Delaware Bay Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Georgetown, Delaware.
- Location
- 110 W. North Street, Georgetown, Delaware 19947
- CMS Provider Number
- 085029
- Inspections on file
- 22
- Latest survey
- October 22, 2025
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Delaware Bay Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident admitted with a stage II sacral pressure ulcer did not receive consistent assessment, documentation, or timely interventions for wound care. The wound worsened, becoming unstageable and necrotic, and expanded to the bilateral buttocks. Staff failed to follow professional standards for pressure ulcer prevention and management, leading to the resident's hospitalization for sepsis and a large, gangrenous ulcer.
A resident who was dependent on staff for all ADLs, including eating and drinking, did not receive sufficient fluids to meet recommended hydration goals. Despite staff awareness of poor intake and the resident's risk factors, there was no evidence of effective interventions or provider consultation to address ongoing dehydration. The resident was ultimately hospitalized with metabolic acidosis, hypokalemia, and AKI, with lab results indicating severe dehydration.
Two residents experienced significant medication errors when one was given another resident's medications due to missing photo ID in the EMR, and another received insulin despite orders to hold for low blood glucose and not eating. Both errors were immediately recognized, reported, and required emergency intervention and hospital transfer.
Sanitizing solutions in two kitchen sanitizer buckets and at the three compartment sink were found to have chemical concentrations below required levels, as confirmed by the Dietary Supervisor. The deficiency was reviewed with facility leadership.
Surveyors observed two residents for whom infection prevention protocols were not followed: an LPN failed to perform hand hygiene and handled oral medications with bare hands, and another LPN accessed and flushed a resident's PICC line without wearing a gown or following transmission-based precautions. Both staff members acknowledged the lapses when questioned.
The facility did not complete required PASRR referrals for two residents after they received new mental health diagnoses and were started on new psychotropic medications. Despite significant changes in diagnoses and medication regimens, staff did not promptly initiate new PASRR reviews as required by policy, as confirmed by record review and staff interviews.
A resident who was admitted to hospice and had a poor prognosis did not have an individualized hospice care plan developed, as required. The care plan lacked specific objectives, goals, and timeframes to address the resident's hospice needs, a deficiency confirmed by the DON and other staff during interviews.
A resident with significant mobility limitations and a moderate risk for pressure ulcers was not turned or repositioned for several hours, despite a care plan requiring repositioning at least every two hours. Observations confirmed the resident remained on one side for an extended period, and staff interviews acknowledged the lapse in care.
Two residents did not receive proper respiratory care when one resident's BiPAP mask was left uncovered on a bedside table instead of being stored in a protective plastic bag, and another resident's oxygen tubing and humidifier bottle were not dated or changed as ordered. These deficiencies were confirmed through observation and staff interviews.
The facility failed to adhere to professional standards by allowing LPNs to conduct admission assessments and progress notes, which should be performed by RNs according to Delaware State Board of Nursing regulations. This deficiency was identified for multiple residents, where LPNs completed various admission forms and evaluations. The DON acknowledged that admission paperwork is often done by the nurse assigned to the room, indicating a systemic issue.
The facility failed to implement toileting programs for four residents experiencing varying degrees of incontinence. Despite changes in continence status, no formal programs were established to restore bladder continence. Interviews with staff confirmed the absence of such programs, indicating a systemic issue in continence care management.
The facility was cited for deficiencies in managing psychotropic medications, including failure to document appropriate diagnoses, not limiting PRN orders to 14 days, and inadequate monitoring of medication use. Physicians acknowledged these oversights during interviews.
The facility failed to follow dietician-approved menus, resulting in residents not receiving the correct food items. Substitutions were made without dietician approval, and residents consistently received incorrect or missing items on their meal trays. Interviews confirmed these issues, highlighting a lapse in protocol for menu adherence.
The facility failed to maintain an effective infection prevention and control program, as two residents with MDRO colonization were not placed under necessary precautions. The infection surveillance program was inadequate, missing critical information and failing to identify infection trends. Additionally, a laundry aide was observed handling soiled laundry without gloves, highlighting insufficient staff training and adherence to safe handling practices.
The facility failed to implement an effective antibiotic stewardship program, leading to inappropriate antibiotic use for four residents. One resident was hospitalized after receiving an ineffective antibiotic for a UTI. Another was treated for a UTI despite only showing colonization, not infection. The facility also failed to document an ESBL pathogen in a resident's urine, and another resident was treated for a UTI without meeting infection criteria.
The facility failed to complete PASARR Level II referrals for two residents with serious mental health diagnoses. Despite initial screenings indicating no immediate need, subsequent diagnoses of conditions such as delusional disorder, bipolar disorder, and schizoaffective disorder warranted further evaluation. However, no evidence of Level II referrals was found, as confirmed by staff interviews and record reviews.
The facility failed to maintain accurate PASARR Level I documentation for two residents. One resident's PASARR did not reflect current diagnoses of schizophrenia and intellectual disability, while another's PASARR failed to account for delirium and medication changes noted during hospitalization. The facility admitted the second resident without ensuring the PASARR was accurate, as confirmed by the State PASRR supervisor.
A resident was discharged without a timely discharge summary, which was not available in the EMR until months after the discharge. The summary, crucial for communicating necessary medical information, was delayed due to it not being e-signed and finalized in the EMR until after the resident had left the facility.
A facility failed to ensure a resident dependent on staff for ADLs received adequate grooming services. The resident, unable to bathe independently, received fewer bed baths than scheduled in June and July. Observations noted long nails with black debris, and a CNA confirmed daily nail care was expected unless otherwise directed. These issues were discussed with facility leadership during an exit conference.
A resident admitted with enterocolitis and protein-calorie malnutrition experienced significant weight loss, which the facility failed to recognize and address. Despite orders for daily weight monitoring and nutritional interventions, the resident lost 14.6 pounds, representing an 8.1% loss. The dietician was unaware of the weight loss until notified by a surveyor, highlighting a lack of timely documentation and intervention.
A resident with enterocolitis, post-abdominal surgery, and malnutrition experienced significant weight loss over three weeks. Despite this, the physician's progress notes failed to document any interventions or treatments to address the weight loss or nutritional needs. The dietician confirmed the need for protein supplementation, but no actions were documented by the physician.
The facility failed to ensure that two residents were free from unnecessary medications. A resident under hospice care was prescribed Haldol for nausea and agitation, leading to excessive daytime sleepiness and missed meals. Despite concerns from the resident's son and staff observations, these issues were not reported to the prescribing physician. The hospice nurse recommended a reduction in medication, but the physician was not informed of the resident's lethargy.
The facility failed to ensure proper food safety and storage practices, leading to potential foodborne illness risks. Observations included food debris on the kitchen floor, improper thawing of hot dogs, undated food items in the refrigerator, rusted storage shelves, and insufficient sanitizer levels. Additionally, undated nutritional shakes and a take-out container without a discard date were found in nourishment refrigerators. These issues were discussed with the NHA, ADON, QA RN, and MDS LPN.
The facility failed to maintain essential kitchen equipment safely, as significant ice build-up was observed on a damaged protective grate covering the freezer fans in the walk-in freezer. The issue was discussed with the NHA, ADON, QA RN, and MDS LPN during the exit conference.
Failure to Prevent and Manage Pressure Ulcer Resulting in Harm
Penalty
Summary
A resident was admitted to the facility with a stage II pressure ulcer to the sacrum, as documented by the hospital prior to admission. Upon admission, the facility completed a Braden scale assessment indicating moderate risk for skin breakdown and noted the presence of a sacral wound. However, the initial skin check lacked detailed assessment, measurement, or staging of the wound. The baseline care plan included several interventions for pressure ulcer prevention, but documentation shows inconsistent and incomplete wound assessments, with missing measurements, staging, and descriptions in the clinical record. There was also a lack of timely and clear communication with the physician regarding changes in the wound's condition. Over the following days, the wound worsened significantly, with documentation indicating the development of necrosis and expansion to the bilateral buttocks. The facility failed to consistently document weekly pressure ulcer assessments, and there was no evidence of a physician order for the use of a low air loss mattress (LLAM) until well after it was reportedly initiated. Staff interviews confirmed that the resident was dependent for all ADLs, including turning and repositioning, and that the wound increased in size and severity during the resident's stay. The wound eventually became unstageable, with 100% necrosis and purulent drainage, and the resident was ultimately hospitalized with sepsis, acute kidney injury, and a large sacral ulcer with suspected gangrene. Throughout the resident's stay, there were inconsistencies in wound documentation, lack of timely intervention, and failure to follow professional standards of practice for pressure ulcer prevention and management. The facility did not ensure that the resident received necessary treatment and services to prevent the development and worsening of pressure ulcers, resulting in significant harm to the resident.
Failure to Ensure Adequate Hydration for Dependent Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was offered sufficient fluids to maintain proper hydration, despite being at risk due to impaired mobility, use of diuretic medication, and a recent history of acute kidney injury (AKI) and urinary tract infection. The resident was dependent on staff for all activities of daily living, including eating and drinking, and had a documented recommended daily fluid intake of 1724-2155 mL. However, daily fluid intake records consistently showed significantly lower amounts, with intake often less than half of the recommended minimum. Staff and clinical documentation confirmed awareness of the resident's poor intake, but there was no evidence of effective interventions or provider consultation to address the ongoing dehydration risk. The resident's clinical record and interviews revealed that staff encouraged fluid intake but did not implement or document additional interventions to increase hydration or consult with the provider regarding the resident's decreased intake. The dietician addressed nutritional needs but did not address hydration status or provide suggestions to improve it. As a result, the resident was transferred to the hospital with diagnoses of metabolic acidosis, hypokalemia, and AKI, with lab values indicative of severe dehydration. The lack of monitoring and timely intervention directly contributed to the resident's harm.
Significant Medication Errors Due to Identification and Order Parameter Failures
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication administration processes. In the first case, a resident with multiple diagnoses, including diabetes and congestive heart failure, was administered another resident's medications, which included narcotics and aspirin, despite a documented allergy to aspirin. The error occurred because the resident's photo identification was not uploaded into the electronic medical record (EMR), leading the LPN to mistake the resident for someone else. The error was immediately recognized, and the resident required emergency intervention with Narcan and oxygen before being transported to the hospital for further care. In the second case, a resident with type 2 diabetes was administered insulin despite physician orders specifying to hold the medication if the finger stick glucose (FSG) was below 180 or if the resident was not eating. The resident did not eat breakfast or lunch, and the lunch FSG was 124 mg/dl, yet insulin was still administered. Shortly after, the resident exhibited symptoms of hypoglycemia, including disorientation, pallor, and diaphoresis, and required emergency glucose administration and hospital transfer. Both incidents were identified as Immediate Jeopardy situations due to the risk of serious adverse outcomes. The deficiencies were attributed to the absence of a photo ID in the EMR in the first case and failure to adhere to medication parameters in the second case. Staff interviews and documentation confirmed that the errors were promptly reported and that the residents received immediate medical attention.
Failure to Maintain Effective Sanitizing Solution in Kitchen Equipment
Penalty
Summary
During a kitchen tour, the sanitizing solution in two red sanitizer buckets was tested by the Dietary Supervisor and found to have a chemical concentration level too low to register at the appropriate sanitizing level of 400 ppm on the test strip. This ineffective level of sanitizer was confirmed by the Dietary Supervisor. Further testing at the source where the sanitizing solution leaves the container and mixes with water into the three compartment sink also revealed a chemical concentration below 200 ppm, which is insufficient for proper sanitization. These findings were confirmed by the Dietary Supervisor and reviewed with facility leadership during the exit conference. No information about residents or their medical history was included in the report, and the deficiency pertains specifically to the maintenance and monitoring of essential kitchen equipment and sanitizing solutions.
Failure to Follow Infection Prevention and Control Practices During Medication and PICC Line Administration
Penalty
Summary
Two deficiencies in infection prevention and control practices were identified during surveyor observations and interviews. In one instance, an LPN was observed administering oral medications to two residents without performing hand hygiene between administrations. The LPN also handled tablets and capsules from multi-dose bottles with bare hands, transferring them from her palm into medication cups, contrary to established protocols that require the use of gloves if direct contact is necessary. The LPN acknowledged during the surveyor's intervention that these actions did not comply with infection prevention standards. In another case, a resident with a PICC line for antibiotic administration reported that staff did not wear gowns when accessing the line. This was confirmed during an observation where an agency LPN accessed and flushed the resident's PICC line without donning a gown or following transmission-based precautions. The LPN admitted to not following the required precautions during an interview. These findings were reviewed with facility leadership during the exit conference.
Failure to Complete PASRR Referrals After New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that new referrals for Pre-Admission Screening and Resident Review (PASRR) were completed when residents received new mental health diagnoses and started new psychotropic medications. For one resident, a PASRR Level I screening was initially completed documenting dementia and anxiety, but later, a new diagnosis of psychotic disorder with delusions was added, and an antipsychotic medication was prescribed. Despite these significant changes, a referral for a new PASRR review was not completed at the time of the new diagnosis and medication initiation, as confirmed by staff interviews and record review. For another resident, a transfer from another facility included diagnoses of dementia with psychotic disturbance and anxiety disorder, and a new diagnosis of delusional disorder was added after admission. The medical record showed a previous PASRR Level II screen that excluded the resident based on a primary neurocognitive disorder, but there was no evidence that a new PASRR referral was submitted after the new diagnosis of delusional disorder. Staff interviews confirmed a lack of awareness and action regarding the need for PASRR resubmission following the updated diagnosis.
Failure to Develop Individualized Hospice Care Plan
Penalty
Summary
A review of the clinical record for one resident revealed that the facility failed to develop a care plan addressing the resident's identified need for hospice care. The resident was admitted to hospice and had a significant change Minimum Data Set (MDS) assessment documenting a poor prognosis and receipt of hospice services. Despite this, the resident's care plans did not include an individualized hospice care plan with specific objectives, goals, or timeframes. This omission was confirmed during interviews with the Director of Nursing and other facility staff, and the findings were discussed during the exit conference. The deficiency was identified through both record review and staff interviews, which confirmed that the care plan for activities of daily living (ADLs) was reviewed but lacked the necessary components to address the resident's hospice needs.
Failure to Reposition Resident as Required for Pressure Ulcer Prevention
Penalty
Summary
A resident with a history of cerebral infarct, hemiplegia, muscle wasting, and contractures was admitted to the facility and assessed as being at moderate risk for pressure ulcers, with documented dependence on staff for turning and repositioning. The resident's care plan specified that turning and repositioning should occur at least every two hours and as needed. However, observations on a specific day showed the resident remained positioned on their right side for several hours, from 9:09 AM through 1:07 PM, without being repositioned. During interviews, a CNA stated that dependent residents are typically turned 2-3 times per shift, and an LPN confirmed that the resident had not been repositioned as required and would instruct the CNA to complete the task.
Failure to Maintain Proper Respiratory Equipment Care and Documentation
Penalty
Summary
Two residents were found to have deficiencies in the provision of respiratory care. For one resident with a history of COPD, respiratory failure, obesity, hypoventilation, and obstructive sleep apnea, the BiPAP mask was observed sitting on the bedside table without being stored in a protective plastic bag as required by facility policy. The resident's care plan documented the use of oxygen therapy and BiPAP, and a physician order specified nightly BiPAP use with a filled humidifier chamber. The lack of proper storage for the BiPAP equipment was confirmed during an observation and interview with the RN Educator, who subsequently placed the mask in a labeled plastic bag. Another resident, admitted with COPD and interstitial lung disease, had a physician's order to change the oxygen mask, nasal cannula tubing, and humidifier bottle every Friday night shift. During an observation, the oxygen tubing and humidifier bottle were found undated, and it was confirmed by an LPN that there were no dates present. The LPN replaced and dated the items immediately after the observation. These findings were reviewed with facility leadership during the exit conference.
LPNs Conduct Admission Assessments Against Regulations
Penalty
Summary
The facility failed to meet professional standards of quality by allowing Licensed Practical Nurses (LPNs) to complete admission assessments and progress notes for residents, which is against the Delaware State Board of Nursing regulations. These regulations specify that Registered Nurses (RNs) are required to perform admission assessments. The deficiency was identified for eight residents, where LPNs completed various admission forms and evaluations, including demographics, activities of daily living (ADLs), skin integrity, oral/nutrition, neurological, respiratory, cardiovascular, gastrointestinal, reproductive, bladder/bowel, sleep, pain, mobility/safety, and sensory evaluations. The report highlights specific instances where LPNs, instead of RNs, conducted these assessments upon residents' admission or readmission to the facility. For example, one resident was admitted and readmitted on separate occasions, with LPNs completing the necessary admission forms each time. Another resident's admission assessments were completed by an LPN, contrary to the state regulations. During an interview, the Director of Nursing (DON) acknowledged that the admission paperwork is typically done by the nurse assigned to the room, which sometimes includes LPNs, indicating a systemic issue in the facility's adherence to professional standards.
Failure to Implement Toileting Programs for Residents
Penalty
Summary
The facility failed to provide appropriate services to restore bladder continence for four residents, identified as R47, R55, R61, and R100. Each of these residents had varying degrees of incontinence, yet no toileting programs were implemented to address their needs. For instance, R47 was always incontinent of bladder and frequently incontinent of bowel, but no toileting program was indicated despite the resident's history of being continent prior to a hospital admission. Similarly, R55 experienced an increase in bladder incontinence over several months, but no toileting program was established. R61 was always incontinent of bladder and frequently incontinent of bowel, with no toileting program in place, despite being dependent on staff for toileting. The resident was toileted every two hours, but this did not constitute a formal program aimed at restoring continence. R100, who was initially always continent, began experiencing occasional bladder incontinence, yet no toileting program was indicated. Interviews with staff, including MDS coordinators and CNAs, confirmed the absence of toileting programs for these residents. The facility lacked evidence of responding to the residents' decreased continence and failed to provide services aimed at restoring continence. This deficiency was identified through observations, interviews, and record reviews, highlighting a systemic issue in the facility's approach to managing and improving continence care for its residents.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility was found to have deficiencies in the management of psychotropic medications for several residents. For one resident, the physician failed to ensure that the diagnosis of generalized anxiety disorder was accurately reflected in the resident's chart while antipsychotic medications were being administered. This oversight was acknowledged by the physician during an interview, who stated that the diagnoses should at least match those from the previous facility. For two other residents, the facility did not adhere to the requirement of limiting PRN (as needed) psychotropic medication orders to 14 days. One resident had a physician's order for Xanax without an end date, and the physician admitted that the order should be reviewed. Another resident had an order for Alprazolam with a 180-day duration without a documented rationale for continued use, which was confirmed by the physician during an interview. Additionally, the facility failed to ensure adequate monitoring and indication for the use of Quetiapine in another resident. The facility's policy required regular monitoring and a clear indication for psychotropic medication use, but the physician did not order the necessary AIMS test or provide a rationale for the medication's use in the context of delirium. This was confirmed during a telephone interview with the physician, who acknowledged the lack of documentation and monitoring.
Failure to Follow Dietician-Approved Menus
Penalty
Summary
The facility failed to ensure that dietician-approved menus were followed to meet the nutritional needs of residents. During a kitchen tour, it was observed that the posted menu did not match the facility's submitted menu for the week, with ravioli being served instead of the planned baked beef patty. The Dietary Director confirmed that the substitution was made without the dietician's approval. Additionally, a dietician interview revealed that the substitution was not communicated for approval, indicating a lapse in the facility's protocol for menu changes. For two residents, the facility did not provide the selected food items from the menu. One resident consistently received incorrect items on their meal trays, such as missing almond milk, cranberry juice, and breakfast ham, with no substitutions provided. The dietician confirmed that the facility had stopped carrying certain items and failed to provide approved substitutes. Another resident's lunch trays were missing several items, and a CNA confirmed that missing items on trays were a consistent issue. These observations and interviews highlight the facility's failure to adhere to the planned and approved menus, impacting the nutritional intake of the residents.
Inadequate Infection Control and Surveillance in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of enhanced barrier precautions for residents with multidrug-resistant organism (MDRO) colonization. Specifically, two residents, R101 and R165, were not placed under the necessary precautions despite having conditions that warranted such measures. R101, who was colonized with Klebsiella pneumoniae ESBL, did not receive enhanced barrier precautions for 94 days, and R165, with an indwelling medical device, did not receive appropriate precautions for 90 days. The facility's infection surveillance program was inadequate, failing to meet national standards and lacking in process surveillance of staff practices. The infection line listings provided by the facility were missing critical information, such as the specific name of the pathogen, infection site, signs and symptoms of infection, and whether the infection was healthcare-associated or community-acquired. Additionally, the facility did not provide necessary monthly summaries, analyses, or interpretations of the data, nor did it identify any infection trends or patterns. Furthermore, staff training and adherence to safe handling practices were insufficient. An observation revealed that a laundry aide was handling soiled laundry without gloves and had not received training on safe handling practices or the proper use of personal protective equipment (PPE). This lack of training and oversight contributed to the facility's failure to maintain a safe and sanitary environment, as required by infection prevention and control standards.
Inadequate Antibiotic Stewardship in LTC Facility
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the inappropriate use of antibiotics for four residents. For one resident, R71, the facility administered Augmentin for a UTI despite the microbiology report indicating resistance to several antibiotics and not testing for Augmentin's sensitivity. The resident was allergic to sulfa antibiotics, and Levaquin was the only oral antibiotic listed as effective. This led to the resident's hospitalization for UTI and encephalopathy. Another resident, R101, was treated with Ciprofloxacin for a UTI despite not meeting the McGeer Criteria for infection. The resident's urine culture showed colonization with Klebsiella pneumoniae ESBL, but no symptoms of UTI were documented, and no fever or elevated white blood cell count was recorded. The physician's decision to treat was based on the pathogen's growth, which was misinterpreted as an infection rather than colonization. For resident R165, the facility failed to document the presence of an ESBL pathogen in the urine, which was necessary to determine if the prescribed antibiotic for osteomyelitis was also treating a potential UTI. Lastly, resident R368 was treated with Ciprofloxacin for a UTI without meeting the infection criteria, as there were no documented symptoms such as fever, increased incontinence, or urgency. The facility's failure to monitor and document the appropriate use of antibiotics led to these deficiencies.
Failure to Complete PASARR Level II Referrals
Penalty
Summary
The facility failed to ensure that a referral for a PASARR Level II screening was completed for two residents, R37 and R47, who were reviewed for PASARR compliance. For R37, a PASARR Level I was initially completed, indicating no further evaluation was needed. However, subsequent diagnoses of delusional disorder, bipolar disorder, hallucinations, generalized anxiety disorder, and dementia with psychotic disturbance were made, which warranted a Level II screening. Despite these significant mental health diagnoses, there was no evidence that a Level II referral was submitted, as confirmed by an interview with the social worker. Similarly, for R47, a PASARR Level 1.5 was completed, indicating a serious mental illness but no immediate need for a Level II screening. Over time, R47 was diagnosed with schizoaffective disorder, major depressive disorder, and dementia, among other conditions. Despite these developments, there was no evidence of a Level II referral being submitted. The facility lacked documentation of any updates to the State PASARR authority for both residents, as confirmed during an exit conference with facility staff.
Deficiency in PASARR Documentation for Two Residents
Penalty
Summary
The facility failed to maintain current and accurate Preadmission Screening and Resident Review (PASARR) Level I documentation for two residents, R104 and R366. For R104, the facility submitted a Level I convalescence categorical admission that was approved for sixty days. However, upon review, it was found that the PASARR did not reflect R104's current diagnoses of paranoid schizophrenia and intellectual disability, nor the services provided. The PASARR expired, and an interview with the social worker confirmed the discrepancies in the documentation. For R366, the PASARR Level I Screen initially documented no known mental health symptoms or medications. However, during a hospital stay, R366 was noted to have hallucinations and behaviors indicative of delirium, requiring medication adjustments. Upon discharge, R366 was prescribed Seroquel for delirium, which was not reflected in the PASARR documentation. The facility admitted R366 without ensuring the PASARR was an accurate reflection of his current condition, as confirmed by email correspondence with the State PASRR supervisor. The facility was responsible for submitting a resident review upon realizing the PASARR's inaccuracies.
Failure to Provide Timely Discharge Summary
Penalty
Summary
The facility failed to ensure that a resident, identified as R113, had a discharge summary that included a reaccounting of her stay and a review of her pre-discharge medications. R113 was admitted with a diagnosis of a broken left arm and was discharged after a 19-day stay. A discharge conference was held with the resident, her two sons, and a social worker. However, the discharge summary was not available in the electronic medical record (EMR) at the time of her discharge. The only provider notes in the EMR were from the first week of her stay, dated 4/15/24 and 4/16/24. The discharge summary, which is crucial for communicating necessary medical information at the time of discharge, was not e-signed and finalized in the EMR until 8/5/24, well after the resident had left the facility. This delay was confirmed during a telephone interview with the medical doctor, who acknowledged that sometimes notes do not make it to the chart. The absence of the discharge summary at the time of discharge was a deficiency identified by the surveyor, as it was not available to the receiving health care provider or the resident upon leaving the facility.
Failure to Maintain Resident Grooming
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to perform activities of daily living (ADLs), specifically in maintaining good grooming. The resident, admitted to the facility in 2017, was assessed as dependent for showering and bathing. In June and July 2024, the resident received significantly fewer bed baths than the opportunities available, with only thirty-two out of sixty in June and twenty-nine out of sixty in July. Observations on multiple occasions in late July and early August 2024 revealed that the resident had long nails with black debris underneath. A Certified Nursing Assistant (CNA) confirmed that nail care was expected to be completed daily unless otherwise directed by a physician or refused by the resident. These findings were discussed with the Nursing Home Administrator (NHA), Assistant Director of Nursing (ADON), Quality Assurance Registered Nurse (QA RN), and MDS Licensed Practical Nurse (LPN) during the exit conference.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to recognize and address a significant weight loss in a resident, identified as R366, who was admitted with diagnoses including enterocolitis due to c-diff infection and protein-calorie malnutrition. Upon admission, the resident's weight was documented as 182.5 pounds, and a regular diet with mechanical soft texture was ordered. Despite daily weight monitoring being ordered, the resident experienced a weight loss of 14.6 pounds, representing an 8.1% loss over a short period. The dietician, E7, documented nutritional risk factors and interventions but was unaware of the significant weight loss until notified by the surveyor. The resident's albumin level was low, indicating poor nutritional status, yet only two nutritional notes were documented in the electronic medical record until the surveyor's intervention. The resident was receiving total parenteral nutrition due to poor intake, and a nutrition consult was ordered. However, the facility did not adequately monitor or address the resident's nutritional needs, as evidenced by the lack of timely documentation and intervention for the weight loss. The dietician confirmed the need for additional protein supplementation only after being informed of the weight loss. The facility's interdisciplinary team meetings, where weight changes are typically addressed, did not result in timely action to prevent the resident's significant weight loss.
Failure to Address Resident's Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a physician adequately reviewed and addressed a resident's significant weight loss and nutritional status during required visits. The resident, admitted with conditions including enterocolitis due to c-diff infection, post-abdominal surgery with a wound vac, and protein-calorie malnutrition, experienced a weight loss from 182.5 pounds to 167.7 pounds over a period of three weeks. Despite the resident's declining weight and low albumin levels, the physician's progress notes on multiple dates did not document any interventions or treatments to address the weight loss or nutritional needs. The physician's notes on 7/16/24, 7/23/24, and 7/30/24 failed to address the resident's weight loss or initiate additional nutritional supplementation, despite the resident's increased caloric needs due to their medical conditions. The dietician confirmed the significant weight loss and the need for protein supplementation, but the physician did not document any actions taken in response to the resident's nutritional status. This lack of documentation and intervention was confirmed during interviews with facility staff, highlighting a deficiency in the resident's care management.
Failure to Monitor and Report Unnecessary Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications. Resident R102 was admitted under hospice care and was prescribed Haldol, an antipsychotic medication, for nausea and vomiting, and later for agitation. Despite concerns raised by R102's son and observations by staff about R102's excessive daytime sleepiness and missed meals, there was no evidence that these concerns were reported to the prescribing physician. Interviews revealed that the unit manager was aware of the issue but did not recall when it was communicated to the physician assistant. The hospice nurse assessed the situation and recommended a reduction in medication, but the physician was not informed of the resident's lethargy and daytime sleepiness.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in a manner that prevents foodborne illness to the residents. During an initial tour of the kitchen, food and debris were observed on the floor near the walk-in refrigerator and the back of the tray line. Additionally, frozen hot dogs were being thawed under warm running water, which is not an acceptable method as it requires cold water. Several food items in the walk-in refrigerator, including cake slices, leftover cooked meat, and corn kernels, were missing date labels, which is necessary for proper food safety management. The storage shelves in the walk-in refrigerator were also found to be rusted in numerous areas. Further observations revealed that the sanitizer levels in two red sanitizing buckets and the three-compartment sink were insufficient for proper sanitization. In the nourishment refrigerator in the [NAME] hallway, two cartons of nutritional shake were undated, despite instructions indicating they should be discarded after four days once opened. Similarly, a take-out container in the nourishment refrigerator near the Sussex hallway nurse's station was labeled with a resident's name but lacked a date for when it should be discarded. These findings were reviewed with the Nursing Home Administrator (NHA), Assistant Director of Nursing (ADON), Quality Assurance Registered Nurse (QA RN), and MDS Licensed Practical Nurse (MDS LPN) during the exit conference.
Failure to Maintain Safe Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition. During an observation of the walk-in freezer, significant ice build-up was noted on a damaged protective grate covering the freezer fans. This observation was made on July 30, 2024, at 11:11 AM. The findings were reviewed with the Nursing Home Administrator (NHA), Assistant Director of Nursing (ADON), Quality Assurance Registered Nurse (QA RN), and Minimum Data Set Licensed Practical Nurse (MDS LPN) during the exit conference on August 9, 2024, at 11:33 AM.
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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