Coral Springs Rehab & Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, Delaware.
- Location
- 505 Greenbank Road, Wilmington, Delaware 19808
- CMS Provider Number
- 085004
- Inspections on file
- 19
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Coral Springs Rehab & Healthcare during CMS and state inspections, most recent first.
Staff failed to follow standardized menus, recipes, and portion sizes for a beef stew lunch meal. Policy required use of planned cycle menus and standardized recipes, including specific ingredients and preparation steps for regular and pureed beef stew, as well as defined portion sizes for each diet level. Observations showed the cook pureeing stew that lacked required vegetables and later adding carrots only to the regular stew, and serving the regular stew with a smaller ladle and the pureed stew with only one scoop instead of the specified two. In interviews, the cook reported not using recipes and relying on a spreadsheet for portions, while dietary leadership and the RD stated they expected adherence to menus, recipes, and portion sizes to meet residents’ nutritional needs.
Surveyors found multiple dietary service deficiencies, including undated and improperly stored food items, such as prepared sandwiches, lunch meat, cut fruit, and raw pork stored above ready-to-eat items, as well as open and unlabeled frozen products. Dietary staff reported they had not been trained to check dish machine temperatures or sanitizer levels, and when a DD tested the machine, no sanitizer was being dispensed and required monitoring logs were incomplete. In addition, a staff member responsible for cooking and serving checked temperatures only for items listed on a log, omitting some hot foods on the steam table, and a DD later determined that at least one hot vegetable item was not at the required temperature for service.
Surveyors found multiple medication and treatment carts unlocked and unattended in several halls, despite facility policy requiring all drugs and biologicals to be stored in locked compartments and carts to be secured when not in the direct line of sight of the nurse. On several occasions, an LPN left a cart unlocked while going down another hall or off the floor for 10–15 minutes, and another LPN left a cart unlocked while responding to a yelling resident in a nearby room. The unlocked carts contained OTC medications, insulin pens and vials, inhalers, nebulizer medications, and resident bubble packs of prescription drugs such as anticoagulants, antipsychotics, antihypertensives, analgesics, diuretics, and potassium chloride. Staff, including agency nurses, acknowledged they had been trained to keep carts locked, and leadership stated they expected carts to be locked when out of the nurse’s sight.
A resident with intact cognition and a history of anxiety, conversion disorder, rheumatoid arthritis, and depression was administered a suppository after repeatedly refusing it and reporting prior bowel movements. The nurse did not verify the resident's report by checking the EHR or consulting with the CNA, as required by facility policy, and proceeded to administer the medication after multiple requests. Supervisory staff confirmed that the protocol was not followed, resulting in a failure to respect the resident's right to refuse treatment.
The facility did not report allegations of abuse and injuries of unknown origin to the state survey agency within required timeframes for three residents. In one case, a CNA delayed reporting witnessed staff-to-resident abuse, and the incident was not reported until over four hours later. Another resident's injury of unknown origin was reported 26 hours after discovery, and an altercation between two residents was reported more than three hours after it occurred. Facility leadership confirmed these delays did not meet policy requirements.
A resident with severe cognitive impairment was allegedly subjected to physical and verbal abuse by an LPN during care, as witnessed by a CNA who delayed reporting the incident. The facility's investigation included staff interviews, medical assessment, and police notification, but failed to assess other cognitively impaired residents for possible abuse, resulting in an incomplete investigation.
A resident with significant mobility impairments was transferred using a mechanical lift by only one staff member, contrary to facility policy requiring two staff for such transfers. During the transfer, the lift made contact with a chair base, causing the resident to be lowered to the floor and resulting in pain and an emergency department visit. Staff interviews confirmed the transfer was not performed according to established procedures.
A resident with dementia, osteoarthritis, and lumbar disc displacement, care planned for fall risk and use of a concave mattress, was found over multiple observations to be using a bed that was visibly uneven and tilting to one side. The resident reported the bed had been broken for a long time, had told family and staff, and expressed fear of falling due to the lopsided bed. An LPN operating the bed confirmed it was uneven, and the Maintenance Director later identified the bed frame as broken and could not recall the last room audit, while the Administrator stated she was unaware of the problem despite facility policy requiring prompt reporting and maintenance of furniture in disrepair.
A resident with Parkinson's Disease and dementia was hospitalized due to the facility's failure to initiate a bowel protocol as per the care plan. Despite orders to monitor bowel movements and initiate interventions after three days without a bowel movement, the protocol was not followed on two occasions, leading to fecal impaction and hospitalization. Staff interviews confirmed the oversight in protocol initiation.
A resident with severe cognitive impairment and extensive leg wounds did not receive consistent pain management before dressing changes, despite hospital discharge instructions and family concerns. The facility failed to administer Oxycodone as needed, leading to the resident experiencing pain during wound care. The resident's condition worsened, resulting in rehospitalization for a wound infection.
The facility failed to ensure qualified personnel were present during kitchen operations, leading to delays in meal delivery and inadequate meal service. Breakfast trays were often delivered late, sometimes close to lunchtime, and meals lacked reasonable portions or selection. These issues were confirmed through interviews and a review of facility records.
The facility failed to maintain a sanitary and comfortable environment, with dirty floors, rusted fixtures, and disrepair observed in multiple rooms. Shower rooms had cleanliness issues, and there was a shortage of clean linens, affecting care. Staff confirmed these deficiencies, and frequent changes in maintenance directors contributed to inconsistent oversight.
The facility failed to develop and implement individualized care plans for residents with seizure disorders and those using bed rails. A resident with a seizure disorder had no specific care plan despite an active medication order. Additionally, three residents using bed rails lacked person-centered care plans, as confirmed by facility staff during interviews.
The facility failed to update care plans for several residents, resulting in deficiencies in person-centered care and infection control. A resident with dementia had an outdated activity care plan, while two residents with bed rails had care plans that did not reflect their current use. Additionally, three residents with medical conditions lacked care plans focused on infection control precautions. These issues were confirmed by facility staff during interviews.
The facility failed to comply with the Delaware Nursing Scope of Practice by allowing LPNs to perform assessments that should have been completed by RNs. This included post-fall and admission assessments for several residents, which were conducted by LPNs instead of RNs, as required by state regulations. Interviews revealed a lack of awareness among LPNs regarding their scope of practice limitations.
The facility failed to properly assess and document the use of bed rails for several residents, lacking evidence of medical necessity, risk assessments, and informed consent. Observations showed bed rails installed without proper evaluation, posing potential risks. Interviews revealed communication gaps between rehabilitation and maintenance staff, and the facility did not provide necessary documentation to surveyors.
The facility failed to provide drinks consistent with the needs and preferences of several residents. A resident reported not being offered fluids regularly, and observations confirmed this. Additionally, nine residents did not receive coffee or tea with their breakfast, despite these being indicated on their meal tickets. Staff interviews revealed this was a recurring issue, and the Dietary Supervisor was unaware of the problem.
The facility failed to maintain sanitary conditions in its food storage and preparation areas. Observations included debris in the walk-in freezer, spills in the refrigerator, and food stored on the floor. Uncovered and undated food items were found, and the ware washing area had food debris and improperly stored clean mugs. A snack refrigerator contained undated and unlabeled items. These issues were confirmed by an RN and discussed with facility leadership.
The facility failed to maintain accurate medical records and provide adequate medical diagnoses for anticoagulant prescriptions. Urine culture results were not documented in residents' EMRs, and medication orders lacked proper medical indications. Additionally, discrepancies were found in the documentation of enteral feed water flushes and incontinence care plans.
The facility failed to implement enhanced barrier precautions for residents with indwelling devices, such as catheters and PICC lines, resulting in staff providing care without appropriate PPE. An environmental tour also revealed infection control issues, including uncleanable materials and uncovered wash bins on dusty floors.
The facility failed to ensure antibiotics were prescribed according to recognized standards for three residents. One resident received antibiotics without a urine culture, another lacked a final microbiology report for a UTI, and a third received an undocumented antibiotic dose for a COPD exacerbation. These issues indicate deficiencies in the facility's antibiotic stewardship and infection control practices.
The facility failed to document pneumococcal vaccinations for four residents, despite orders and records in the DELVAX system. The Infection Preventionist confirmed the lack of documentation and acknowledged that the facility had not held a vaccine clinic the previous year. This issue was reviewed with facility leadership and a representative from the Ombudsman office.
The facility failed to treat residents with respect and dignity. A resident's catheter bag was improperly positioned, visible from the hallway, and staff were unaware of the care plan details. Additionally, a CNA was observed inattentive and using a cellphone while sitting between two residents during lunch, showing a lack of engagement and respect.
The facility failed to support the self-determination of three residents by not allowing them to go outside independently, despite their care plans indicating a preference for outdoor activities. Residents reported restrictions on accessing an enclosed courtyard without staff supervision, which was not always available. Additionally, one resident faced scheduling conflicts due to late lunch tray deliveries, impacting their ability to participate in activities.
A facility failed to notify the Ombudsman of a resident's transfer to the hospital, as required. The resident was admitted in August and transferred in April, but the facility's records lacked evidence of notification to the Ombudsman. The Nursing Home Administrator confirmed the oversight during an interview, and the issue was reviewed with facility staff and an Ombudsman representative.
The facility failed to notify the state PASARR authority for two residents diagnosed with new mental disorders, as required. One resident was diagnosed with adjustment disorder with depressed mood and prescribed citalopram, while another was diagnosed with a delusional disorder and prescribed Risperdal. The facility did not refer these cases for PASARR Level II screening, and errors in the PASARR application were not corrected.
The facility failed to provide outdoor activities for two residents, despite their care plans indicating the importance of such activities. Both residents, who were cognitively intact and had mobility aids, reported being unable to go outside without staff supervision, which was often unavailable. Their activity logs showed minimal participation in outdoor activities, with none recorded in October. The deficiency was confirmed by the Activities Director and discussed with facility leadership.
A facility failed to provide appropriate services to maintain a resident's bladder continence. Initially documented as continent, the resident's care plan inaccurately noted incontinence, and staff were not informed about assisting with toileting. Despite occasional incontinence, there was no evidence of interventions to restore continence, and the resident expressed a desire to use the toilet independently but feared falling. The deficiency was confirmed by the NHA and DON.
A resident with a care plan for nutrition risks was not provided with the appropriate food texture as per his physician's order for a regular diet. Despite the resident's requests for regular texture food, he continued to receive mechanical soft meals. An LPN was unaware of the resident's dietary needs, leading to the deficiency being confirmed by a Regional Clinical Consultant.
The facility failed to accommodate meal preferences for two residents, resulting in one receiving an incorrect lunch despite requesting an alternative, and another reporting no alternative breakfast options. Communication lapses between staff and the kitchen were identified as contributing factors.
The facility failed to provide evening snacks to two residents, leading them to store food in their rooms due to inconsistent meal times and insufficient snack availability. Interviews with CNAs revealed that snacks were sometimes unavailable, and backup snacks were inaccessible after hours. These issues were discussed with facility leadership and an Ombudsman representative.
The facility failed to document the COVID-19 vaccination status of two residents in their EMR, despite records in the DELVAX system confirming their vaccinations. The Infection Preventionist acknowledged the lapse in maintaining vaccination records and the absence of a vaccine clinic in the previous year. These findings were reviewed with facility leadership and an Ombudsman representative.
The facility did not have the survey results from the past three years readily accessible to residents, family members, and legal representatives. The survey results binder was kept behind the reception desk, as confirmed by the receptionist. This issue was discussed with the NHA, DON, RCC, RDO, and an Ombudsman representative.
Failure to Follow Standardized Menus, Recipes, and Portion Sizes for Beef Stew Meal Service
Penalty
Summary
The facility failed to follow its planned menus and standardized recipes for a lunch meal, affecting both regular and pureed beef stew preparations and portions. Facility policy required that nourishing, palatable meals be provided based on RDAs, with standardized cycle menus planned in advance and utilized, and that cooks prepare menu items following written menus and standardized recipes. For the lunch meal in question, the facility’s recipe for beef stew specified beef, Spanish onions, red potatoes, carrots, and celery, and the pureed version was to be made by processing the prepared beef stew until smooth. Observations showed the cook preparing pureed beef stew without potatoes or carrots present in the stew being pureed, and then adding carrots only to the regular beef stew, indicating the recipe was not followed for the pureed diet. The facility’s menu extension for that lunch specified that regular diets were to receive beef stew using an 8 oz serving spoon or two #8 (4 oz) disher scoops, and pureed diets were to receive two #8 (4 oz) disher scoops. However, observations showed the cook serving the regular beef stew with a 6 oz ladle and the pureed beef stew with only one #8 (4 oz) disher scoop, contrary to the planned portions. In interviews, the cook stated he did not follow any recipes because he believed the facility did not have any, and that he relied on a spreadsheet for portion sizes, thinking he had used an 8 oz ladle for regular stew and a #10 (3.2 oz) disher scoop for pureed stew, and that he had been told to always use the #10 scoop. The Regional Dietary Services Consultant, the Registered Dietitian, and the Administrator each stated their expectation that staff follow menus, recipes, and specified portion sizes to meet residents’ nutritional needs and maintain weight, underscoring that the observed practices did not align with facility policies or expectations.
Food Storage, Sanitization, and Hot Holding Temperature Failures in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage practices based on observations, interviews, and policy review. The facility’s undated Food Storage policy required that cooked foods be stored above raw foods, raw animal foods be separated and stored on lower shelves in drip-proof containers, and all foods be covered, labeled, and dated. During a kitchen observation, surveyors found prepared sandwiches in a reach-in cooler that were not dated, lunch meat and cut cantaloupe in the walk-in cooler with no dates, and raw pork breakfast meat stored on a shelf above eggs and lettuce. In the walk-in freezer, frozen waffles were found open to the air and frozen chicken was stored in an unlabeled bag. The Regional Dietary Services Consultant acknowledged that the raw meat should not be stored above lettuce due to cross contamination risk and commented that she had not seen the kitchen look that bad in a long time. A second deficiency involved failure to ensure proper dish machine sanitization and staff competency in monitoring it. The facility’s Cleaning Dishes/Dish Machine policy required dish machines to be checked prior to meals to ensure proper functioning and appropriate temperatures for cleaning and sanitizing. During observation, two dietary aides were washing dishes and reported that they believed the manager checked the dish machine temperature and sanitizer, and that they had never been trained to do so. When a Dietary Director from a sister facility checked the dish machine, no sanitizer was being dispensed, and the dish machine log showed no temperature or sanitizer levels recorded that morning. The manufacturer’s guidelines required a minimum sanitizer concentration of 50 ppm. Later, another Dietary Director checked the sanitizer level in the three-compartment sink and found the concentration appropriate, but stated that dishes needed to soak for 15 seconds, while the posted manufacturer’s guidelines required immersion for 1 to 2 minutes, or a minimum of 60 seconds, prompting recognition that the stated contact time was incorrect. A third deficiency involved improper hot holding temperature monitoring for food being served. The FDA 2022 Food Code requires hot-held food to have an internal temperature of at least 135°F when removed from hot holding temperature control. During a meal service observation, a staff member responsible for cooking and serving took temperatures of certain hot foods on the steam table, including beef stew, pureed beef stew, and pureed carrots, but did not check the temperature of the carrots or mechanical soft beef stew because those items were not listed on the temperature log sheet. The staff member stated that he only checked temperatures of items listed on the log. A Dietary Director later checked the remaining food items and found the carrots were not hot enough, returning them to the stove to be reheated. The Regional Dietary Services Consultant later stated that training of dietary staff was the responsibility of the Dietary Director, that staff working with the dish machine should be checking temperature and sanitizer levels, and that the staff member who had been cooking had only recently transitioned from a dietary aide role.
Unlocked and Unattended Medication and Treatment Carts
Penalty
Summary
The deficiency involves the facility’s failure to keep medication and treatment carts locked when not under the direct observation of the assigned nurse, contrary to facility policy requiring all drugs and biologicals to be stored in locked compartments and secured when not in use. Surveyors observed an unlocked and unattended medication cart on one hall early in the morning, with the assigned LPN acknowledging that the cart should have been locked, stocked, and secured when she left it to go down another hall approximately 64 feet away. Additional observations showed two medication carts and a treatment cart unlocked and unattended near the nurses’ station for two halls, with one cart’s narcotic box door open (though the narcotic box itself was locked). The drawers of these carts contained OTC medications, insulin pens and vials, inhalers, nebulizer medications, and multiple resident bubble packs of prescription drugs including anticoagulants, antipsychotics, antihypertensives, analgesics, diuretics, and potassium chloride. Surveyors further observed another unlocked and unattended medication cart on a different hall, and staff interviews confirmed that nurses had been off the floor and out of sight of their assigned carts for approximately 10–15 minutes while the carts remained unlocked. One agency LPN stated she and another nurse were assigned to the treatment cart and that the carts should not have been left unlocked, acknowledging she had been trained by both the agency and the facility on the importance of locking carts when out of sight. Later that morning, another medication cart on a hall was found unlocked while the assigned LPN was approximately 35 feet away in a resident’s room; the LPN stated she left the cart unlocked to respond to a yelling resident but recognized it should have been locked when not in her line of sight. The DON and the Administrator both stated their expectation that medication and treatment carts be locked when nurses are away and out of sight of the carts, confirming that the observed practices did not meet facility expectations or policy.
Failure to Honor Resident's Right to Refuse Medication
Penalty
Summary
A deficiency occurred when facility staff failed to respect a resident's right to refuse medication. The resident, who had intact cognition and a medical history including anxiety disorder, conversion disorder, rheumatoid arthritis, and depression, was on a bowel protocol due to concerns about constipation. Despite the resident reporting to the nurse that they had already had a bowel movement earlier in the day and refusing the suppository, the nurse continued to attempt administration and ultimately gave the medication with the resident's nighttime medications after repeated requests. Documentation showed that the resident had a large and a medium bowel movement on the day in question, which was not recognized by the nurse at the time of medication administration. The nurse stated he was unaware of any documentation of the resident's bowel movements and relied on a printed list indicating the resident had not had a bowel movement in three days. The nurse did not verify the resident's report by checking the electronic health record or consulting with the assigned CNA, as outlined in facility policy and as described by supervisory staff during interviews. Interviews with supervisory staff, including the LPN Supervisor, ADON, Quality Assurance nurse, DON, and Administrator, confirmed that the expected protocol was to verify a resident's report of a bowel movement by reviewing documentation and consulting with staff before proceeding with further interventions. In this case, the nurse did not follow these steps, resulting in the administration of a suppository against the resident's expressed wishes and without proper verification, thereby failing to honor the resident's right to self-determination and choice.
Failure to Timely Report Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report allegations of abuse and injuries of unknown origin to the state survey agency within the required timeframes for three residents. According to facility policy, all alleged violations involving abuse or serious bodily injury must be reported immediately, but not later than two hours after the allegation is made. In the case of one resident with severe cognitive impairment and a history of behavioral issues, a CNA witnessed an LPN strike and verbally abuse the resident during care. The CNA delayed reporting the incident until after her shift, and the RN Supervisor also waited until the LPN had left the building before notifying the DON. The DON subsequently reported the incident to the state agency over four hours after the alleged abuse occurred. Another resident, who had intact cognition and a history of a recent hip fracture, was found to have a dislocated femur following a routine X-ray. The injury was of unknown origin, and the resident denied any trauma or falls. The injury was not reported to the state survey agency until 26 hours after it was identified, despite facility expectations that such incidents be reported immediately to allow for prompt investigation. The LPN responsible for reporting could not explain the delay. A third incident involved an altercation between two residents, where one resident entered another's room and pulled their hair. Staff intervened and separated the residents, and law enforcement and responsible parties were notified. However, the incident was not reported to the state survey agency until more than three hours after it occurred. Interviews with facility leadership confirmed that these reports were not made within the required timeframes, as outlined in facility policy.
Failure to Thoroughly Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident physical and verbal abuse involving one resident with severe cognitive impairment. The incident involved a resident with a history of type two diabetes mellitus, cirrhosis of the liver, and aphasia, who was admitted with a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The resident was known to refuse care and exhibit combative behaviors. On the date of the incident, a CNA reported that an LPN called the resident derogatory names and struck the resident on the hand and face during care. The CNA did not intervene at the time, stating she was in shock, and delayed reporting the incident until after the LPN had left the building. The facility's investigation included statements from the involved staff, assessment by the Medical Director, and notification of the police, who found no evidence of criminal activity. The resident was assessed and found to have no injuries, and interviews with other cognitively intact residents assigned to the LPN revealed no concerns. However, the investigation did not include assessment of other cognitively impaired residents under the LPN's care for possible signs of abuse. The facility unsubstantiated the allegation based on the lack of physical evidence and the LPN's history, and the LPN was allowed to return to work after a suspension. Despite the steps taken, the facility's investigation was incomplete as it failed to assess all potentially affected residents, particularly those with cognitive impairment who may not be able to report abuse. The deficiency was further highlighted by the fact that the CNA did not intervene or immediately report the incident, and the facility did not ensure that all residents were protected from potential harm during and after the investigation, as required by their own policy.
Failure to Ensure Safe Mechanical Lift Transfer Procedures
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards related to the improper use of a mechanical lift, as required by facility policy. The policy specified that two staff members must assist with mechanical lift transfers to ensure resident safety, dignity, and comfort. Despite this, a certified nursing assistant (CNA) attempted to transfer a resident with significant mobility impairments using a mechanical lift without the required second staff member. The resident's care plan and Kardex clearly indicated the need for two-person assistance during transfers. The incident involved a resident with a history of stroke, hemiplegia, and impaired mobility, who was dependent on staff for transfers. During the transfer from a chair to a bed, the CNA was unable to find another staff member to assist and accepted help from the resident's family member instead. The mechanical lift did not clear the bed properly, and as the CNA attempted to maneuver the resident onto the bed, the lift made contact with the base of the geriatric chair. This caused the resident's weight to shift, resulting in the lift tilting and the resident being lowered to the floor by the CNA and family member. Following the incident, the resident complained of pain and was sent to the emergency department, where imaging showed no fractures or acute injuries. Interviews with staff and the family member confirmed that the transfer was performed by only one staff member, contrary to facility policy and training. The CNA admitted to acting impatiently and not following the required procedure for mechanical lift transfers.
Failure to Maintain Resident Bed in Safe Operating Condition
Penalty
Summary
The facility failed to maintain a resident’s bed in safe operating condition, resulting in a persistently uneven, left-tilting bed over multiple days. Facility policy on providing a safe and homelike environment required staff to report any furniture in disrepair to maintenance promptly. Resident #142, admitted with diagnoses including unspecified dementia, osteoarthritis, and intervertebral disc displacement of the lumbar region, had a care plan identifying potential for falls with injury related to non-compliance with safety measures and specifying use of a concave mattress and other safety interventions. Despite this, surveyors observed on four separate dates that the resident’s bed was visibly uneven with a noticeable left-sided downward tilt. Resident #142 reported that the bed had been broken for a long time, had informed family and facility staff, and expressed fear of falling because the bed was lopsided, although no fall had occurred. When an LPN acting as unit manager operated the bed controls, he confirmed the bed was not even, with the right side higher and tilting to the left, and stated it was the first time he was aware of the issue. The Maintenance Director later examined the bed, stated the bed frame was broken, and could not recall the last time an audit had been done for the resident’s room. The Administrator stated that the expectation was for the Maintenance Director to follow policy and perform routine maintenance, and reported having no prior knowledge that the bed was broken.
Failure to Initiate Bowel Protocol Leads to Hospitalization
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident, identified as R159, who was admitted with diagnoses including Parkinson's Disease, muscle weakness, and dementia. The resident's care plan highlighted a potential for constipation due to decreased motility, with specific interventions to monitor and document bowel movements. Despite these orders, the facility did not initiate the bowel protocol as required when the resident did not have a bowel movement for several days. This oversight occurred on two separate occasions, each lasting five days, during which the bowel protocol was not followed, and the physician was not notified of the lack of bowel movements. As a result of the facility's failure to monitor and initiate the bowel protocol, the resident experienced abdominal pain and was hospitalized for fecal disimpaction. The hospital records indicated a large stool burden in the rectum, and the resident's condition improved after treatment for constipation. Interviews with facility staff confirmed that the bowel protocol should have been initiated after three days without a bowel movement, but this was not done, leading to the resident's hospitalization.
Inadequate Pain Management for Resident with Severe Wounds
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R157, who was admitted for wound care and physical therapy following a hospital stay for septic shock due to an infection in her left lower leg. Despite the hospital discharge summary indicating the need for Oxycodone 10 mg to be administered 30 minutes before dressing changes, the facility did not consistently follow this directive. The resident's pain was not adequately assessed or managed, particularly during dressing changes, leading to the resident experiencing pain during these procedures. R157 had multiple diagnoses, including cellulitis, open wounds, a fractured spine, arthritis, and dementia, which made her a vulnerable resident with significant cognitive impairment. The facility's records lacked evidence of using alternative pain assessment tools for cognitively impaired residents, except for one instance. The resident's daughter, who was actively involved in her care, expressed concerns about her mother's pain management, specifically noting that pain medication was not administered consistently before dressing changes. The facility's inaction in adjusting pain management despite the resident's deteriorating condition and the daughter's expressed concerns resulted in harm to the resident. The resident's wounds showed signs of infection, and her pain management remained unchanged even as her condition worsened. The facility did not document any reasons for not making changes to the pain management plan, and the resident was eventually hospitalized again for treatment of a wound infection.
Inadequate Staffing and Meal Service Delays in Facility
Penalty
Summary
The facility failed to ensure that a qualified person was in charge during kitchen operations, as evidenced by the absence of food service members with valid Food Protection Manager certificates on multiple dates. This was confirmed through interviews and a review of dietary time cards. Additionally, there were significant delays in meal delivery, with breakfast trays not being provided to residents within 45 minutes of the scheduled time. Observations and interviews revealed that breakfast was often delivered late, sometimes close to lunchtime, particularly in the B unit. Further issues were noted with meal delivery on specific dates, where lunch and dinner meals were late and lacked reasonable portions or selection. The facility's dietary time cards confirmed that no qualified food service member was present during these times. These findings were corroborated through interviews with staff and a review of facility records, highlighting a consistent pattern of inadequate staffing and meal service management in the facility's food and nutrition service.
Facility Fails to Maintain Sanitary Environment and Adequate Linen Supply
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment for residents, as observed in multiple rooms across different hallways. In the B hallway, several rooms had dirty floors with stains and dust, and some had additional issues such as exposed nails, rusted bathroom fixtures, and disrepair of windowsills and heating systems. The F hallway had a resident's bed rail improperly placed on a dresser for two weeks, indicating a lack of timely maintenance. The environmental tour confirmed these issues, and it was noted that the facility had experienced frequent changes in maintenance directors, contributing to the lack of consistent oversight. In the shower rooms, there were significant cleanliness issues, including broken tiles, discolored grout, and evidence of insect debris. The shower chairs and floors were dirty, and there was clutter in the form of shoes and wheelchair parts scattered on the floor. Despite claims that the shower rooms were cleaned daily, there was no evidence of housekeeping audits being conducted, and the maintenance director was unable to provide records of monthly maintenance audits. Additionally, there was a shortage of clean linens in the facility, with minimal supplies observed in the linen closets of the E and D wings. Staff confirmed the lack of linens, which affected their ability to provide proper care to residents. The absence of an overnight laundry shift contributed to delays in restocking clean linens, as the morning shift had to manage the backlog from the previous night. These deficiencies were confirmed during interviews with various staff members and reviewed with facility leadership and a representative from the Ombudsman's office.
Failure to Implement Individualized Care Plans for Seizure Disorder and Bed Rail Usage
Penalty
Summary
The facility failed to develop and implement individualized care plans for residents with specific needs related to seizure disorders and bed rail usage. For one resident with a seizure disorder, the clinical record showed an active physician's order for Levetiracem, yet the comprehensive care plan lacked evidence of an individualized seizure disorder care plan. This deficiency was confirmed during an interview with the Director of Nursing and a Licensed Practical Nurse. Additionally, the facility did not have a person-centered care plan for another resident's use of a left-sided quarter-length bed rail, as observed during incontinence care. The absence of a care plan was confirmed during an interview with the Director of Nursing and a Resident Care Coordinator. Furthermore, the facility failed to develop and implement care plans for two other residents regarding their use of bed rails. One resident was observed with bilateral grab bars, but the facility lacked evidence of a person-centered care plan for these bed rails. Another resident, admitted to the facility in 2023, was observed with a left-sided quarter bed rail, yet the care plan did not focus on this aspect. These findings were confirmed during interviews with facility staff, including the Director of Nursing, a Licensed Practical Nurse, and a representative from the Ombudsman's office.
Deficiencies in Care Plan Updates and Infection Control
Penalty
Summary
The facility failed to review and revise the comprehensive care plans for several residents, leading to deficiencies in individualized and person-centered care. For one resident with dementia, the activity care plan was not updated to reflect the resident's preferences and capabilities, despite documented refusals to participate in various activities. The care plan also lacked input from the resident's family, which was noted as important in the admission assessment. Two residents were observed with bilateral quarter-length bed rails, but their care plans did not reflect this current use. The care plans were outdated and did not include person-centered goals or measurable outcomes related to the use of bed rails. This oversight was acknowledged during interviews with facility staff, indicating a failure to ensure that care plans were current and reflective of the residents' needs. Additionally, the care plans for three residents with specific medical conditions, such as dysphagia and dialysis, lacked a focus on infection control precautions. Despite the presence of feeding tubes and dialysis ports, the care plans did not address enhanced barrier precautions, which are critical for preventing infections. This deficiency was confirmed by a registered nurse during an interview, highlighting a gap in the facility's infection control practices.
Improper Delegation of Nursing Assessments
Penalty
Summary
The facility failed to adhere to the Delaware Nursing Scope of Practice by allowing Licensed Practical Nurses (LPNs) to perform assessments that should have been completed by Registered Nurses (RNs). Specifically, for five residents, the facility did not ensure that RNs conducted the necessary admission and post-fall assessments. For one resident, an LPN completed the post-fall assessment, which included vital signs, pain assessment, and neurological checks, instead of an RN as required. Interviews with the Director of Nursing (DON) and Quality Assurance (QA) staff confirmed that the initial post-fall assessment should have been conducted by an RN. Additionally, for four other residents, LPNs completed various admission assessments, including medical history, sensory orientation, pain, musculoskeletal evaluations, and other health-related assessments. These actions were in violation of the state regulations that mandate RNs to perform such assessments. Interviews with the involved LPNs revealed a lack of awareness regarding the scope of practice limitations, and the DON confirmed the facility's requirement for RNs to conduct these assessments. The findings were reviewed with facility leadership and a representative from the Ombudsman office.
Deficiency in Bed Rail Assessment and Documentation
Penalty
Summary
The facility failed to implement a comprehensive system for assessing and documenting the use of bed rails for residents, leading to deficiencies in compliance with federal requirements. For seven residents reviewed, there was a lack of evidence regarding the specific date of bed rail installation, the medical necessity for their use, and attempts to use appropriate alternatives before installation. Additionally, there was no documentation of assessments for risks such as entrapment, nor was there evidence of informed consent being obtained from residents or their representatives. The facility's policy requires a person-centered approach to bed rail use, including a comprehensive assessment of the resident's medical conditions, cognition, mobility, and risk of falling. However, the records for residents R6, R14, R16, R60, R67, R76, and R119 lacked documentation of these assessments. Observations revealed that bed rails were installed without proper evaluation of their necessity or safety, and in some cases, the bed rails were stationary and could not be lowered, posing potential risks to the residents. Interviews with facility staff, including the Rehab Director, revealed that the rehabilitation team evaluates residents for bed rail use but does not specify the size of the bed rails when communicating with maintenance. Despite requests from surveyors, the facility failed to provide the necessary documentation and evidence to support compliance with federal requirements for bed rail use. This lack of documentation and assessment highlights a significant deficiency in the facility's processes for ensuring resident safety and informed decision-making regarding bed rail use.
Failure to Provide Consistent Hydration and Beverage Preferences
Penalty
Summary
The facility failed to provide drinks consistent with the needs and preferences of 10 out of 13 residents reviewed for food. One resident, R6, reported that fluids were not always offered during the day, and they had to request them. An observation confirmed that R6 had not been offered fresh water for two shifts, as evidenced by a dated Styrofoam cup on their bedside table. This issue was discussed with the Nursing Home Administrator, Director of Nursing, and other staff members. Additionally, an observation on the B unit revealed that nine residents did not receive coffee or tea with their breakfast meal trays, despite these beverages being indicated on their meal tickets. Interviews with CNAs confirmed the absence of these beverages, and it was noted that this was a recurring issue. The Dietary Supervisor was unaware of the problem, indicating a breakdown in the kitchen system. The Regional Dietary Consultant confirmed that residents should receive the beverages listed on their meal tickets. This deficiency was also discussed with the facility's administrative and clinical staff.
Unsanitary Food Storage and Preparation Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in its food storage and preparation areas, as observed during an initial tour of the kitchen. The walk-in freezer was found to contain bread, ice cream, and debris on the floor. The standard refrigerator had a pink and orange substance spilled inside at the base. In the dry food storage room, bags of onions, a bag of potatoes, and a container of icing were stored on the floor. Additionally, a pan with meat was left uncovered and unattended on a table, and a prepared salad inside the refrigerator was undated. In the ware washing room, the table where clean dishes come out of the ware washing machine was covered in food debris, and clean plastic mugs were stored in a wet location with visible white spots on them. Furthermore, paper towels were not available at the hand washing sink. A follow-up visit to the kitchen revealed further unsanitary conditions, including small containers of ice cream and muffins turned over on the floor of the walk-in freezer, and a box of muffins left partially uncovered. The ware washing room's dish area table still contained visible food debris. Additionally, a snack/nourishment refrigerator serving multiple units contained a personal lunch bag and food items in Styrofoam inside an undated and unlabeled plastic bag. These findings were confirmed by a registered nurse and discussed with the Nursing Home Administrator, Director of Nursing, and Regional Clinical Consultant.
Deficiencies in Medical Record Keeping and Medication Orders
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for several residents. For instance, the urine culture results for multiple residents were not properly documented in their electronic medical records (EMR). The contracted laboratory did not upload the final culture results to the residents' EMR, and the facility relied on sending these results via email to providers, which led to the absence of these critical results in the residents' records. This issue was confirmed during interviews with facility staff, and the surveyor was provided with copies of the results only upon request. Additionally, the facility did not provide adequate medical diagnoses for the prescription of anticoagulant medications for several residents. The orders for medications such as rivaroxaban, warfarin, and apixaban were documented with indications like 'anticoagulation' or 'blood thinner,' which are not considered valid medical diagnoses. The residents had underlying conditions such as atrial fibrillation and pulmonary embolism, which were the actual medical indications for these medications, but these were not properly documented in the orders. Furthermore, there were discrepancies in the documentation of enteral feed water flushes for residents with feeding tubes. The medication administration records showed inaccuracies in the recorded amounts of water flushes, either being undocumented or incorrectly documented, which was confirmed by facility staff. Additionally, there was a failure to ensure that a resident's care plan accurately reflected their incontinence care needs, as there was a mismatch between the care plan and the CNA Kardex regarding the resident's toileting program.
Inadequate Infection Control and Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of implementation of enhanced barrier precautions for several residents with indwelling medical devices. For instance, a resident with a suprapubic catheter did not have enhanced barrier precautions ordered or implemented for 46 days, despite meeting the criteria for such precautions. During this period, staff provided high-contact care without donning the appropriate personal protective equipment (PPE), such as gowns, which is a requirement for handling indwelling devices. Another resident with a cholecystostomy tube also did not have enhanced barrier precautions ordered or implemented for 103 days. The facility's failure to order and implement these precautions was consistent across multiple residents, including those with PICC lines, Foley catheters, and wounds. The lack of appropriate orders and PPE usage was observed during direct care activities, such as dressing changes and incontinence care, where staff either did not wear the required PPE or were unaware of the need for enhanced precautions. Additionally, an environmental tour revealed infection control issues, such as uncleanable materials on bed frames and uncovered wash bins on dusty floors. These findings were confirmed by facility staff, indicating a broader issue with maintaining a sanitary environment. The facility's policies on infection prevention and enhanced barrier precautions were not effectively implemented, leading to multiple deficiencies in infection control practices.
Deficiencies in Antibiotic Stewardship and Infection Control
Penalty
Summary
The facility failed to ensure antibiotics were prescribed in accordance with recognized standards for three residents. For one resident, antibiotics were prescribed without evidence of a urine culture specimen order or results, despite the resident being treated for a urinary tract infection (UTI). The nurse practitioner ordered two different antibiotics, Cephalexin and Levaquin, without a documented reason or supporting laboratory evidence. The facility's Infection Preventionist was unaware of the rationale behind the antibiotic prescriptions, indicating a lack of communication and adherence to the facility's infection prevention and control program policy. Another resident was readmitted to the facility with a history of a catheter-associated UTI. Although a urine culture was ordered, the facility could not provide the final microbiology report with sensitivity results, which is necessary to meet the McGeer's Criteria for Infection Surveillance. Additionally, a third resident received a one-time dose of an antibiotic for a COPD exacerbation without documentation on the facility's line list or supporting laboratory or radiology reports to confirm the infection. These deficiencies highlight a failure in the facility's antibiotic stewardship program and infection control practices.
Failure to Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to maintain accurate and complete documentation of pneumococcal vaccinations for four residents, R15, R33, R102, and R138, as required by their Infection Prevention and Control Program. For R15, although there was a medical order for a pneumococcal vaccine upon admission, the vaccine was not offered, and there was no documentation of its administration. R33's electronic medical record lacked evidence of an up-to-date pneumococcal vaccine, despite the DELVAX website showing a complete vaccination schedule. Similarly, R102's record did not document the pneumococcal vaccine, even though DELVAX confirmed the administration of PCV20. R138's record also failed to document the administration or refusal of the pneumococcal vaccine, although DELVAX indicated a previous PCV13 vaccination, and the resident was due for PCV20 upon admission. The facility's failure to document these vaccinations was confirmed during an interview with the Infection Preventionist, who acknowledged that the facility had not conducted a vaccine clinic the previous year and that the previous Infection Preventionist had not maintained the vaccination records. The current Infection Preventionist confirmed that the residents' vaccination statuses were documented in the DELVAX system but not in the facility's electronic medical records. This lack of documentation was reviewed with the Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, Resident Care Coordinator, Regional Director of Operations, and a representative from the Ombudsman office.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by two main observations. In the first instance, a resident with a suprapubic catheter had their catheter bag and tubing visibly positioned from the hallway, contrary to the care plan instructions. The CNA responsible for the resident's care was unaware of the proper positioning, and the LPN was not familiar with the care plan details. This oversight was confirmed by the Director of Nursing and other staff members during the survey. In the second instance, a CNA was observed sitting in an armchair with her legs over the armrest and using her cellphone while positioned between two residents eating lunch in the dining room. The CNA was not facing or assisting the residents, indicating a lack of engagement and respect for the residents' dining experience. This behavior was immediately reviewed with a Registered Nurse/Unit Manager and later discussed with the Nursing Home Administrator and other staff members.
Failure to Support Resident Self-Determination in Outdoor Activities
Penalty
Summary
The facility failed to honor the rights of three cognitively intact residents to self-determination and choice regarding outdoor activities. Despite having care plans that included preferences for outdoor activities, residents reported being unable to go outside independently. One resident expressed that new management policies restricted access to an enclosed courtyard unless accompanied by staff, which was not always available. Another resident confirmed the inability to go outside without staff supervision, and the Activities Director corroborated that staff supervision was mandatory for safety reasons, even in the enclosed courtyard. Additionally, a third resident was unable to access the facility lobby or courtyard independently due to locked doors, requiring staff assistance to unlock them. This resident also faced scheduling conflicts between late lunch tray deliveries and afternoon activities, forcing a choice between eating and participating in activities. The facility's meal delivery logs confirmed delays in lunch tray deliveries, which sometimes extended past the scheduled end time, further impacting the resident's ability to engage in preferred activities.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the Ombudsman of a resident's transfer to the hospital, which was a requirement. The resident was admitted to the facility on August 20, 2023, and was transferred to the hospital on April 27, 2024. Upon review of the resident's electronic medical record and the facility's Ombudsman Transfer log for April 2024, there was no evidence that the Office of the State Long-Term Care Ombudsman was notified of this transfer. During an interview, the Nursing Home Administrator (E1) confirmed that the resident was sent to the hospital on the specified date and acknowledged that the resident's name was not on the Ombudsman Transfer log. Additionally, there was no documentation available to prove that the Ombudsman's Office had been notified. These findings were reviewed with several facility staff members and a representative from the Ombudsman office.
Failure to Notify State PASARR Authority of New Mental Disorder Diagnoses
Penalty
Summary
The facility failed to notify the appropriate state-designated authority for two residents when new diagnoses of mental disorders were identified, which is a requirement under the PASARR program. For one resident, R141, the clinical record showed that a PASARR Level I Screen Outcome indicated no Level II was required upon admission. However, after being diagnosed with adjustment disorder with depressed mood and prescribed citalopram for depression, the facility did not inform the state PASARR authority until it was pointed out by a surveyor. This oversight was confirmed by the Nursing Home Administrator (NHA) during an interview. Similarly, for another resident, R125, the facility did not refer the resident for a PASARR Level II screening after being diagnosed with a delusional disorder and prescribed Risperdal, an atypical antipsychotic medication. The resident's PASARR application was also incorrectly filled out by the hospital, stating the medication was for major depression disorder instead of the actual delusional disorder. The facility failed to recognize and correct this error, which was acknowledged by the NHA during an interview.
Failure to Provide Outdoor Activities for Residents
Penalty
Summary
The facility failed to provide outdoor activities for two residents, R20 and R80, during appropriate weather, as outlined in their comprehensive assessments and care plans. R20, who was admitted with an amputation of the left leg above the knee, had an activity care plan that included community outings and outdoor activities during suitable weather. Despite being cognitively intact and self-propelling with a manual wheelchair, R20 expressed that under new management, residents were not allowed to go outside unless accompanied by staff. A review of R20's Daily Activities Log showed minimal participation in outdoor activities over several months, with no outdoor activity recorded in October 2024. Similarly, R80, admitted with muscle weakness and lack of coordination, had a care plan emphasizing the importance of outdoor activities. R80, who used a rolling walker for mobility, also reported being unable to go outside without staff supervision, which was often unavailable. The Daily Activities Log for R80 mirrored that of R20, with limited outdoor activity participation and none in October 2024. The Activities Director confirmed that residents required staff supervision to access the courtyard, and the deficiency was acknowledged by the Regional Clinical Consultant and discussed with the Nursing Home Administrator and Director of Nursing.
Failure to Maintain Bladder Continence for a Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R92, received appropriate services and assistance to maintain bladder continence. Upon admission, R92 was documented as continent of bladder and bowel, but the care plan inaccurately noted incontinence. Despite a three-day voiding diary showing no episodes of incontinence, the care plan interventions included assistance to the toilet as requested and application of barrier cream after incontinent episodes. Over time, R92's records indicated occasional bladder incontinence, but there was no evidence of interventions to restore continence. Interviews with staff revealed a lack of communication and understanding regarding R92's toileting needs. A CNA stated they were not informed about assisting R92 to the toilet, and the resident expressed a desire to use the toilet independently but feared falling. The RNAC explained the facility's process for creating a toileting plan based on voiding diary results, but there was no evidence of a person-centered plan to promote continence for R92. The facility's failure to provide adequate services and assistance to maintain R92's bladder continence was confirmed by the Nursing Home Administrator and Director of Nursing.
Failure to Provide Appropriate Food Texture for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R141, received food prepared in a form that met his individual needs and care plan. R141 was admitted to the facility with a care plan addressing nutrition and hydration risks due to poor food intake and potential weight changes. Despite having a physician's order for a regular texture diet for comfort feeding, R141 was observed receiving a mechanical soft texture meal. During an interview, R141 expressed that he had repeatedly informed the nursing staff of his preference for regular texture food, yet continued to receive chopped and ground food. An LPN confirmed the discrepancy, stating she was unaware of R141's dietary allowance for regular texture food. The deficiency was confirmed by a Regional Clinical Consultant and discussed with the Nursing Home Administrator, Director of Nursing, and the Regional Clinical Consultant.
Failure to Accommodate Resident Meal Preferences
Penalty
Summary
The facility failed to accommodate food preferences for two residents, leading to deficiencies in meal service. One resident expressed a desire for an alternative meal option, specifically requesting a tuna sandwich instead of the primary menu of fried chicken with gravy, mashed potatoes, seasoned spinach, and a dinner roll. Despite communicating this preference to a staff member, the resident received the primary menu items on their lunch tray. The LPN on duty was unaware of the resident's request and confirmed the incorrect meal was served. The Dietary Supervisor acknowledged that alternative menu requests sometimes do not reach the kitchen due to communication lapses, such as staff not placing the request forms in the designated bin outside the kitchen. Another resident reported that the facility does not offer alternative meal choices for breakfast, and there are no breakfast items listed on the always available menu. This was confirmed by the Food Service Director, who admitted the absence of an alternative breakfast menu. These findings were discussed with the Nursing Home Administrator, Director of Nursing, Regional Clinical Consultant, and other relevant staff, highlighting a systemic issue in accommodating resident meal preferences and ensuring effective communication between staff and the kitchen.
Failure to Provide Evening Snacks to Residents
Penalty
Summary
The facility failed to ensure that two residents, R23 and R78, received their evening snacks as per their needs and preferences. R23, who was admitted to the facility on August 3, 2021, reported to a surveyor on October 28, 2024, that she was not receiving her bedtime or evening snacks. She mentioned having to request food from the nursing staff, who informed her that the kitchen had no more snacks available. A review of R23's CNA flowsheet from September to October 2024 showed no evidence of evening snacks being provided. Interviews with CNAs E42 and E43 revealed that there were instances when evening snacks were insufficient or unavailable, and backup snacks stored in the Unit Manager's office were inaccessible after 3:00 PM due to the room being locked. Similarly, R78 reported that the facility did not consistently provide evening snacks, leading residents to store food in their rooms due to the unpredictability of meal times and the lack of timely provision of bedtime snacks. These findings were discussed with the Nursing Home Administrator (E1), Director of Nursing (E2), Resident Care Coordinator (E47), Regional Director of Operations (E58), and a representative from the Ombudsman's office on November 13, 2024.
Failure to Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to properly document the COVID-19 vaccination status of two residents, R25 and R33, in their electronic medical records (EMR). For R25, the clinical record showed no documentation of COVID-19 vaccines administered, despite the DELVAX website indicating that R25 had received vaccines on four separate occasions. Similarly, R33's EMR lacked documentation of COVID-19 vaccines, although DELVAX confirmed that R33 had received vaccines on three different dates. Additionally, the facility could not provide evidence of education or declination of the COVID vaccine for either resident. During an interview, the Infection Preventionist (E4) acknowledged that the facility had not conducted a vaccine clinic in the previous year and that the previous Infection Preventionist had not maintained the vaccination records. E4 confirmed that both R25 and R33 had received COVID-19 vaccines as documented in DELVAX but not in the facility's EMR. These findings were reviewed with the Nursing Home Administrator (E1), Director of Nursing (E2), Assistant Director of Nursing (E27), Resident Care Coordinator (E47), Regional Director of Operations (E58), and a representative from the Ombudsman office.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to make the survey results from the past three years readily accessible to residents, family members, and legal representatives. During a random observation in the facility lobby, it was noted that the survey results were not visible. Upon request by the surveyor, the receptionist retrieved the survey results binder, which was kept behind the reception desk. An interview with the receptionist confirmed that the binder was always stored in this location. These findings were reviewed with the Nursing Home Administrator, Director of Nursing, Resident Care Coordinator, Regional Director of Operations, and a representative from the Ombudsman's office.
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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