without a home health care agency referral and that, after one week at home, the resident had not received any physical or occupational therapy or a wellness check from a nurse. During an interview on 2/16/26, the social worker reported needing to check if a referral was made and later confirmed that the referral for home health and therapy services was not requested until 8/15/25, with services opened on 8/20/25. The director of therapy confirmed that physical and occupational therapy were recommended for the resident and stated that such recommendations are typically communicated to social services to set up home care. Findings were reviewed with facility leadership during the exit conference.
Failure to Revise Care Plans and Involve Resident in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise person‑centered care plans and to involve a cognitively intact resident and/or representative in the care planning process. One resident with an intact BIMS score of 15 was admitted and had a documented care conference shortly after admission, but there was no evidence of any subsequent care conferences during the following year despite multiple care plan updates. The resident reported not recalling quarterly care plan meetings, and staff confirmed that no care conferences occurred after the initial one, with no documentation that the resident or representative participated in the later care plan revisions. Additional residents’ care plans were not revised to reflect current, individualized needs and behaviors. One resident had a physician’s order for a right palm protector or substitute, was repeatedly observed without it in place, and routinely refused it according to nursing and CNA interviews, yet the care plan did not address potential refusals. Two cognitively impaired residents whose MDS assessments documented dependence for bathing had care plans that continued to list only setup assistance or one‑person assist, without updating to reflect full dependence. Another cognitively impaired resident with documented combative behaviors toward staff and a reported incident of striking another resident with a remote had a behavior care plan that was not revised to include the new behavior of attempting to hit other residents or the potential for resident‑to‑resident altercations.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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