Delaware Hospital F/t Chronically Ill (dhci)
Inspection history, citations, penalties and survey trends for this long-term care facility in Smyrna, Delaware.
- Location
- 100 Sunnyside Road, Smyrna, Delaware 19977
- CMS Provider Number
- 085035
- Inspections on file
- 20
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 10 (2 serious)
Citation history
Health deficiencies cited at Delaware Hospital F/t Chronically Ill (dhci) during CMS and state inspections, most recent first.
Multiple residents with documented upper extremity impairments, balance problems, poor vision, seizure history, and unsafe smoking behaviors were allowed to keep cigarettes and lighters and to smoke without direct supervision, despite care plans and smoking safety evaluations identifying significant risks. One resident with quadriplegia and severely contracted fingers independently retrieved and lit cigarettes from a cross‑body bag while staff left him alone in the smoking area. Other residents with stroke, epilepsy, neuropathy, and vascular dementia were observed smoking outside without staff present, declining smoking aprons, and disposing of cigarettes in non‑fire‑safe metal cans, while the smoking areas lacked fire extinguishers, fire blankets, and properly assembled safety ashtrays. A resident who used oxygen via nasal cannula with an oxygen concentrator in the room kept a cigarette lighter in the room, even though staff acknowledged this should not occur for someone on oxygen. Facility leadership confirmed that certain smoking areas were not supervised, residents were permitted to retain smoking materials if care planned, and there were no smoking blankets available, contributing to the identified deficiency.
The facility failed to use menus that included defined portion sizes for regular, mechanical soft, and pureed diets during two observed lunch meal services. Staff plated food based solely on residents’ pre-selected menu choices, without portion sizes on the menus and using only a generalized serving-size list that did not address mechanical soft or pureed foods. The Dietary Manager confirmed that the current menus and pre-selected menus lacked portion sizes, and the RD reported she was unaware that such menus were being used. A comparison of what was actually served to menus that did include portion sizes showed multiple food items, including proteins, starches, vegetables, soups, and potatoes, were served in amounts less than the specified portions or without a defined portion, and the facility reported it had no menu policy.
The facility failed to develop person-centered, comprehensive care plans addressing psychotropic medication use for four residents receiving antipsychotic and related psychotropic drugs. In each case, MDS assessments and CAAs triggered psychotropic drug use and directed staff to develop a care plan, yet the EMR care plans did not include the specific antipsychotic or related medications being administered. One resident with severe cognitive impairment received a monthly IM antipsychotic without a corresponding care plan; another cognitively intact resident on quetiapine and escitalopram, and a third resident with moderate cognitive status on a twice-daily antipsychotic, also lacked psychotropic-focused care plan entries. A fourth cognitively intact resident with schizophrenia and schizoaffective disorder had only a general neurobehavioral health care plan without specific antipsychotic planning. MDS coordinators reported they decide whether to develop care plans after completing CAAs and stated the EMR lacks fields to specifically address psychotropic medications or black box warnings, while the DON indicated psychotropic information is contained in consent forms rather than in the care plans.
Surveyors found that the facility did not offer or document pneumococcal vaccinations according to current CDC guidelines for several older residents. Record review showed that some residents over age 50 or 65 had no documentation of receiving or being offered PCV20 or PCV21, even when they had only received PPSV23 in prior years. A pharmacy report showed very limited use of PCV20 over multiple years. The DON/IP confirmed that specific residents had not been offered PCV20, and the Medical Director reported no recent communication about pneumococcal vaccines and acknowledged that the facility’s vaccination policy, which still referenced PCV13 and PPSV23 for adults 65 and older, had not been updated to reflect current CDC recommendations.
Surveyors found that MDS assessments were inaccurately coded for pneumococcal vaccination status for three residents. For two residents with moderate cognitive impairment, the EMR showed only prior PPSV23 administration and no evidence that PCV13, PCV20, or PCV21 had been offered when they reached the recommended age, yet one MDS indicated the resident was up to date on pneumococcal vaccines and another left the pneumococcal section blank. For a third resident, the MDS documented that staff could not determine the BIMS score and that the resident was up to date on pneumococcal vaccination, while the EMR showed only PPSV23 and no documentation of PCV13, PCV20, or PCV21 being offered. During interviews, MDS staff reported relying on the clinical record for vaccine status and one coordinator stated she was not familiar with CDC pneumococcal vaccine recommendations.
A resident with an anoxic brain injury and a tracheostomy had physician orders for complete trach changes every three months, but EMR review showed missing TAR entries and lack of RT documentation for some scheduled changes. Nursing staff documented performing trach changes on certain dates, then later stated these entries were mistakes and that only the physician or RT should remove and replace the trach. The RT documented trach care only on multiple occasions, reported limited recent visits due to medical issues, and was unaware of the specific ordered schedule for trach changes. The DON expected the TAR to accurately reflect care provided, and the Medical Director stated staff were to follow his orders and notify him if they could not be carried out, noting the trach changes were required to maintain patency, prevent infections, and provide cleanliness.
Two residents with severe cognitive impairment and significant physical limitations were using bilateral side rails without complete assessment or informed consent. For one resident, side rails were included in the care plan but there was no physician order, and the bed rail assessment lacked documentation of risk–benefit discussion, entrapment risk evaluation, or attempted alternatives, despite staff stating the resident could not use the rails functionally. For the second resident, an order for bilateral upper side rails for safety and a care plan intervention for side rails were present, but the bed rail assessment again only cited keeping the resident in bed, with no documented explanation of risks versus benefits, no entrapment assessment, and no evidence of alternatives tried, while staff reported the resident could not grab the rails. An RN acknowledged that the assessments omitted required elements and that there was no facility policy for side rails, and surveyors noted this had the potential to place residents at risk of injury or death.
A resident with intact cognition and diagnoses of anemia and vitamin and vitamin D deficiencies had daily orders for ferrous sulfate, a multivitamin, and cholecalciferol. During a morning med pass, the resident was found in bed with three pills on the chest after reporting that the medications, given in a cup, had missed the mouth. An LPN confirmed she had given the medications and then left, not realizing they were not taken, while the unit manager and DON stated that no residents self-administer medications and that nurses are expected to remain with residents until medications are taken. The facility’s medication administration policy prohibits leaving meds at the bedside but does not explicitly require staff to verify ingestion.
A resident with a gastrostomy and receiving tube feeding was given medication via a PEG tube by an LPN who did not wear required PPE, and there was no Enhanced Barrier Precautions signage on the resident’s door. The LPN reported she thought PPE was only needed for treatments like cleaning the PEG site, while the IP and DON confirmed that PPE is required for PEG medication administration and that staff had been trained on this. Facility policy states that Standard Precautions, Enhanced Barrier Precautions, and Transmission-Based Precautions must be used as clinically indicated to prevent and control infectious diseases, including MDROs.
Two residents experienced serious incidents due to inadequate supervision: one, with severe cognitive impairment and a high risk for elopement, was able to leave the facility undetected through an unsecured window after repeated exit-seeking behaviors were not addressed with individualized care planning or consistent monitoring; another, who was non-ambulatory and fully dependent, suffered a femur fracture after falling from bed during care, as staff did not recognize the need for fall prevention measures.
A resident with severe cognitive impairment and total dependence on staff for transfers was being moved from bed to wheelchair using a mechanical lift by a CNA and an LPN. During the transfer, the LPN was not in position to provide hands-on assistance as required, and the resident's legs slipped from the sling, causing her to fall and sustain fatal head injuries. The facility did not follow its policy or the resident's care plan requiring two-person, hands-on assistance during such transfers.
Failure to Ensure Safe, Supervised Smoking for Residents With Impairments and Oxygen Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe smoking practices and adequate supervision for multiple residents who smoked, despite identified physical impairments and safety risks. Several residents were assessed as having upper extremity limitations, balance problems, or a history of unsafe smoking behaviors, yet were allowed to keep cigarettes and lighters and to smoke without direct supervision. The facility’s own smoking safety assessments and care plans documented that certain residents had impaired range of motion, poor vision, difficulty safely handling or extinguishing cigarettes, and a pattern of burning clothing or dropping ashes, but these findings were not consistently translated into supervised smoking or restricted access to smoking materials. One resident with quadriplegia and bilateral upper extremity impairment was care planned as preferring to keep his lighter and to smoke at his leisure, and he declined to wear a smoking apron. Staff interviews confirmed that this resident kept his cigarettes and lighter in a cross‑body bag and that staff would transport him to the front smoking area and then leave him to smoke alone. Observations showed the resident, with severely contracted fingers and limited arm movement, independently retrieving and lighting a cigarette while staff present nearby were not actively supervising and were unaware of the availability of a smoking blanket. The front smoking area contained buckets and a large metal ashtray, but there was no indication of specialized fire‑safety equipment being used during these observations. Another resident with tobacco use, cataracts, vascular dementia, and a documented smoking safety evaluation indicating poor vision, balance problems, and inability to safely light, hold, or extinguish cigarettes was observed being wheeled to the smoking area without being offered a smoking apron. The LPN left this resident outside alone with his own cigarettes and lighter, and the resident confirmed that staff did not supervise him while he smoked. The 500‑unit smoking area lacked a fire extinguisher, fire blanket, and fire‑safe ashtrays, with only large metal cans present. A third resident with epilepsy, neuropathy, hemiplegia, and upper extremity impairment was similarly assessed as having balance problems and limited range of motion, yet was observed wheeling himself with a cigarette and lighter in hand, refusing a smoking apron, and smoking outside alone after staff left the area; he confirmed he kept his cigarettes and lighter, and used non‑fireproof metal cans for cigarette disposal. A fourth resident with a history of stroke and seizure disorder had a smoking safety evaluation documenting balance problems, burning of skin and clothing, dropping ashes on self, non‑adherence to smoking location and time policies, and inability to safely extinguish cigarettes or use an ashtray. The care plan stated this resident often declined a smoking apron, was supposed to keep cigarettes at the nurse’s station, and needed reminders to follow the smoking schedule and designated area. Despite this, the resident was observed in his room with a pack of cigarettes and a lighter concealed under a washcloth on the wheelchair armrest, and later was seen smoking outside the 500‑unit smoking area without staff supervision, confirming he kept his cigarettes and lighter. Another resident who smoked and used oxygen via nasal cannula with an oxygen concentrator in her room was care planned to have aides assure proper storage of smoking materials, with cigarettes kept at the nurse’s station and some cigarettes in her room. Her smoking safety evaluation indicated she could safely light, hold, and extinguish cigarettes and use an ashtray, but staff interviews revealed that while her cigarettes were stored at the nurse’s station, she kept her own lighter in her private room. Multiple staff, including RNs and CNAs, acknowledged that it was not appropriate for a resident using oxygen in the room to keep a lighter there. The facility’s administrator and other leadership confirmed that residents from the 500 unit using the back smoking area did not require supervision, that residents were permitted to keep cigarettes and lighters if care planned, and that there were no smoking blankets in either the front or back smoking areas. The maintenance director verified that the necks to the safety ashtray bottoms were not attached in the smoking areas. The report also cites NFPA 99 provisions requiring removal of smoking materials from patients receiving respiratory therapy and prohibiting smoking in areas where oxygen is used or stored. Immediate Jeopardy was identified when three residents with upper extremity impairments who smoked were found to be unsupervised and retaining their smoking materials, and the facility’s practices and environment did not align with the documented risks and applicable fire safety standards.
Failure to Use Menus With Defined Portion Sizes for Regular, Mechanical Soft, and Pureed Diets
Penalty
Summary
The deficiency involves the facility’s failure to use menus that included portion sizes for regular, mechanical soft, and pureed diets for two observed meals. Review of the week-two Spring 2025 menus showed they did not include portion sizes for these diet types, and individual residents’ pre-selected menu sheets for lunch on 01/06/26 and 01/07/26 also lacked portion sizes. A diet type report showed multiple residents on regular, mechanical soft, and pureed diets. During observations of the tray line on the 200 unit on both days, a food service worker plated meals by reading residents’ pre-selected menus without any portion sizes listed and without using any other menu to determine portions. The worker stated he relied on a list of portion sizes kept in the main kitchen. The Dietary Manager confirmed that portion sizes were not included on the facility’s week-two Spring 2025 menus or pre-selected menus and provided a “Standard Serving Sizes” list that contained only generalized food groups and did not address mechanical soft or pureed foods. The Registered Dietitian stated she was not aware that menus without portion sizes were being used and acknowledged the requirement for menu portion sizes. When actual servings on 01/06/26 and 01/07/26 were compared to the week-two Spring 2025 menus with portion sizes, multiple items, including roasted potatoes, pureed salmon, pureed soup, pureed stuffed pasta shells, pureed asparagus, mechanical soft roast beef, rice, pureed roast beef, baked potatoes, asparagus, and regular soup, were found to have been served in amounts less than the specified portions or without a measurable portion. The facility also reported that it did not have a policy for menus.
Failure to Care Plan Psychotropic Medication Use for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop person-centered, comprehensive care plans with measurable goals and interventions for residents receiving psychotropic medications. For one resident admitted with schizophrenia and a BIMS score of 0/15 indicating severe cognitive impairment, the admission MDS and CAA triggered the use of psychotropic medications and directed staff to develop a care plan. Despite a physician’s order for a monthly intramuscular antipsychotic injection, the resident’s care plan in the EMR did not contain any evidence that the use of aripiprazole was addressed. Another resident, cognitively intact with a BIMS score of 15/15, had physician orders for oral medications to treat bipolar disorder and major depressive disorder and was receiving an antipsychotic medication on a routine basis. The annual MDS and CAA triggered for psychotropic drug use and directed staff to develop a care plan, but the care plan did not address the use of quetiapine fumarate or escitalopram. A third resident, admitted with major depressive disorder and a BIMS score of 10/15 indicating moderate cognitive status, had an order for an oral antipsychotic medication and had been administered the medication twice daily, as shown on the MAR. The CAA documented that the resident had received antipsychotic medication for seven days prior to the assessment, yet the care plan dated later that month did not address the resident’s use of the antipsychotic medication. A fourth resident, cognitively intact with a BIMS score of 15/15 and diagnoses including schizophrenia and schizoaffective disorder with related depression, had orders for oral medications for these conditions. The annual MDS and CAA triggered psychotropic drug use for care planning, but the care plan, revised later in the year, only contained a Neurobehavioral Health problem and did not include a specific care plan for antipsychotic medications. During interviews, MDS coordinators stated that they complete the CAAs and then decide whether to develop a care plan, and reported that the EMR care plan system does not have the capacity to specifically address psychotropic medications or include black box warning information. The DON stated that care plans were individualized and that information about psychotropic use was contained in residents’ consents. The RAI Manual excerpt in the report states that MDS and CAA findings are to be used by the IDT to develop care plans that address identified problems, including psychotropic drug use.
Failure to Offer and Document Pneumococcal Vaccinations per Current CDC Guidelines
Penalty
Summary
Surveyors identified that the facility failed to offer influenza and pneumococcal vaccinations in accordance with current CDC guidelines and its own policies for multiple residents. Record review showed that several residents over age 50 or 65 did not have documentation of being offered or receiving the recommended pneumococcal conjugate vaccines PCV20 or PCV21. One resident admitted in January 2025, over age 55, had no record of receiving any pneumococcal vaccine or being offered PCV20 or PCV21. Another resident admitted in February 2024, over age 65, similarly had no documentation of pneumococcal vaccination or an offer of PCV20 or PCV21. A third resident, admitted in 2016, had received PPSV23 in December 2016, but there was no evidence that she or her representative had been offered PCV20 or PCV21. Two additional long-stay residents who turned the qualifying age during their stays had received PPSV23 in 2015, but their records lacked any indication that they or their representatives were offered PCV20 or PCV21. A pharmacy report showed only a small number of residents received PCV20 between 2023 and 2025. In interviews, the pharmacist stated PCV20 was ordered in 2025 and would require a report to determine ordering frequency, and the DON/Infection Preventionist confirmed that the identified residents had not been offered PCV20. The Medical Director reported there had been no communication regarding pneumococcal vaccines for at least six months and acknowledged that the facility’s policy had not been updated to reflect current CDC recommendations. Review of the facility’s written protocol showed it still referenced PCV13 and PPSV23 for adults 65 and older, which did not align with the CDC’s updated guidance recommending PCV15, PCV20, or PCV21 for adults 50 and older and shared decision-making use of PCV20 or PCV21 in certain adults 65 and older.
Inaccurate MDS Coding for Pneumococcal Vaccination Status
Penalty
Summary
The deficiency involves inaccurate completion of the Minimum Data Set (MDS) assessments related to pneumococcal vaccination status and cognitive assessment for three residents. For one resident admitted in 2016, a quarterly MDS with an Assessment Reference Date (ARD) in December 2025 documented that staff could not determine the resident’s Brief Interview for Mental Status (BIMS) score and indicated the resident was up to date on pneumococcal vaccination. However, the electronic medical record (EMR) immunization section showed only a PPSV23 vaccine given in 2019, with no evidence that the resident or representative had been offered PCV13 before age 55 or PCV20/PCV21 after age 55, as referenced in CDC guidance. For another resident admitted in 2018, the EMR showed a PPSV23 vaccine given in 2015, but there was no evidence in the record that PCV13, PCV20, or PCV21 had been offered during the stay when the resident reached the applicable age. The quarterly MDS for this resident, with an ARD in October 2025 and a BIMS score of 12 (moderate cognitive impairment), left blank the section that identifies whether the resident was offered or was up to date on pneumococcal vaccination. A third resident, admitted in 2008, had an EMR immunization record showing PPSV23 administration in 2015, with no evidence that PCV13, PCV20, or PCV21 had been offered during the stay when the resident reached the applicable age. Despite this, the quarterly MDS with an ARD in December 2025, which documented a BIMS score of 9 (moderate cognitive impairment), indicated that the resident was up to date on pneumococcal vaccination. During an interview, the MDS Coordinators stated they obtained pneumococcal vaccine information from the clinical record and relied on its accuracy, noting that influenza vaccine information was easier to locate because it appeared on the Medication Administration Record. One MDS Coordinator acknowledged not being familiar with CDC recommendations for pneumococcal vaccination. These findings, combined with the RAI Manual and CDC guidance cited in the report, demonstrate that the facility failed to ensure accurate MDS coding for pneumococcal vaccination status for the three residents.
Failure to Ensure Ordered Tracheostomy Changes Were Completed and Accurately Documented
Penalty
Summary
The facility failed to ensure a resident with an anoxic brain injury received complete tracheostomy (trach) changes as ordered by the physician and respiratory therapist (RT). The resident was admitted with a trach and had physician orders for a complete trach change every three months in April, July, October, and January, specifying a size six extra-long Shiley cuffed trach tube with disposable inner cannula. Review of the electronic medical record (EMR) showed missing or blank Treatment Administration Records (TARs) for some of the months when trach changes were due, including January and October, and there were no corresponding RT progress notes documenting that the ordered trach changes were completed. Documentation showed that on some dates nursing staff (RNs) recorded that they had changed the trach, but during interviews those RNs stated these entries were errors and that only the physician or RT should perform a complete trach change. RT progress notes and interviews further demonstrated inconsistency and lack of awareness of the specific physician orders. The RT documented performing trach care only on several dates and stated in interview that she tried to come weekly but had not been able to recently due to medical issues, and that the last time she changed the resident’s trach was in December. She also stated she was not aware of the physician’s specific schedule for trach changes and clarified that a trach change meant removal of the trach and was to be done only by the RT. The DON stated that the TAR was expected to reflect the care provided and that nursing needed to ensure documentation was correct, while the Medical Director stated that clinical staff were to follow his orders and notify him if they could not be implemented, and that the complete trach changes were required to maintain patency, prevent infections, and provide cleanliness.
Failure to Assess Bed Rail Need and Obtain Informed Consent
Penalty
Summary
The deficiency involves the facility’s failure to properly assess the need for bed/side rails and obtain informed consent, including discussion of risks and benefits and assessment of entrapment risk, for two residents who were using side rails. For one resident with severe cognitive impairment, epilepsy, traumatic brain injury, tracheostomy status, and total dependence for all ADLs, the care plan documented use of a wide low air loss mattress and bilateral side rails, but there was no physician order for side rails in the EMR. A bed rail assessment indicated side rails/assist bar were used as an enabler to promote independence and included the resident representative’s signature, but there was no documentation that risks versus benefits were explained, no assessment of entrapment risk, and no indication that alternatives were tried before using bed rails. Observations showed this resident in a low bed with side rails in use and fall mats in place, and a CNA stated the side rails were used to keep the resident in bed so she did not fall, while also stating the resident had not fallen from bed and could not grab or use the side rails. For a second resident with severe cognitive impairment, functional limitations in upper and lower extremities, a feeding tube, and diagnoses including Alzheimer’s disease, epilepsy, and cerebrovascular accident, there was a physician order for bilateral upper side rails for safety without specified directions. The care plan for falls and safety included bilateral side rails to ensure safety, and the bed rail assessment documented the reason for side rail use as keeping the resident in bed. The assessment included the resident representative’s signature but lacked documentation that risks versus benefits were explained, did not assess entrapment risk, and did not show that alternatives were attempted before side rail use. Observations showed this resident in a low bed with fall mats and contracted hands with cloth rolls, and a CNA reported the side rails were for falling and that the resident could not grab or use them. An RN stated that side rail assessments did not include risks versus benefits or entrapment risk and that she was unsure what alternatives had been tried, and also reported that there was no facility policy for side rails. The surveyors noted that this failure had the potential to place residents at risk of injury or death.
Medications Left Unattended and Not Administered as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered medications were properly administered to a resident and not left unattended. The resident had intact cognition with a BIMS score of 15 and diagnoses including unspecified vitamin deficiency, anemia, and vitamin D deficiency. Physician orders in the EMR included daily ferrous sulfate for anemia, a daily multivitamin for vitamin supplementation, and daily cholecalciferol for vitamin D. The resident’s care plan indicated a need for some assistance with ADLs due to arthritis and physical challenges. During a morning medication pass, the resident was found awake in bed wearing a hospital gown with three pills (a small white tablet, a medium off-white tablet, and a medium black tablet) on her chest. The resident stated she had been given her medications in a cup but must have missed her mouth. When questioned, an LPN confirmed she had given the medications to the resident in a medicine cup but did not notice that the resident had not taken them, and identified the pills as a multivitamin, iron, and a medication “to reduce fat.” The LPN was in the hallway when the pills were discovered rather than remaining with the resident. The Unit Manager (an RN) stated there were no residents who self-administered medications and confirmed that the LPN should have stayed with the resident to ensure the medications were taken, adding that medications should never be left with the resident. The DON also stated there were no residents who self-administered medications and that her expectation was for the nurse to stay with the resident until medications were taken, and she was unaware of the incident at the time it occurred. The facility’s Medication Administration policy stated that medications should never be left at the bedside to be taken later, but did not specifically include language requiring staff to ensure residents actually take the medications.
Failure to Use PPE During PEG Tube Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff used appropriate personal protective equipment (PPE) during medication administration via a percutaneous endoscopic gastrostomy (PEG) tube. A resident admitted with a diagnosis of gastrostomy status and documented on the MDS as receiving nutrition through a feeding tube was observed receiving medications through the PEG tube from an LPN who did not wear any PPE. At the time of the observation, there was no signage on the resident’s door indicating the use of Enhanced Barrier Precautions (EBP). During an interview, the LPN stated she believed PPE was only required when providing treatments such as cleaning the PEG tube area and acknowledged she should have worn PPE during PEG tube medication administration. In a subsequent interview, the Infection Preventionist and the DON confirmed that staff are required to wear PPE when administering medications to residents with PEG tubes and that staff had been trained on this requirement, including at a recent skills fair. Review of the facility’s policy on Enhanced Barrier Precautions and Isolation Procedures indicated that the facility is to use Standard Precautions, EBP, and Transmission-Based Precautions as clinically indicated to prevent and control infectious disease, including MDROs.
Failure to Prevent Elopement and Fall-Related Injury Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for two residents identified as being at risk for accidents. One resident, who was severely cognitively impaired and assessed as high risk for elopement, was admitted to a secured unit and repeatedly expressed a desire to leave the facility. Despite multiple documented episodes of exit-seeking behavior and verbalizations about wanting to return to his previous residence, the resident's care plan lacked person-centered interventions specific to elopement risk. The resident was able to elope from the facility during the overnight shift by opening an unsecured window, which was later found to lack an alarm and could be easily opened. Video review showed that staff failed to perform required visual checks, missing 18 out of 20 opportunities to observe the resident as per the care plan. Staff interviews revealed a lack of awareness regarding the resident's elopement risk and the need for frequent checks. Another resident, who was non-ambulatory, completely dependent on staff for all activities of daily living, and had severe intellectual disability and cerebral palsy, sustained a right femur fracture after falling from the bed during care. The resident was not care planned for falls because staff believed she was unable to move herself. During care, a CNA turned the resident on her side and, while reaching for a washcloth, the resident rolled off the bed and fell face down on the floor. The incident resulted in a right femur fracture requiring surgery. The facility's investigation confirmed that the resident was not provided adequate supervision or assistance to prevent the fall during care. Both incidents demonstrate failures in the facility's implementation of policies and procedures designed to prevent accidents and ensure resident safety. The first resident's repeated exit-seeking behaviors and high elopement risk were not adequately addressed through individualized care planning or environmental safeguards, and staff did not consistently follow monitoring protocols. The second resident's complete dependence on staff was not reflected in her care plan for fall prevention, leading to inadequate supervision during a high-risk activity.
Removal Plan
- All staff in the facility and staff reporting for scheduled shifts were in-serviced on the current elopement policy and face-to-face checks for residents at risk for elopement.
- The facility reviewed all current residents and identified residents deemed to be at higher risk for elopement. These residents were placed on every one-hour face-to-face checks.
- The care plans were updated to reflect specific interventions for high elopement risks.
- An alarm was placed on R1's window and all the windows on the units were checked and locked. When windows were found to be damaged, maintenance was called for immediate repair.
- R1 was moved to another secure unit with alarm on the window and double locks on both entrances.
- All the windows on the secure unit have hard wired alarms and were tested.
- Window limiters were approved by the fire marshal and will be installed upon delivery.
- Staff interviews conducted, and in-service education and training verified.
- Staff training records reviewed and verified.
- R2's care plan was revised and updated for 2 staff members assistance with bed mobility.
- All nursing staff were trained on fall prevention during resident care. The training included not rolling the resident away from the staff's body. Ensure that the resident is in the middle of the bed before turning him/her away from your body (if you must turn the resident away from you.)
- The certified nursing assistant (CNA) involved in the fall was required to re-take new hire orientation, which included shadowing another CNA before she could return to provide resident care independently.
Failure to Provide Required Two-Person Assistance During Mechanical Lift Transfer Results in Fatal Fall
Penalty
Summary
A cognitively impaired and fully dependent resident with diagnoses including dementia, chronic kidney disease, and weight loss was admitted to the facility and required two-person assistance with a mechanical lift for all transfers, as documented in her care plan. The resident's MDS indicated complete dependence on staff for all activities of daily living, including transfers. On the day of the incident, two staff members, a CNA and an LPN, attempted to transfer the resident from her bed to a wheelchair using a mechanical lift. During the transfer, the CNA attached the sling to the lift and began raising the resident, while the LPN was occupied with another task in the room and was not in position to provide hands-on assistance as required by the care plan. As the transfer proceeded, the resident's legs slipped out of the sling, and the LPN, upon noticing this, attempted to intervene but was unable to reach the resident in time. The resident slid from the sling and fell to the floor, sustaining a subdural hematoma and two scalp lacerations. Both staff members confirmed in their statements that the LPN did not have hands on the resident during the lift, and the CNA was behind the lift, attempting to maneuver it. The facility's fall prevention policy required adequate supervision and adherence to care plans specifying two-person, hands-on assistance during mechanical lift transfers, which was not followed in this instance. Following the fall, the resident was found with significant head bleeding and was emergently transferred to the hospital, where she was diagnosed with an intracranial traumatic hemorrhage and large scalp lacerations. The resident was placed on comfort care and subsequently expired at the hospital. The failure to provide the required two-person, hands-on assistance during the mechanical lift transfer directly resulted in the resident's fall and fatal injuries.
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Multiple cognitively impaired residents with known behavioral issues, including wandering, agitation, and physical aggression, were not adequately protected from resident‑to‑resident abuse. In one case, a resident with dementia and PTSD was pushed to the floor by another resident who had a history of combative behavior, resulting in multiple fractures and facial lacerations after staff initially documented the event as an unwitnessed fall. In another case, two residents with dementia and psychotic features engaged in a physical altercation in a dayroom after one placed his hand on the other’s chest, leading to mutual punching. A separate incident occurred when a resident with dementia and behavioral disturbances entered another resident’s room, pulled at the bedcovers, yelled that the room was his house, and allegedly struck the other resident, who was later noted with puffiness around one eye. In all incidents, the involved residents had documented behavioral care plans and significant cognitive impairment, yet physical confrontations still occurred.
A resident with dementia, spinal stenosis, and total dependence for transfers, care-planned for Hoyer lift use with two-person assist, was being transferred from a shower bed to a Geri-chair when the Hoyer lift tipped sideways. Staff reported the lift’s legs had been widened and that one CNA manually pushed the feet apart instead of using the control, and straps may have been unevenly positioned. The resident was lowered to the floor while still in the sling and sustained a small skin tear to the elbow; imaging later showed no fractures. The DON stated that three CNAs were involved, including one on light duty who was not supposed to be using the lift, and that no mechanical defect was found with the lift.
The facility failed to thoroughly investigate several allegations of verbal and potential physical abuse involving four cognitively intact residents with conditions including hemiplegia, rheumatoid arthritis, type 2 DM, epilepsy, and heart disease. In each case, the facility’s investigations were limited, often including only the directly involved resident and omitting interviews with other potentially knowledgeable residents or staff. One resident reported a verbal altercation with a CNA after a fall to the floor, another reported being verbally abused by a roommate’s family member, a third reported a male CNA was too rough and upset while changing linens, and a fourth reported a staff member insulted her and refused brief care. Investigation files lacked broader resident and staff interviews, timely physical and psychosocial assessments, and review of the accused staff member’s employee record, contrary to the facility’s abuse policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
A resident with rectal cancer and intact cognition reported that an RN on night shift confronted him when he returned from smoking off campus, spoke to him loudly about his smoking, used profanity, and threatened to have staff refuse to buzz him back into the building. A CNA corroborated that the RN was upset about being called in to work and used curse words toward the resident, but did not report the incident at the time because the RN was the night supervisor. The resident reported the event to the Social Services Director the next day, yet the facility initially treated it as a grievance rather than abuse and delayed submitting a report to the State Survey Agency until weeks later, after determining it was a reportable abuse incident.
Two residents did not receive required ADL and hygiene care as care planned. One resident with dementia and osteoarthritis, dependent for toileting and personal hygiene, was not toileted during an evening shift, with CNA documentation showing no toileting and the oncoming CNA finding the resident’s clothing, linens, and mattress saturated with urine; the assigned CNA reported care resistance but did not notify an RN or LPN. Another resident with dementia and stroke, requiring assistance with dressing and personal hygiene, remained in bed in pajamas into the afternoon without having received morning care, despite CNA documentation indicating dressing was completed; the CNA later confirmed that care was only provided after being questioned by an RN supervisor following a family complaint.
A resident with left-sided weakness after a stroke, high fall risk, and total dependence for ADLs and bed mobility was being turned onto their side for peri care by an aide when they fell from the bed to the floor, sustaining head trauma and a scalp laceration while on blood thinners. The care plan required extensive to total assistance with two-person support for bed mobility, but the fall occurred during care without documentation of the required level of assistance, indicating the facility did not provide adequate supervision and assistance to prevent accidents as outlined in its own fall prevention practices.
A resident with significant upper extremity weakness and recent surgery was discharged home to a multi-story residence without confirmed DME delivery, home health services, or caregiver support. Although referrals for home health, skilled nursing, and DME were made and family attended a discharge care plan meeting, staff did not verify that services were active, did not set or confirm a start-of-care date with the agency, and did not confirm delivery of a hospital bed. The resident, who lived alone and could not manage fine motor tasks, arrived home without in-home assistance, reported difficulty with eating and self-care, and was later found by an HHA RN in unsafe conditions, unable to access food or medications, leading to emergency transport back to the hospital.
A resident with dementia, Parkinson’s disease, CHF, and a history of AKI had documented fluid goals and was identified as at risk for dehydration and malnutrition, yet daily intake records repeatedly showed fluid consumption well below the recommended amounts. Despite severely impaired cognition, poor oral intake, and documented changes in mentation, lethargy, falls, and restlessness, the facility did not consistently implement or document enhanced monitoring, assistive feeding measures, or timely provider consultation focused on hydration. The resident was hospitalized twice with AKI, dehydration, hypotension, and anemia, and staff interviews confirmed that while expectations existed to encourage fluids and notify providers when goals were not met, there was no clear evidence that these expectations were carried out for this resident.
A resident with cardiac conditions was discharged home with a documented post-discharge plan for home health aide, home health RN/LPN, and PT/OT, but the facility did not complete the home health referral before discharge. The resident went home with a family member and, according to a complaint, did not receive PT, OT, or a nursing wellness check for about a week. The SW later confirmed the referral for home health and therapy services was not requested until several days after discharge, and services did not begin until even later, despite therapy recommendations that are typically communicated to social services to arrange home care.
The facility failed to consistently revise care plans to reflect residents’ current needs and behaviors and did not ensure a cognitively intact resident was involved in ongoing care planning. One resident participated in an initial care conference but was not included in later care plan updates. Another resident with an order for a palm protector was frequently observed without it and often refused it, yet the care plan did not address refusals. Two cognitively impaired residents whose MDS assessments showed dependence for bathing had care plans that still listed only setup or one‑person assist. A cognitively impaired resident with combative behaviors and an incident of striking another resident had a behavior care plan that was not updated to include attempts to hit other residents or the risk of resident‑to‑resident altercations.
Failure to Prevent Resident‑to‑Resident Physical Abuse Among Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from resident‑to‑resident physical abuse. One resident with dementia, agitation, depression, anxiety, and PTSD, and a BIMS score indicating moderate cognitive impairment, was pushed to the floor by another resident after that resident entered his room and followed him into the hallway. Staff initially documented the event as an unwitnessed fall after hearing loud screaming and finding the resident on the floor with complaints of right shoulder and left wrist pain, active bleeding from facial lacerations, and clamminess. Subsequent review of surveillance footage showed that another resident walked into the victim’s room, then followed him out and pushed him, causing the fall that resulted in multiple fractures, including a closed left distal radius fracture, a closed, displaced comminuted right proximal humerus fracture, and a closed, displaced distal clavicle fracture. The resident who pushed him had dementia with mood disturbances, bipolar disorder with psychotic features, PTSD, insomnia, and depression, and a BIMS score indicating severe cognitive impairment. His care plan identified a behavior problem related to bipolar disorder and dementia, including wandering, refusal of care, and physical aggression toward staff and others, such as biting a CNA and swinging a walker at a CNA. The care plan directed staff to anticipate and meet his needs, divert him with alternative objects or activities, intervene to protect the rights and safety of others, and conduct safety checks. Despite these identified risks and interventions, he was able to enter another resident’s room and subsequently push that resident in the hallway, resulting in serious injury. Another incident involved two residents with significant cognitive impairment and behavioral symptoms, including delusions, physical behaviors toward others, agitation, and a tendency to invade others’ personal space. One resident, who was described as aggressive toward others, easily agitated, and prone to getting into others’ personal space, walked next to another resident sitting in a dayroom chair and placed his hand on that resident’s chest. The seated resident responded by punching him in the face with the back of his fist, and the first resident then punched back. Staff and psychiatric documentation noted this altercation and ongoing behavioral concerns such as combativeness with care, agitation, and wandering, but the record contained no additional progress notes describing the incident itself beyond the brief psychiatric follow‑up entry. A further incident occurred when a resident with anxiety, major depressive disorder, dementia with behavioral disturbances, agitation, and severe cognitive impairment entered another resident’s room on the memory care unit. The resident in the room, who had depression, anxiety, dementia without behavioral disturbances, PTSD, insomnia, hallucinations, verbal behaviors toward others, other behavioral symptoms, and wandering, reported that he was hit in the face. Staff heard yelling and found the intruding resident pulling covers at the foot of the bed and yelling that the room was his house, while the other resident sat on the side of the bed and stated that he had been hit and told staff to get a gun and shoot the other resident. Slight puffiness was noted around the reporting resident’s left eye. The intruding resident’s care plan documented compulsiveness, invading others’ personal space, yelling, restlessness, physical aggression, and attempts to assist other residents he believed needed help, with interventions to divert him, familiarize him with his surroundings, and intervene to protect the rights and safety of others. Despite these identified behaviors and interventions, he was able to enter another resident’s room, engage in a confrontation, and allegedly strike the resident.
Resident Injury from Improper Hoyer Lift Operation During Transfer
Penalty
Summary
The deficiency involves the facility’s failure to prevent an accident during a Hoyer lift transfer, resulting in a fall and skin tear injury to a resident. The resident had diagnoses including spinal stenosis, Alzheimer’s disease, vascular dementia with behavioral disturbance, bipolar disorder, and pain, and was documented on the MDS as dependent on staff for transfers from bed to chair. The care plan and physician orders specified that the resident required a Hoyer lift with assistance of two staff for transfers. On the day of the incident, the resident was being transferred via Hoyer lift after a shower, from a shower bed back to a Geri-chair. Progress notes and the post-fall evaluation documented that the fall occurred in the bathroom during a Hoyer transfer with staff assistance of two, and that the Hoyer lift tipped sideways. The resident was found on the floor in the sling, with staff reporting that the Hoyer lift’s legs were widened and that as the resident was being positioned over the chair, the lift tipped to the side. Staff held the sling on each side of the resident’s head and lowered the resident to the floor, after which a skin tear measuring 1.0 cm x 0.1 cm was noted on the elbow. The facility’s investigation determined that the Hoyer tipped because one CNA pushed the lift’s feet apart manually instead of using the designated button to open the legs. Interviews indicated that the manual mechanical lift used at the time was considered less steady and required manual operation of a foot pedal to open the legs, and that the straps may have been more to one side than the other. The DON reported that three CNAs were involved with operating the lift at the time of the incident, including one CNA on light duty who was not supposed to be using the Hoyer lift, and that the lift itself was later found to have no mechanical problems. As a result of the tipping incident, the resident sustained a skin tear to the elbow and required diagnostic imaging to rule out fractures.
Incomplete Investigations of Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of verbal or potential physical abuse as required by its abuse, neglect, and exploitation policy. One cognitively intact resident with hemiplegia following a stroke reported a verbal altercation with a CNA after sliding to the floor while being assisted back to bed. The resident requested use of a Hoyer lift, the CNA told him he could get himself up, and an argument ensued in which the CNA told the resident it was not his room and did not leave until directed by an LPN. The facility’s investigation file for this incident contained only the resident’s interview and no interviews with other residents on the unit who might have had knowledge of similar verbal abuse by the CNA. Another cognitively intact resident with rheumatoid arthritis, hypertension, and peripheral vascular disease reported that her roommate’s daughter came into her room and verbally abused her after the roommate had been relocated due to aggression. The daughter allegedly cursed at the resident, calling her an offensive name and telling her she was going to hell. The investigation file for this incident contained no interviews with other residents on the unit to determine whether they had experienced verbal abuse by this family member or had knowledge of the event. The DON acknowledged that no such interviews were conducted. A third cognitively intact resident with type 2 diabetes and epilepsy reported, through her daughter, that a male CNA wearing a red shirt was too rough with her and appeared upset about having to change her linens. The facility’s investigation into this potential staff-to-resident abuse included an interview with the resident but did not include interviews with other interviewable residents in the same area who might have had knowledge of the incident. A fourth cognitively intact resident with type 2 diabetes and heart disease, later discharged, reported that a staff member entered her room, called her a poor excuse for a human being, and refused to assist with changing her brief. The investigation documentation for this allegation lacked interviews with additional residents or staff, did not show that the resident was promptly assessed physically and psychosocially in relation to the allegation, and did not include a review of the accused staff member’s employee record, resulting in an incomplete investigation contrary to facility policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
Failure to Protect Resident From Verbal Abuse and Delay in Reporting Incident
Penalty
Summary
The facility failed to protect a cognitively intact resident from verbal abuse by a staff member. The resident, admitted with rectal cancer and independently ambulatory with a rolling walker, reported that during an overnight shift he left the campus to smoke and, upon returning and walking toward the nursing station, was confronted by an RN. According to the resident’s report, the RN told him that when she was on the night shift he was not allowed to go outside, using profanity toward him, and further stated that if he went out the door she would instruct staff not to buzz him back into the building. A CNA later confirmed that the RN had been upset about being called in to work, spoke loudly to the resident about his smoking, and used curse words when he responded to her. The incident was not promptly reported to facility administration despite occurring during the night shift, with the CNA stating that the RN involved was the supervisor at the time. The resident reported the incident the following day to the Social Services Director, but the facility did not immediately recognize or treat the allegation as reportable abuse. Instead, the administration initially considered it a grievance and investigated it in that manner. The incident report was not submitted to the State Survey Agency until several weeks after the resident’s report, and only after the facility later determined that the event constituted a reportable abuse incident.
Failure to Provide Required ADL and Hygiene Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL assistance to maintain grooming and personal hygiene for two dependent residents. One resident with dementia, osteoarthritis, and moderately impaired cognition was care planned to receive partial to substantial assistance with personal and oral care, scheduled toileting every two hours, and assistance with toilet transfers. CNA documentation for an evening shift showed “N/A” for all scheduled toileting times, and a facility incident report stated that the CNA assigned to this resident failed to provide incontinence care during that shift. The oncoming night-shift CNA later found the resident’s clothing, linens, and mattress saturated and soaked with urine and provided the needed care, with the prior-shift LPN confirming the condition when notified. The assigned CNA reported the resident was resistant to care but did not notify the LPN or RN for assistance or document the issue. The second resident, with dementia, stroke, weakness, and moderately impaired cognition, was care planned for an ADL self-care deficit requiring setup or cleanup assistance with eating, partial to substantial assistance with personal hygiene and oral care, and substantial assistance with toileting, showering/bathing, and lower body dressing. On a morning shift, the resident’s daughter-in-law reported to the LSW that she did not believe the resident had received morning care because he was still in bed wearing pajamas and had not yet received his lunch tray. A CNA statement indicated the resident had eaten breakfast and was later found asleep in bed, and CNA documentation for that shift showed the dressing task as completed. However, the facility’s follow-up summary documented that the CNA confirmed care had not been provided to the resident prior to being questioned by the RN supervisor, and the LSW confirmed that the CNA changed the resident only after the family reported the concern and nursing was notified.
Failure to Provide Adequate Supervision and Assistance During Bed Mobility for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for a resident with significant functional and cognitive impairments. The resident was admitted with left-sided weakness after a stroke and was care planned as extensively to totally dependent for bed mobility, requiring the support of two persons. A fall risk evaluation documented a score of 10, indicating high fall risk, and a quarterly MDS assessment showed the resident was unable to participate in a cognitive assessment and was completely dependent on staff for all ADLs. Despite these identified needs and risks, the resident was being turned onto their side for peri care by an aide when they fell from the bed to the floor. During this incident, the resident sustained head trauma and a small scalp laceration, and was on blood thinners at the time of the fall. The fall occurred while the aide was providing peri care and turning the resident, but the report does not document the presence of a second staff member, despite the care plan indicating the need for two-person assistance for bed mobility. The facility’s own policy on falls emphasized instituting individualized practices to minimize fall risk and maximize safety for residents identified as high risk, but the resident’s documented high fall risk and total dependence were not adequately addressed in the supervision and assistance provided at the time of the fall.
Failure to Ensure Safe Discharge with Confirmed Home Services and Support
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s discharge home included confirmed durable medical equipment (DME), home health services, and adequate caregiver support. The resident was admitted with spinal stenosis, cervical disc disorder, muscle weakness, carpal tunnel syndrome, and a recent post-fasciotomy to the right arm, and was documented as cognitively intact with a BIMS score of 14/15. Despite these physical limitations, the facility discharged the resident home in the evening via medical transport to a three-story residence, where no caregiver support was present. The facility’s own policy required a post-discharge plan of care developed with the resident and representative, and orientation to ensure a safe and orderly transfer or discharge, but the record lacked evidence that services were confirmed as in place prior to discharge. Prior to discharge, the social worker documented that the resident would have a safe discharge home with services and supports in place, and that referrals for home health care, skilled nursing services, and DME had been made, with family members in attendance at the discharge care plan. However, the clinical record did not contain confirmation that these services were actually arranged and active before the resident left the facility. The resident was discharged with medications called to the pharmacy for home delivery, but there was no documentation that the hospital bed had been delivered or that home health nursing, therapy, or home health aide services were scheduled to start at the time of discharge. The social worker later acknowledged not informing the agency of a specific start-of-care date, assuming the agency and VA would contact the resident, and confirmed not calling to verify delivery of the hospital bed. After discharge, it was discovered that the hospital bed ordered days earlier was not delivered until the morning after the resident arrived home, and that therapy, RN, and HHA services had not yet begun or contacted the resident by the time the facility followed up. The resident reported living alone, being unable to use their hands, needing a caretaker, and having to rely on a sister-in-law for limited assistance with hygiene, meals, and rearranging furniture for the bed that arrived later. The significant other confirmed that no one lived with the resident, that they had their own health issues, and that neither they nor their son stayed with the resident after discharge. When a home health RN eventually visited, the resident was found sitting on a couch in minimal clothing, reporting not having eaten adequately for two days, having little or no accessible food, and being unable to open medications or bottles due to impaired fine motor skills. The RN observed the resident’s inability to grip or perform fine motor tasks, assisted with toileting, and then contacted the agency director and emergency services due to the unsafe conditions in which the resident had been left. These events led surveyors to determine that the facility failed to ensure services and caregiver support were in place prior to discharge, resulting in an immediate jeopardy situation.
Removal Plan
- Audited discharge documentation related to home health services, appropriate caregiver/family support, and any necessary services to meet residents' care needs to determine if any residents were affected.
- Reviewed planned discharges by the Administrator, DON, Director of Social Services, and Director of Rehabilitation to ensure home health services, appropriate caregiver/family support, and necessary services to meet the resident's care needs are in place before discharge.
- Completed a root cause analysis identifying failure to have a robust discharge care plan meeting with the interdisciplinary team (IDT), resident, and resident representative.
- Reviewed the procedure for safe and effective discharge planning with the IDT.
- Re-educated the discharge planning IDT on the discharge policy and procedure to ensure sufficient preparation and orientation for a safe discharge.
- Implemented review of residents scheduled to be discharged to ensure appropriate discharge planning is in place.
- Implemented review of residents scheduled for discharge to ensure ADL support is in place, durable medical equipment is available prior to or on the discharge date, medications are available upon discharge, and identified needs/support are available.
- Implemented review of residents scheduled for discharge to ensure safe discharge planning is in place and to address any issues identified.
- Implemented oversight during utilization review by the NHA/designee to ensure discharge planning preparation and services are in place prior to discharge.
- Initiated audits and educational in-services to the IDT team and conducted staff interviews to confirm education received regarding discharge to the community and/or transfers to other facilities.
Failure to Maintain Adequate Hydration Resulting in Recurrent AKI and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate hydration for a resident with significant medical conditions, including acute kidney injury (AKI), congestive heart failure (CHF), dementia, and Parkinson’s disease. Upon admission, the resident’s care plan identified potential for altered nutrition and included interventions such as assisting at meals, encouraging oral fluids, and monitoring for additional nutrition interventions. A nutrition assessment established an initial fluid goal of 1943–2098 mL/day and documented that the resident was at risk for dehydration and malnutrition, with early labs showing a BUN of 29, creatinine of 1.4, and eGFR of 53. The admission MDS documented that the resident was severely cognitively impaired and required setup assistance for feeding and hydration. Daily fluid intake records from CNA task flow sheets and the MAR showed that the resident’s intake frequently fell below the recommended fluid goals, with multiple days of intake under 1200 mL and some days as low as 360–720 mL. A malnutrition risk assessment identified the resident as at risk for malnutrition due to severe dementia and tremors. A subsequent nutrition note on 5/12/25 documented that the resident’s average fluid intake was 330 mL/day, recommended discontinuing a prescribed hydration pass due to CHF, and set a new fluid goal of 1635–1766 mL/day, while continuing to recommend encouraging oral fluids. Despite these documented risks and low intakes, there is no evidence in the record of intensified monitoring or additional interventions to ensure the resident met the revised fluid goals. The resident experienced multiple clinical deteriorations associated with poor intake and changes in condition. On 6/1/25, after a day with only 360 mL of recorded intake, the resident was transferred to the hospital following falls, hypotension, and confusion, and was admitted with AKI and dehydration. After readmission to the facility, nursing documentation noted low oral intake and a plan to discuss adding the resident to an assist-to-feeding list, but the record lacked evidence that this occurred. Subsequent notes documented lethargy, increased confusion, agitation, restlessness, and continued poor intake, yet a physician progress note following two unwitnessed falls did not include an assessment of hydration status or interventions to improve hydration. On 6/19/25, labs showed a BUN of 62 mg/dL and creatinine of 1.7 mg/dL, and the resident was again sent to the hospital and admitted with AKI, hypotension, and anemia, requiring IV fluid resuscitation. Staff interviews confirmed expectations to monitor intake, encourage fluids, and notify providers when fluid goals were not met, but there was no documentation that the provider was consistently notified or that appropriate interventions were implemented in response to the resident’s ongoing inadequate fluid intake and changes in condition.
Failure to Arrange Timely Home Health Services Prior to Discharge
Penalty
Summary
The facility failed to ensure a timely referral for home health care services prior to discharge for one resident. Facility policy dated 5/1/25 required sufficient preparation and orientation to residents to ensure an orderly transfer or discharge. The resident was admitted on 7/28/25 with diagnoses including aortic valve replacement, aortic regurgitation, and congestive heart failure. A discharge summary dated 8/11/25 documented a post-discharge plan for home health aide, home health RN/LPN, and occupational and physical therapy. The resident was discharged home with a family member on 8/12/25. A complaint received by the Division on 9/30/25 stated that the resident was discharged to a family member's home without a home health care agency referral and that, after one week at home, the resident had not received any physical or occupational therapy or a wellness check from a nurse. During an interview on 2/16/26, the social worker reported needing to check if a referral was made and later confirmed that the referral for home health and therapy services was not requested until 8/15/25, with services opened on 8/20/25. The director of therapy confirmed that physical and occupational therapy were recommended for the resident and stated that such recommendations are typically communicated to social services to set up home care. Findings were reviewed with facility leadership during the exit conference.
Failure to Revise Care Plans and Involve Resident in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise person‑centered care plans and to involve a cognitively intact resident and/or representative in the care planning process. One resident with an intact BIMS score of 15 was admitted and had a documented care conference shortly after admission, but there was no evidence of any subsequent care conferences during the following year despite multiple care plan updates. The resident reported not recalling quarterly care plan meetings, and staff confirmed that no care conferences occurred after the initial one, with no documentation that the resident or representative participated in the later care plan revisions. Additional residents’ care plans were not revised to reflect current, individualized needs and behaviors. One resident had a physician’s order for a right palm protector or substitute, was repeatedly observed without it in place, and routinely refused it according to nursing and CNA interviews, yet the care plan did not address potential refusals. Two cognitively impaired residents whose MDS assessments documented dependence for bathing had care plans that continued to list only setup assistance or one‑person assist, without updating to reflect full dependence. Another cognitively impaired resident with documented combative behaviors toward staff and a reported incident of striking another resident with a remote had a behavior care plan that was not revised to include the new behavior of attempting to hit other residents or the potential for resident‑to‑resident altercations.
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