Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Encore At Parkside during CMS and state inspections, most recent first.
Inadequate supervision allowed a resident with dementia, repeated falls, and a history of wanting to go home to leave the facility unnoticed. Despite multiple notes showing he repeatedly expressed a desire to discharge home and spent time near the lobby, he self-ambulated from the healthcare area into the independent living lobby and exited the building without staff knowledge. He was later found by police on a main traffic road after stating he did not want to be there anymore and felt trapped.
The facility failed to maintain a documented and updated facility assessment with required addendum attachments. Review of the assessment completed by the Interim NHA showed no evidence that key items were included, such as the PBJ report, staff certification requirements, education schedule summary, infection control risk assessment, inventory listing, all hazards risk assessment/emergency preparedness plan, HIPAA security compliance information, and authorization for disclosure policy & procedure. The Interim NHA confirmed the facility did not have the attachments.
Laundry handling and transport were not managed to prevent cross-contamination. A housekeeping staff member stated that residents’ personal clothing was washed and dried in a small auxiliary room that opened directly into the dirty laundry area, and clean items were then carried back out through the main washer/dirty room. A designated clean laundry room existed but was not being used for these items.
The facility failed to document resident or representative participation in care plan conferences for multiple residents. Records showed completed MDS assessments and care plan reviews, but no evidence of invitations, attendance, or conference notes for residents with conditions including anxiety disorder, PE, MS, and intact cognition by BIMS. Residents and family members stated they did not recall being invited or attending care plan meetings, and staff confirmed the documentation was missing.
Undated food items were found in the walk-in freezer during a kitchen tour with the DFB. The items included bags of French fries, sweet potato fries, dinner rolls, bagels, English muffins, and sliced wheat bread, and one bag of bagels contained a moldy bagel. The findings were reviewed with the Interim NHA.
Infection Control Line Listing Missing Organism Documentation for Antibiotic Use: The facility failed to document the organism being treated on the monthly infection control line listing for multiple residents who received antibiotics. A resident with a suprapubic catheter was treated for a UTI after an ER visit, and other residents received ciprofloxacin, amoxicillin, and doxycycline, but the pathogen was not recorded on the line listing. For one resident, the record also lacked supporting McGeer criteria documentation, and the IP confirmed the facility had not followed up with outside providers to identify the organism.
Missing Mandatory QAPI Training for Staff: Review of training records showed no evidence that QAPI training was completed for seven staff members, including RNs, CNAs, a Maintenance Tech, and a Restorative Aide/CNA. The findings were discussed with the Interim NHA and reviewed with the DON during the exit conference.
The facility failed to ensure required Corporate Compliance and Ethics training was completed for four of four staff reviewed. Training records showed no evidence of the required training for two CNAs, a Maintenance Tech, and a Restorative Aide/CNA after each began working at the facility. The findings were discussed with the Interim NHA and reviewed again with the Interim NHA and DON at the Exit Conference.
Behavioral Health Care Needs training was not documented for seven of seven staff reviewed, including RNs, CNAs, a Maintenance Tech, and a Restorative Aide/CNA. Facility training records showed no evidence that the required training had been completed for any of the staff reviewed, and the findings were discussed with the Interim NHA and DON during the exit conference.
A resident with moderately impaired cognition was observed with her legs, thighs, and incontinence pad uncovered and visible from the hallway while her roommate had a male visitor in the room. The condition was seen repeatedly over several minutes, and an LPN confirmed the finding and stated the resident tended to kick her blanket off.
Family Signed Consents Instead of Residents A facility failed to honor resident self-determination when family members or POAs signed admission and treatment consents for residents who were documented as alert, oriented, and cognitively intact. One resident had a POA sign multiple forms, including DMOST, despite later BIMS scores showing intact cognition; another resident with pancreatic cancer and improved mentation had his wife sign consents and DMOST; and a third resident with normal BIMS scores had his daughter sign treatment-related consents by phone even though staff and the resident confirmed he could make decisions and sign his name.
Failure to notify a resident’s wife of abnormal CMP and CBC results after labs were drawn on the day of discharge. The resident had pancreatic cancer and normal cognition, and the results later showed abnormalities including hyponatremia and anemia. The RN/UM stated the wife was told labs were drawn that morning, but the facility did not call with the results and had no protocol for same-day discharge labs.
A resident who was cognitively intact and discharged home with a plan for HH PT, OT, HHA, and RN services was found to have no confirmed home health arrangement in place at discharge. The record showed the resident had a suprapubic catheter and nephrostomy tube and needed moderate to substantial assistance with mobility, transfers, bathing, and dressing, yet the facility’s referrals were unsuccessful because of insurance, staffing, and service-area barriers.
A resident’s MDS assessments did not match the clinical record for repeated behaviors including agitation, yelling, cursing, and physical aggression, and the annual MDS also failed to identify Depakote as an anticonvulsant despite the MAR showing it ordered three times daily. The MDS Coordinator stated the resident’s hitting, yelling, and cursing should have been documented, and the DON and ADON confirmed the findings.
Failure to develop person-centered care plans was identified for two residents. One resident admitted with a stroke had an order for bladder scans, straight cath if PVR was over 400 mL, and output documentation every 6 hours, but the care plan did not address urinary retention or how needs would be met. Another resident with severe dementia had an ADL care plan, but the record lacked a person-centered plan for refusal to wear a bra; a family member reported staff were not putting the bra on, and a CNA said the resident refused and she did not notify the nurse.
Failure to Update Care Plan for Supplemental Oxygen: A resident was re-admitted after hospitalization for COVID pneumonia with acute respiratory failure and hypoxia, and the MDS documented supplemental O2 use. However, the care plan did not include oxygen therapy interventions, goals, or tasks, and the RNAC acknowledged there was no mention of oxygen therapy in the care plan.
Out-of-date oxygen tubing was cited for a resident who had been re-admitted after COVID pneumonia with acute respiratory failure and hypoxia. The MD ordered the mask/cannula and tubing to be changed weekly, but observations showed the tubing remained marked as changed 11 to 15 days earlier instead of within the 7-day interval.
Failure to provide medically-related social services for a resident whose POA/friend stated she was no longer available to assist with his care and whose facesheet still listed her as the POA. The record lacked evidence that social services followed up on the change in support or on the MD’s determination that the resident lacked medical decision-making capacity, had poor insight, was unsafe to live alone, and had recently eloped from the facility. The facility also did not obtain the actual DPOA document and relied only on an attorney cover letter naming multiple potential agents.
Failure to provide routine dental services for a resident with intact cognition. The resident said it had been a long time since she last saw a dentist and did not know she could be seen in the facility. Records showed no dental consults or appointments for the year reviewed. The family/POA reported an unsuccessful outside dental visit because the clinic could not accommodate the resident’s motorized chair, and the ADON stated the facility had a dentist who comes to the facility and could see the resident.
The facility failed to maintain a written transfer agreement with at least one Medicare/Medicaid-certified hospital. During record review, surveyors requested the agreement from the Interim NHA, who confirmed that no written transfer agreement was in place. The findings were reviewed with the Interim NHA and DON during the exit conference.
Failure to disclose ownership change to the State Agency: Facility records showed a sale agreement between the former owner and the new owner, but the facility did not have the required written notice documenting disclosure of ownership requirements at the time of the change. The Interim NHA confirmed the document was not available, and the findings were reviewed with the Interim NHA and DON at exit conference.
The facility failed to include a resident’s bilateral bed rails in routine maintenance safety checks. Observations showed the rails up on the bed, and the resident said he used them during therapy sessions. The Maintenance Director stated that the facility did not perform routine bed rail inspections and that bed rails were applied only when requested through the work order system; he also said therapy would remove rails if they were no longer needed.
Missing Required Communications Training for Direct Care Staff: Review of training records showed no evidence of required Communications training for seven of seven staff members reviewed, including RNs, CNAs, an LPN, and a Restorative Aide/CNA. The deficiency was identified during record review and discussed with the Interim NHA and DON during the exit conference.
No active governing body was identified to establish and implement facility management policies. After the facility changed ownership, surveyors requested the names and contact information for governing body members, and the Interim NHA confirmed the facility did not have that information. Findings were reviewed with the Interim NHA and DON at exit.
A resident with chronic lorazepam use was readmitted with an order for lorazepam, but did not receive any doses for several days due to the medication not being available. Nursing staff documented the delay, and the resident subsequently experienced withdrawal symptoms, including a seizure that required hospital transfer. Review of records confirmed the missed doses and lack of documentation for some scheduled administrations.
Admission assessments for four residents were completed by LPNs instead of an RN, contrary to state requirements and facility policy. Multiple admission evaluations, such as clinical admission, Braden Scale, and fall risk, were documented by LPNs, and this was confirmed by the DON during interviews.
A resident with chronic anxiety disorder and a physician's order for lorazepam did not receive the medication for two days due to pharmacy profiling errors and issues with matching the prescription to available emergency stock. Nursing staff documented missed doses and delays, and the resident ultimately experienced a seizure and required hospitalization after missing four doses.
The facility's kitchen was found to be unsanitary, with trash, food debris, and a greasy substance on the floors and equipment. The juice machine and grease interceptor box were also unclean. Despite a cleaning schedule, the kitchen remained dirty, potentially affecting 89 of 91 residents. The CDM and Administrator acknowledged the issues, citing challenges in maintaining cleanliness.
A facility failed to include a resident in their person-centered care planning process. Despite the resident being cognitively intact, there was no evidence of their attendance at care plan meetings, and the resident confirmed not being invited. The Social Services Director admitted that inviting the resident had been missed, contrary to the facility's policy requiring resident participation.
A resident's privacy was compromised during medication administration when an LPN applied a Lidocaine pain patch at the nurses' station, exposing the resident's shoulder and upper chest area in front of others. The LPN and DON acknowledged this action violated the resident's dignity and privacy.
A facility failed to provide written notification of the bed hold policy to a resident and their representative during a hospitalization. Despite a verbal request for a bed hold, there was no documented evidence that written information was provided, as required by the facility's policy. Staff interviews revealed inconsistencies in the notification process, with some indicating verbal communication and others mentioning inclusion in the discharge packet.
A facility failed to accurately document a resident's continuous oxygen therapy in the MDS assessment. The resident, admitted with congestive heart failure and shortness of breath, was ordered to receive oxygen therapy, but this was not recorded in the MDS. The omission was confirmed by the MDS Coordinator upon review of the resident's records.
The facility failed to update care plans for three residents, affecting their care. One resident's plan lacked details on oxygen therapy, another's did not address wandering behavior, and a third's omitted a urinary catheter. Staff interviews confirmed the expectation to update plans as needed, but this was not done.
A facility failed to increase assessment frequency for a resident diagnosed with COVID-19, as required by their policy. Despite orders to monitor vital signs and symptoms daily, documentation was inconsistent during the resident's isolation period. Interviews with staff revealed an expectation for shift-based assessments, but the resident's records showed gaps in documentation.
A resident with severe cognitive impairment wandered into another resident's room at night, leading to an incident where he pulled down his pants and sat on a chair. The facility failed to revise the resident's care plan or implement interventions to address his wandering behavior, as revealed by interviews with staff and a lack of documentation.
A facility failed to provide appropriate care for a resident with a urinary catheter. The resident's physician orders for the catheter were not transcribed, and the care plan was not updated. Observations showed the drainage bag and tubing on the floor, potentially affecting urine flow. Staff interviews confirmed the oversight in documentation and care plan updates.
The facility failed to administer oxygen at the prescribed levels for two residents, leading to potential respiratory distress. One resident with COPD had their oxygen concentrator set incorrectly at 4.5 LPM and later at 2 LPM, instead of the prescribed 3 LPM. Another resident with congestive heart failure had their oxygen set at 3 LPM instead of the prescribed 2 LPM, and the concentrator's filter was clogged with dust. The Medical Director and LPN Supervisor confirmed the importance of adhering to physician orders and maintaining equipment.
A facility failed to document an end date for a PRN psychotropic medication for a resident with anxiety, depression, and bipolar disorder. The resident had an order for clonazepam as needed, but it lacked a 14-day end date or a documented rationale for extension, contrary to facility policy. Staff interviews confirmed the oversight, highlighting the potential for medication use without ongoing physician assessment.
A medication cart on the second floor was left unlocked and unattended, posing a risk to a resident with impaired decision-making skills. Additionally, expired supplies were found in the medication storage room, indicating lapses in weekly inspections by the LPN Supervisor.
Three residents with cognitive impairments and a history of wandering were able to exit the facility unsupervised on multiple occasions, despite care plans and interventions such as wander-guards. Staff were unaware of the residents' absence until notified by others, and facility doors and alarm systems were not consistently secured or monitored, allowing residents to leave undetected.
Three separate elopement incidents involving three residents were not recognized or reported by facility staff as allegations of neglect, despite policy and state law requiring immediate reporting to the state agency. Staff interviews revealed misunderstandings about what constitutes an elopement and when reporting is necessary.
Seven staff members, including a receptionist, RN, LPN, and three CNAs, did not complete required Behavioral Health training as determined by the facility assessment. This was confirmed by facility leadership and documented in employee training records.
A resident eloped from the facility, and the required investigation into this incident was not conducted. When surveyors requested documentation, the DON confirmed that no investigative records were available, despite facility policy requiring thorough investigation of such events.
Mandatory QAPI training was not completed for six staff members, including an RN, an LPN, and several CNAs, as confirmed by facility leadership and employee training records.
Inadequate supervision allowed a resident to elope from the facility
Penalty
Summary
The facility failed to provide adequate supervision for a resident who had repeatedly told multiple staff that he wanted to go home. The resident was admitted for short-term rehab with diagnoses including orthostatic hypotension, repeated falls, and dementia. Although several elopement evaluations documented that he was not at risk for elopement, other records showed ongoing discussions about his desire to return home, concerns about his safety living alone, and notes that he sat near the lobby or in the hall from time to time. On the morning of the incident, the resident self-ambulated his wheelchair from the healthcare area to the independent living front lobby entrance and exited the building without staff knowledge. A police report documented that he was found on a main traffic road after walking away from the facility and stated that he did not want to be there anymore and had walked out the door because he felt trapped. Facility documentation and interviews established that he had left the building before staff realized he was missing, and staff later confirmed the timeline of his exit from the room, movement through the independent living hallway, and departure from the building. The record also showed that the resident had continued to express his wish to go home in the weeks before the incident, including statements to social services and medical staff. On the day of the event, nursing documentation noted that he was seen leaving his room and later was not in his usual location near the nurses station before the search began. The incident was identified by surveyors as an elopement that occurred without adequate supervision and resulted in the resident leaving the facility unnoticed.
Missing Required Addendum Attachments to Facility Assessment
Penalty
Summary
The facility failed to ensure it had a documented and updated facility assessment that included the required addendum attachments. Review of facility documents showed that a Significant Organizational Change facility assessment tool was completed by the Interim NHA on 1/5/26, but a subsequent review on 1/9/26 found no evidence that the following addendums were included and attached: Facility Payroll Based Journal Report, Staff Certification Requirements, Education Schedule Summary, Infection Control Risk Assessment, Inventory Listing, All Hazards Risk Assessment/Emergency Preparedness Plan, HIPAA Security Compliance Information, and Authorization for Disclosure Policy & Procedure. On 1/12/26, a request was made for the attachments, and the Interim NHA confirmed later that day that the facility did not have the attachments to the facility assessment addendum. The findings were reviewed with the Interim NHA and the DON during the exit conference.
Laundry Handling and Transport Cross-Contamination
Penalty
Summary
The facility failed to handle, store, process, and transport laundry in a manner that prevents cross-contamination. During a laundry tour, a smaller auxiliary laundry room was observed adjacent to the main washer/dirty room, with its only entrance/exit door opening directly into the dirty laundry area. The room contained household-type washers and dryers, and the door was open at the time of observation. Housekeeping staff stated that residents' personal clothing is washed and dried in this smaller room, and that clean laundry is then transported out through the main washer/dirty room. The staff member reported that this practice has been in place for years. Although a designated clean laundry room existed on the opposite side of the main washer room, it was not being used for processing or transporting these personal clothing items.
Failure to Document Resident Participation in Care Plan Conferences
Penalty
Summary
The facility failed to ensure residents and/or their resident representatives were included in the development and implementation of person-centered care plans for four reviewed residents. For R22, the record showed admission on 7/10/25, completion of the admission MDS on 7/16/25, and completion of the quarterly MDS on 10/16/25, but there was no evidence that a care plan conference was held with the resident or resident representative. For R94, the record showed admission on 12/13/25, completion of the admission MDS on 12/19/25, discharge to the hospital and return on 12/24/25, and completion of the 5-day MDS on 12/30/25, but again there was no evidence of a care plan conference. R94 and a family member stated they did not recall participating in a care plan conference since admission. For R3, who had diagnoses including anxiety disorder, pulmonary embolism, and multiple sclerosis, the record lacked evidence of care plan meeting notes for 2025. R3 stated she could not recall attending a care plan meeting, and a family member stated she had not been invited to any care plan meetings in years. For R28, whose annual MDS documented a BIMS score of 13 indicating intact cognition, the facility had a care plan report showing the last care plan review was completed on 12/03/2025, but no care plan documentation was found. R28 stated she had not been informed of or invited to care plan meetings, and the DON stated R28 and her son did not come to meetings and there was no documentation showing they were informed or invited. Staff interviews also confirmed the facility lacked evidence of documented care plan conferences and invitations for resident or representative participation.
Undated and Moldy Frozen Food Found in Kitchen
Penalty
Summary
Food was not stored, prepared, and served in accordance with professional standards, as observed during a kitchen tour with the Director of Food and Beverages. Multiple open food items in the walk-in freezer were found without dates, including one bag of potato French fries, one bag of uncooked sweet potato fries, three bags of dinner rolls, three bags of bagels, three bags of English muffins, and seven bags of sliced wheat bread. One of the undated bags of bagels contained a moldy bagel. The findings were reviewed with the Interim NHA later that day.
Infection Control Line Listing Missing Organism Documentation for Antibiotic Use
Penalty
Summary
The facility failed to maintain an infection control program that obtained and documented on the monthly line listing the organism being treated by antibiotics for four residents reviewed for infection control. For R3, who was admitted with multiple sclerosis and neurogenic bladder with an indwelling suprapubic catheter, the record showed treatment with Cefpodoxime after a recent ER visit for a UTI, but the December 2025 infection control line listing did not document the organism being treated. The Infection Preventionist confirmed the facility had not followed up with the ER to determine the urinary tract organism. For R4, R39, and R87, the infection control line listings also documented antibiotic use without identifying the organism being treated. R4 received ciprofloxacin, R39 received amoxicillin for a UTI noted by the NP, and R87 received doxycycline, yet none of these entries included the pathogen/organism on the line listing. For R39, the record also lacked documentation supporting antibiotic use under McGeer criteria, with no fever documented in November 2025, no lab work since August 2025, and no microbiologic urine specimen results. The Infection Preventionist stated the facility used McGeer's criteria for antibiotic stewardship and confirmed it had not followed up with the urology practice to determine the organism being treated.
Missing Mandatory QAPI Training for Staff
Penalty
Summary
Mandatory QAPI training was not completed for seven of seven facility staff reviewed. Review of training records on 1/12/26 at 1:30 PM showed no evidence of QAPI training for E14, whose first day as an RN was 2/4/25; E15, whose first day as an RN was 4/1/25; E16, whose first day as a CNA was 3/18/25; E17, whose first day as a CNA was 9/16/25; E18, whose first day as a CNA was 6/10/25; E20, whose first day as a Maintenance Tech was 9/30/25; and E21, whose first day as a Restorative Aide/CNA was 11/18/25. The findings were discussed with E1, Interim NHA, at 2:00 PM and reviewed with E1 and E2, DON, during the exit conference at 3:30 PM.
Missing Corporate Compliance and Ethics Training for New Staff
Penalty
Summary
The facility failed to ensure required Corporate Compliance and Ethics training was completed for four of four staff reviewed. Review of training records on 1/12/26 found no evidence of this training for E16, whose first day as a CNA was 3/18/25; E18, whose first day as a CNA was 6/10/25; E20, whose first day as a Maintenance Tech was 9/30/25; and E21, whose first day as a Restorative Aide/CNA was 11/18/25. The findings were discussed with E1, the Interim NHA, and later reviewed with E1 and E2, the DON, during the Exit Conference.
Missing Behavioral Health Care Needs Training for Multiple Staff
Penalty
Summary
Behavioral Health Care Needs training was not completed for seven of seven facility staff reviewed, including an RN, CNAs, a Maintenance Tech, and a Restorative Aide/CNA. Review of the facility training records showed no evidence that E14, E15, E16, E17, E18, E20, or E21 had completed the required training, despite each staff member having a documented first day in the facility. The findings were discussed with the Interim NHA and later reviewed with the Interim NHA and DON during the Exit Conference.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure that one resident was treated with dignity and respect when R92 was observed with her legs and thighs uncovered and her incontinence pad visible from the hallway. R92 had been admitted to the facility and her admission MDS indicated that her cognition was moderately impaired. During observations on 1/7/26, R92’s bed was near the open door, and her uncovered legs, thighs, and incontinence pad could be seen from the hallway while her roommate had a male visitor in the room. The same condition was observed repeatedly over several minutes, and an LPN confirmed the finding and stated that R92 tended to kick her blanket off and that she would attend to R92 and put on her pants.
Family Signed Consents Instead of Cognitively Capable Residents
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by allowing family members or other representatives to sign consents for residents who were documented as capable of making their own decisions. For R22, the record showed a consent for treatment signed by the resident, but multiple admission-related consents, including treatment, medication, resident rights, transportation, dental care, immunizations, pain management, foot care, patient portal access, bed rails, and the Delaware Medical Orders for Scope of Treatment (DMOST), were signed by the resident’s POA instead of the resident. The admission note documented R22 as alert and oriented x2-3 and confused, while later therapy and social services documentation recorded a BIMS score of 13 and described R22 as cognitively intact. R22’s record also showed that the DMOST was signed by the POA and the contracted NP, but the note did not document a determination of incapacity for R22. The initial consult note documented dementia and major neurocognitive disorder, but also stated that R22 was alert and oriented x2-3 and that goals of care were discussed with both R22 and the POA. During interview, the Admissions Coordinator stated that the facility’s practice was for the admitting nurse to obtain signed consents and the POA document if applicable. For R106, who was admitted with pancreatic cancer and had a hospital discharge diagnosis of acute hyperactive delirium due to another medical condition, the wife signed the resident’s admission consents, including resident rights, treatment and medication, pain management, bed rails, dental care, and the DMOST. The admission summary documented that the patient was awake, alert, and oriented x3-4, and later psychiatric evaluation documented calm and cooperative behavior with alert orientation to person, place, and time; the admission MDS later showed a BIMS of 13, reflective of normal cognition. For R80, who had a quarterly BIMS of 14 and was documented on readmission as alert, oriented x3, coherent, and able to understand others, the daughter was contacted by telephone to provide consent for bed rails, treatment and medication, pain management, psychopharmacologic medication, and appointment scheduling instead of R80 signing those forms himself. Staff later stated that R80 was his own person, could make his own decisions, and was able to sign his name, and R80 confirmed he could sign with his right arm.
Failure to Notify Family Representative of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the resident’s family representative of the resident’s 8/1/25 lab work results for one resident (R106) reviewed for quality of care. The record showed that on 7/24/25, the physician ordered a CMP and CBC to be drawn one week after admission. R106 was admitted on 7/25/25 with diagnoses including pancreatic cancer, and the admission MDS dated 7/31/25 showed a BIMS score of 13, indicating normal cognition. The labs were drawn at 8:12 AM on 8/1/25, and the resident was discharged at 10:00 AM the same day after the wife signed the discharge paperwork. The lab results were reported to the facility at 11:29 AM on 8/1/25 and included several abnormalities, including hyponatremia and anemia. During interview, the resident’s wife stated that the facility never called her with the lab results and that, had she known on Friday, August 1st, she would have taken the resident to the ED immediately and believed the outcome might have been different. The RN/UM stated that she remembered telling the wife that the resident had labs that morning, but did not call her with the results and said there was no protocol for that because labs are rarely received on the day of discharge.
Failure to Arrange Home Health Services at Discharge
Penalty
Summary
The facility failed to ensure that a resident discharged to home had home health services arranged according to the discharge plan. The resident was cognitively intact with a BIMS score of 15 and had been care planned for discharge to home with home health services, physician review of discharge and admission orders, care plan and prior level of function, and therapy services per physician order. The resident’s record also included an insurance appeal determination stating the resident could be transferred home with support from home health services, and discharge documentation listed home health nursing and therapy services as recommended upon discharge. The discharge record showed the resident had a suprapubic catheter and a left percutaneous nephrostomy tube, and therapy summaries documented the resident required partial to substantial assistance with bed mobility, dressing, bathing, bathroom activity, transfers, and moving from one location to another. On the discharge date, the facility faxed a referral to one home health company for PT, OT, HHA, and RN services, and an email later confirmed receipt of the referral information. However, the facility later documented that multiple home health agencies either could not accept the resident’s insurance, did not service the area, or had no staff during the referral period, and the SSD stated that the resident was advised to contact the PCP for an outpatient therapy script. The deficiency was cited because the facility did not ensure home health services were arranged per the discharge plan.
Inaccurate MDS Documentation of Behaviors and Medication Status
Penalty
Summary
The facility failed to complete MDS assessments that accurately reflected R46’s documented behavior changes and medication status. R46 was admitted on 11/15/2024 with diagnoses including hypertension and osteoarthritis. The clinical record contained multiple behavior notes documenting agitation, yelling at the nurse’s station, cursing at staff and residents, verbal and physical aggression, swatting at another resident, and a statement asking a nurse if she had a gun so he could shoot another resident. Despite these documented behaviors, the quarterly MDS assessments on 5/29/2025 and 9/2/2025 indicated that R46 had not exhibited behaviors such as delusions, yelling, hitting, threatening, or cursing at others. The annual MDS assessment on 11/22/2025 also stated that R46 had not exhibited verbal behaviors of threatening, screaming, or cursing at others and documented that he was not taking an anticonvulsant medication. However, the MAR showed Depakote Oral Tablet 125 mg ordered three times daily beginning 11/5/2025. During interview, the MDS Coordinator stated the MDS assessments should have documented R46’s hitting, yelling, and cursing behaviors, and that Depakote should have been documented as an anticonvulsant on the MDS. The DON and ADON confirmed the findings.
Failure to Develop Person-Centered Care Plans for Urinary Retention and ADL Needs
Penalty
Summary
Failure to develop person-centered care plans was identified for two residents. R94 was admitted with a diagnosis of stroke and had a physician order dated 12/15/25 for bladder scans every 6 hours, straight catheterization if post void residual was greater than 400 mL, and documentation of output every 6 hours. Review of R94’s care plan showed no evidence that urinary retention or the approaches the facility would use to meet this resident’s needs had been addressed. R91 was admitted with diagnoses including severe dementia with agitation. A care plan developed on 12/17/25 addressed impaired ability to perform activities of daily living and included providing assistance as needed, but the record lacked evidence of a person-centered care plan for R91’s refusal to wear a bra when dressed. The admission MDS indicated severely impaired cognition with no mood or behavioral issues and substantial to maximal assistance needed for upper body dressing. A family member stated that staff were not putting the resident’s bra on, and a CNA stated she did not put it on because the resident refused and fought back, and that she did not notify the nurse.
Failure to Update Care Plan for Supplemental Oxygen
Penalty
Summary
The facility failed to review and revise R80’s care plan to include supplemental oxygen after the resident’s admission and subsequent re-admission following hospitalization for COVID pneumonia with acute respiratory failure and hypoxia. R80’s EMR included an order for oxygen equipment care, and the 10/1/25 MDS documented that the resident was using supplemental oxygen, but a 1/8/26 review of the care plan found no evidence of oxygen therapy interventions, goals, or tasks. During interview, the RNAC stated that there was no mention of oxygen therapy in the care plan and that it would be added.
Out-of-date oxygen tubing
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was cited for one resident, R80, whose supplemental oxygen tubing was not replaced according to the physician’s order. R80 was re-admitted to the facility after hospitalization for COVID pneumonia with acute respiratory failure and hypoxia and was ordered to have the mask/cannula and tubing changed and the oxygen concentrator filter cleaned every Thursday night shift. Although the tubing was documented as changed on 12/26/25, observations on 1/5/26, 1/8/26, and 1/9/26 showed the tubing still marked as having been changed 11, 14, and 15 days earlier, respectively, rather than within the ordered seven-day interval.
Failure to Provide Medically-Related Social Services
Penalty
Summary
Medically-related social services were not provided for one resident when the facility failed to follow up after the resident’s POA/friend sent a letter stating she would no longer be available to assist with his care. The resident’s record showed that the POA remained listed on the facesheet after the letter, and there was no evidence that social services addressed the change in support or clarified the resident’s decision-making contacts. The social services note documented the resident’s concern that the POA was trying to prevent him from returning home, while the POA had stated she was retiring and no longer involved in his care. The deficiency also involved the facility’s failure to respond to the medical director’s determination that the resident lacked capacity for medical decision making. The progress note stated that the resident had poor insight, was unaware of safety risks, could not live at home alone without 24-hour supervision, and had recently eloped from the facility and was found off the grounds down the street. Despite the note stating that social services would continue to work with the resident and family members regarding disposition and discharge planning, the record lacked evidence of social services follow-up after the incapacity determination. The facility also did not obtain the actual durable power of attorney document, and instead had only an attorney cover letter listing multiple named agents, including the resident’s only family member.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide or obtain routine dental services for one resident who was reviewed for dental care. The resident had a quarterly MDS assessment showing a BIMS score of 15 and intact cognition. During interview, the resident stated it had been a long time since she was last seen by a dentist and said she did not know she could be seen by a dentist in the facility. Record review showed no evidence of dental consults or appointments for 2025. The resident’s family member and POA stated they preferred to arrange the resident’s outside appointments and transportation, and reported an unsuccessful dental clinic visit in which the resident was not seen because the clinic could not accommodate her motorized chair. The ADON stated she was aware the resident had canceled a dental appointment in the past and was aware of the accessibility issue at the outside clinic; she also stated the facility had a dentist who comes to the facility and could see the resident.
No Written Hospital Transfer Agreement
Penalty
Summary
The facility failed to ensure that it had a written transfer agreement in effect with one or more hospitals approved for participation in Medicare/Medicaid programs. Review of facility documents showed that a sale between the former owner and the new owner was entered into on 12/15/25. On 1/12/26 at 9:00 AM, surveyors requested the facility's written transfer agreement from the Interim NHA, and at 2:46 PM the Interim NHA confirmed that the facility did not have a written transfer agreement. The findings were reviewed with the Interim NHA and the DON during the exit conference at 3:30 PM.
Failure to Disclose Ownership Change to State Agency
Penalty
Summary
The facility failed to ensure compliance with disclosure of ownership requirements after a sale agreement was entered into between the former owner and the new owner. Facility records showed that a request was made to the Interim NHA for the facility's written notice to the State Agency responsible for licensing regarding the required disclosure at the time of the ownership change, but the facility did not have the document. During interview, the Interim NHA confirmed that the facility did not have the disclosure of ownership requirements document. The findings were reviewed with the Interim NHA and the DON during the exit conference.
Failure to Include Bed Rails in Routine Safety Checks
Penalty
Summary
The facility failed to ensure that R94’s bilateral bed rails were included in a routine maintenance safety check. Review of the resident’s clinical record showed bilateral bed rails positioned up on the bed during observation on 1/5/26 and again on 1/9/26, when R94 was observed in bed with bilateral bed rails up and no gap; R94 confirmed that he used the rails during therapy sessions. During interview on 1/9/26, the Maintenance Director stated that the facility did not perform routine maintenance or safety inspections of bed rails and that he would start doing so. He also stated that maintenance staff applied resident bed rails only when a request was submitted through the maintenance work order system, and that therapy would remove bed rails if they were no longer necessary.
Missing Required Communications Training for Direct Care Staff
Penalty
Summary
The facility failed to ensure that required Communications training was completed for seven of seven staff members reviewed. Review of training records on 1/12/26 at 1:30 PM showed no evidence of Communications training for E14, whose first day in the facility as an RN was 2/4/25; E15, whose first day as an RN was 4/1/25; E16, whose first day as a CNA was 3/18/25; E17, whose first day as a CNA was 9/16/25; E18, whose first day as a CNA was 6/10/25; E19, whose first day as an LPN was 10/8/24; and E21, whose first day as a Restorative Aide/CNA was 11/18/25. Findings were discussed with E1, Interim NHA, at 2:00 PM and reviewed with E1 and E2, DON, during the exit conference at 3:30 PM.
No Active Governing Body Identified
Penalty
Summary
The facility failed to ensure that it had an active governing body responsible for establishing and implementing policies regarding the management of the facility. Review of facility documents showed that a sale between the former facility owner and the new facility owner was entered into on 12/15/25. During surveyor review, a request was made on 1/12/26 for the names and contact information of the governing body members, and the Interim NHA later confirmed that the facility did not have the names and contact information for the governing body members. The findings were reviewed with the Interim NHA and the DON during the exit conference.
Significant Medication Error: Missed Lorazepam Doses Result in Withdrawal Seizure
Penalty
Summary
A resident with a history of anxiety disorder and chronic lorazepam use was readmitted to the facility with an order for lorazepam 2 mg twice daily. Upon readmission, the medication was not available, and multiple nursing staff documented in the electronic medical record that the resident was waiting for pharmacy delivery. Despite these notes, the resident did not receive any doses of lorazepam for several days following readmission. During this period, the resident began to experience withdrawal symptoms, culminating in a seizure that required transfer to the hospital. Hospital records confirmed that the resident had not received lorazepam since returning to the facility, and both the resident and hospital staff noted the absence of the medication. The resident reported a long-term history of lorazepam use and stated that she had not received her medication due to it being unavailable at the facility. A review of the medication administration record confirmed that several scheduled doses of lorazepam were not administered, with some doses lacking any documentation. Facility leadership confirmed during interviews that the resident did not receive any lorazepam doses during the specified period, resulting in benzodiazepine withdrawal and a seizure event.
Failure to Ensure RN Completion of Admission Assessments
Penalty
Summary
The facility failed to ensure that admission assessments for four residents were completed by a registered nurse (RN) as required by the Delaware State Code and the facility's own policy. Instead, licensed practical nurses (LPNs) completed multiple admission evaluations, including clinical admission, Braden Scale for pressure ulcer risk, lift/transfer evaluation, elopement evaluation, fall risk evaluation, dehydration risk evaluation, trauma informed care, and functional abilities and goals. The records for each resident showed that these assessments were documented and completed by LPNs at the time of admission or readmission, rather than by an RN. Interviews with facility staff, including the Director of Nursing (DON), confirmed that LPNs had performed several of the required admission evaluations. The deficiency was identified for all four residents reviewed for admission, with each case lacking RN-completed admission assessments as mandated. The findings were discussed with facility leadership during the exit conference.
Failure to Provide Timely Pharmaceutical Services Resulting in Missed Medication and Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to provide pharmaceutical services to meet the needs of a resident who was readmitted with diagnoses including diabetes and chronic anxiety disorder. Upon admission, the resident had an active order for lorazepam 2 mg orally twice daily, as documented in the hospital discharge summary and confirmed by the attending physician. However, the medication was not available for administration, and nursing staff documented multiple missed doses over a two-day period, noting that the resident was a new admit and the facility was waiting for pharmacy delivery. The delay in receiving lorazepam was due to a series of communication and procedural errors between the facility and the pharmacy. The pharmacy received the prescription but had the resident profiled under independent living rather than the skilled nursing facility, resulting in a lack of necessary allergy information and confusion about the resident's location. Additionally, the pharmacy could not release lorazepam from the emergency medication box because the available formulation (0.5 mg) did not match the physician's order (1 mg or 2 mg), and regulations required an exact match between the prescription and the medication formulation in the E box. As a result of these failures, the resident missed four doses of lorazepam and subsequently experienced a seizure, requiring transfer to the hospital. Documentation from the hospital confirmed that the resident had missed several doses of her chronic lorazepam regimen for unclear reasons, and the facility's records indicated that the medication was delivered only at the time the resident was experiencing a medical emergency and was unable to swallow.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which has the potential to affect 89 of 91 residents who received meals and beverages prepared in and served from the facility's kitchen. During an initial kitchen tour, surveyors observed trash, food debris, dust, dirt, and a greasy blackish-brown substance on the floors, underneath the dishwasher, freezer, cooler, and shelving. This substance was also found on the legs and feet of equipment, and underneath freestanding coolers, freezers, the range, ovens, prep tables, and shelving. Additionally, the commercial juice machine had water lines stained with a brownish-red substance, and the drip tray and spout covers were stained with a reddish substance. The 3-compartment sink's grease interceptor box was covered in food debris and a brownish greasy substance. Interviews with the Certified Dietary Manager (CDM) and Cook1 revealed that the kitchen floors were supposed to be cleaned twice daily, as outlined in the kitchen's Utility Cleaning Schedule. However, despite these cleaning efforts, the floor remained dirty, with debris and stains still visible underneath the kitchen equipment. The CDM stated that the juice machine vendor was responsible for cleaning the internal parts of the machine, while facility staff were to clean the drip pan daily. The Administrator acknowledged the concerns and suggested that meal delivery carts might be contributing to the dirt and debris in the kitchen, but also noted that the kitchen could benefit from a deep cleaning.
Resident Excluded from Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a resident was included in the development and implementation of their person-centered care plan. The facility's policy requires the Interdisciplinary Team (IDT) to develop and implement a comprehensive care plan in conjunction with the resident and their family or legal representative, ensuring the resident is informed of their right to participate and is given advance notice of care plan conferences. However, there was no documented evidence that the resident attended care plan meetings on two occasions, despite being cognitively intact with a perfect BIMS score. The resident confirmed not being invited to recent care plan meetings, and the Social Services Director acknowledged that inviting the resident had been overlooked.
Resident Privacy Breach During Medication Administration
Penalty
Summary
The facility failed to maintain the personal privacy of a resident during medication administration. The resident, who was admitted with diagnoses including sarcopenia and osteoarthritis, was observed receiving a Lidocaine 4% pain patch at the nurses' station. During this process, the LPN pulled the resident's shirt over her shoulder, exposing her shoulder and upper chest area in the presence of a male cognitively impaired resident, three staff members, and a visitor. The LPN did not offer the resident the option to return to her room for the application of the pain patch. Interviews conducted with the LPN and the Director of Nursing confirmed that the resident's privacy was not maintained during the procedure. The LPN acknowledged that the resident should have been taken back to her room for the application of the pain patch. The Director of Nursing also confirmed that the nurse's actions violated the resident's dignity and privacy, as outlined in the facility's policy on dignity, which emphasizes the protection of resident privacy during personal care and treatment procedures.
Failure to Provide Written Bed Hold Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to a resident and their responsible party during a hospitalization event. The resident, who was admitted with acute respiratory failure and dysphagia, was diagnosed with COVID-19 and transferred to a hospital. Despite the spouse's verbal request for a bed hold, there was no documented evidence in the electronic medical record (EMR) that written information regarding the facility's bed hold policy was provided to the resident or their representative. Interviews with facility staff revealed inconsistencies in the process of notifying residents and their representatives about the bed hold policy. The Social Services Director indicated that nurses verbally informed families, while the Administrator and Unit Manager mentioned that a copy of the bed hold policy was included in the discharge packet. However, the Assistant Director of Nursing confirmed that unless documented, there was no evidence that the resident or representative received the written notification. The facility's policy requires that written information about the bed hold policy be provided at least twice, including at the time of transfer, which was not adhered to in this case.
Inaccurate MDS Assessment for Resident Receiving Oxygen Therapy
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident, identified as R22, out of 25 sampled residents. R22 was admitted with diagnoses including congestive heart failure and shortness of breath and was ordered to receive continuous oxygen therapy at two liters via nasal cannula. However, the admission MDS, with an Assessment Reference Date of 09/29/24, did not document the resident's continuous oxygen therapy in Section O, which is designated for Special Procedures, Treatments, and Programs. This oversight was confirmed during an interview with the MDS Coordinator, who reviewed the resident's physician orders and treatment records and acknowledged the omission in the MDS documentation.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise care plans for three residents, which could potentially affect the care provided to them. For one resident, the care plan was not updated to include continuous oxygen therapy, despite physician orders indicating its necessity and observations confirming its use. Another resident's care plan was not revised following an incident where the resident wandered into a female resident's room and exhibited inappropriate behavior. Although the facility conducted an investigation, the care plan did not reflect the incident or any interventions to prevent future occurrences. Additionally, a third resident's care plan was not updated to include the use of a urinary catheter, which was necessary due to urinary retention. Interviews with facility staff, including the MDS Coordinator, ADON, and DON, revealed that it was expected for nurses to update care plans as needed. The facility's policy also emphasized the importance of revising care plans when there are changes in a resident's condition. However, these expectations were not met, leading to deficiencies in the care planning process.
Failure to Increase Assessment Frequency for COVID-19 Positive Resident
Penalty
Summary
The facility failed to increase the frequency of assessments for a resident diagnosed with COVID-19, which was a deficiency identified during a survey. The resident, who was admitted with acute respiratory failure and dysphagia, tested positive for COVID-19 during outbreak testing. Despite an order to monitor vital signs and symptoms daily, the facility did not document these assessments consistently during the resident's isolation period. Specifically, there was no documented evidence of assessments, including vital signs and lung sounds, on several days within the ten-day isolation period. Interviews with facility staff, including an LPN, the Infection Preventionist (IP), and the Director of Nursing (DON), revealed that there was an expectation for nurses to complete and document COVID-19 assessments every shift for residents with COVID-19. However, the resident's electronic medical record showed less than daily documentation of these assessments. The facility's policy required increased clinical monitoring for residents with confirmed COVID-19, but this was not adhered to, leading to the deficiency.
Inadequate Supervision of Resident with Wandering Behavior
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as R65, who was admitted with diagnoses including cognitive communication, dementia, anxiety disorders, and altered mental status. R65 was assessed to have severely impaired cognitive skills for daily decision-making, with a BIMS score of 00. Despite this, the facility did not document any wandering behaviors during the initial assessment period. However, an incident occurred where R65 wandered into a female resident's room at night, pulled down his pants, and sat on a chair next to her bed. The female resident, upon waking, took pictures and called for nursing staff, but R65 had returned to his room by the time they arrived. The female resident reported no physical contact and expressed a desire for R65 not to enter her room again. The facility's investigation into the incident revealed a lack of documented evidence that R65's care plan was revised to address his wandering behavior. There were no interventions identified or implemented to protect R65 or other residents from potential harm. Interviews with the Social Services Director, Medical Director, and Assistant Director of Nursing indicated a lack of documentation and clarity on the interventions discussed or implemented following the incident. The facility's policy on incident/accident reports was not effectively utilized to analyze and address individual resident vulnerabilities, contributing to the deficiency in supervision and safety measures for R65 and other residents.
Failure to Provide Appropriate Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a urinary catheter. The resident, who was admitted with diagnoses including urinary tract infection, hydronephrosis, urinary retention, and chronic kidney disease, did not have physician orders for the use of a urinary catheter transcribed into their monthly orders. Additionally, the resident's care plan was not updated to reflect the presence of the urinary catheter. Observations revealed that the urinary drainage bag and tubing were placed directly on the floor, which could inhibit proper urine flow. Interviews with facility staff confirmed that the discharge orders for the urinary catheter were not transcribed to the resident's monthly orders, and the care plan was not revised accordingly. The LPN involved acknowledged the oversight and indicated a misunderstanding regarding the transcription of orders and care plan updates. This lack of proper documentation and catheter management had the potential to contribute to the resident's risk of developing reoccurring urinary tract infections.
Failure to Administer Oxygen at Prescribed Levels
Penalty
Summary
The facility failed to administer oxygen at the physician-prescribed dose for two residents, leading to potential respiratory distress. Resident 9, who was admitted with pneumonia, COPD, and chronic respiratory failure, had a physician order for oxygen at 3 liters per minute (LPM) via nasal cannula. However, observations revealed the oxygen concentrator was set incorrectly at 4.5 LPM and later at 2 LPM. The Medical Director confirmed the importance of maintaining the prescribed oxygen level due to the resident's risk of hypoxia. Licensed Practical Nurse (LPN) 1 acknowledged the discrepancy and suggested that another staff member might have changed the settings by mistake. Resident 22, admitted with congestive heart failure and shortness of breath, was prescribed continuous oxygen therapy at 2 LPM. Observations showed the oxygen was set at 3 LPM, and the oxygen concentrator's filter was clogged with dust. The Medical Director emphasized the need for oxygen to be delivered according to the physician's orders and for any changes to be communicated to the physician. The LPN Supervisor confirmed that nurses were responsible for maintaining the oxygen concentrator's cleanliness and ensuring the correct oxygen settings.
Failure to Document End Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to document an end date for a PRN psychotropic medication for one resident, which was identified during a review of unnecessary medications. The resident, who was admitted with diagnoses of anxiety, depression, and bipolar disorder, had an order for clonazepam 0.5mg every 24 hours as needed for anxiety, but the order lacked an end date. This oversight was confirmed during interviews with the resident, who reported infrequent use of the medication, and with staff members, including an LPN and a Unit Manager, who acknowledged the absence of a 14-day end date or a documented rationale for extending the order. The facility's policy on psychotropic medication use requires PRN orders to have a 14-day limit unless a rationale for extension is documented. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed the expectation for PRN psychotropic medications to have a 14-day end date or a documented rationale for extension. The failure to adhere to this policy had the potential for residents to receive psychotropic medications without ongoing assessment by a physician or practitioner for continued appropriateness.
Medication Cart Security and Expired Supplies
Penalty
Summary
The facility failed to secure a medication cart on the second floor, which was observed to be unlocked and unattended for nearly ten minutes. The cart contained insulin pens, over-the-counter medications, and a locked narcotic box. During this time, a resident with severe decision-making impairments and a tendency to wander was nearby, posing a potential hazard. Licensed Practical Nurses (LPNs) 4 and 5, who were sharing the cart, were unaware of its unlocked state, acknowledging the risk it posed to the resident. Additionally, an inspection of the second-floor medication storage room revealed expired supplies, including hypodermic needles, syringes, extension sets, nutritional supplements, and various dressings. The LPN Supervisor admitted to attempting weekly inspections but had missed these expired items. The facility's policies on medication cart security and medication storage and labeling were reviewed, highlighting the requirement for carts to be locked when not in use and for expired medications to be managed according to pharmacy instructions.
Failure to Prevent Resident Elopements Due to Inadequate Supervision and Unsafe Environment
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for three residents identified as at risk for wandering and elopement. Each of these residents had documented cognitive impairments, including dementia and severe cognitive deficits, and were assessed as high risk for elopement upon admission or following incidents. Despite care plans and physician orders for interventions such as wander-guards and frequent checks, the residents were able to exit the facility unsupervised on multiple occasions. In each case, staff were unaware that the residents had left the building until notified by visitors, other staff, or by finding the residents outside. One resident with a history of dementia and unsteadiness was found outside the facility by a visitor, prompting a reassessment and the application of a wander-guard. Another resident, also with dementia and severe cognitive impairment, eloped twice within a short period. On one occasion, the resident was found in the parking lot, and on another, near a busy roadway. Staff interviews revealed that alarms were sometimes disarmed by non-nursing staff or family members, and that signage intended to restrict alarm disarming to nursing staff was not consistently posted. Additionally, the resident was able to remove her own wander-guard using scissors found in her room, further compromising her safety. A third resident, initially assessed as not at risk for elopement, was later found outside the building by a speech therapist after being reported by a visitor. This resident was subsequently reassessed as high risk and provided with a wander-guard. Observations during the survey revealed that certain doors between the healthcare and independent living areas were routinely left open, and that alarms could not be heard at a distance, allowing residents to exit undetected. Staff interviews confirmed a lack of awareness regarding the residents' whereabouts at the time of the elopements, and documentation of frequent rounding was not maintained.
Failure to Report Elopements as Neglect
Penalty
Summary
The facility failed to recognize and report three separate elopement incidents involving three residents as allegations of neglect, as required by their own policy and state law. The incidents occurred on multiple dates, with each resident leaving the facility premises. Despite the facility's policy stating that any suspicion of abuse, neglect, exploitation, or misappropriation must be reported immediately to the administrator and state agency, the facility did not report these elopements. Record review showed that the last elopement reported to the State Agency was in the previous year, and interviews with facility staff confirmed that the incidents were not reported due to a misunderstanding of what constitutes an elopement and uncertainty about reporting requirements.
Failure to Provide Required Behavioral Health Training to Staff
Penalty
Summary
The facility failed to ensure that seven out of ten reviewed staff members completed the required Behavioral Health training as determined by the facility assessment. Review of employee training records showed that a receptionist, an RN, three CNAs, an LPN, and another staff member did not have evidence of completing this training, despite being hired between November 2021 and October 2023. During an interview, the Executive Director confirmed that these staff members had not received the required training. These findings were discussed with facility leadership during the exit conference.
Failure to Investigate Resident Elopement
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving one resident who eloped from the facility. According to the facility's policy, all allegations of abuse, neglect, exploitation, or misappropriation are required to be thoroughly investigated. On 7/11/24, a progress note documented that the resident had eloped. When surveyors requested investigative documents related to this incident, the Director of Nursing confirmed that no such documents existed for the resident's elopement. This lack of investigation was confirmed during the exit conference with facility leadership.
Failure to Provide Required QAPI Training to Staff
Penalty
Summary
The facility failed to ensure that mandatory Quality Assurance and Performance Improvement (QAPI) training was completed for six out of ten staff members reviewed. Employee training records showed no evidence that a registered nurse, a licensed practical nurse, three certified nursing assistants, and one other staff member received the required QAPI training, despite being hired between November 2021 and October 2023. During an interview, the Executive Director confirmed that these staff members had not received the necessary training. These findings were reviewed with facility leadership during the exit conference. No information regarding residents, their medical history, or their condition at the time of the deficiency was provided in the report.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 397 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Newark
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Newark Manor Nursing Home | 2.2 mi | ★★★★★ | 7 | 0 |
| Pike Creek Nursing & Rehabilitation Center | 3.2 mi | ★★★★★ | 6 | 0 |
| Jeanne Jugan Residence | 3.7 mi | ★★★★★ | 4 | 0 |
| Cadia Rehabilitation Pike Creek | 3.8 mi | ★★★★★ | 3 | 0 |
| Excelcare At Newark Llc | 4 mi | ★★★★★ | 12 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.