Encore At West Meadow
Inspection history, citations, penalties and survey trends for this long-term care facility in Newark, Delaware.
- Location
- 255 Possum Park Road, Newark, Delaware 19711
- CMS Provider Number
- 085021
- Inspections on file
- 21
- Latest survey
- October 29, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Encore At West Meadow during CMS and state inspections, most recent first.
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.
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.
Latest citations in Delaware
Multiple cognitively impaired residents with known behavioral issues, including wandering, agitation, and physical aggression, were not adequately protected from resident‑to‑resident abuse. In one case, a resident with dementia and PTSD was pushed to the floor by another resident who had a history of combative behavior, resulting in multiple fractures and facial lacerations after staff initially documented the event as an unwitnessed fall. In another case, two residents with dementia and psychotic features engaged in a physical altercation in a dayroom after one placed his hand on the other’s chest, leading to mutual punching. A separate incident occurred when a resident with dementia and behavioral disturbances entered another resident’s room, pulled at the bedcovers, yelled that the room was his house, and allegedly struck the other resident, who was later noted with puffiness around one eye. In all incidents, the involved residents had documented behavioral care plans and significant cognitive impairment, yet physical confrontations still occurred.
A resident with dementia, spinal stenosis, and total dependence for transfers, care-planned for Hoyer lift use with two-person assist, was being transferred from a shower bed to a Geri-chair when the Hoyer lift tipped sideways. Staff reported the lift’s legs had been widened and that one CNA manually pushed the feet apart instead of using the control, and straps may have been unevenly positioned. The resident was lowered to the floor while still in the sling and sustained a small skin tear to the elbow; imaging later showed no fractures. The DON stated that three CNAs were involved, including one on light duty who was not supposed to be using the lift, and that no mechanical defect was found with the lift.
The facility failed to thoroughly investigate several allegations of verbal and potential physical abuse involving four cognitively intact residents with conditions including hemiplegia, rheumatoid arthritis, type 2 DM, epilepsy, and heart disease. In each case, the facility’s investigations were limited, often including only the directly involved resident and omitting interviews with other potentially knowledgeable residents or staff. One resident reported a verbal altercation with a CNA after a fall to the floor, another reported being verbally abused by a roommate’s family member, a third reported a male CNA was too rough and upset while changing linens, and a fourth reported a staff member insulted her and refused brief care. Investigation files lacked broader resident and staff interviews, timely physical and psychosocial assessments, and review of the accused staff member’s employee record, contrary to the facility’s abuse policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
A resident with rectal cancer and intact cognition reported that an RN on night shift confronted him when he returned from smoking off campus, spoke to him loudly about his smoking, used profanity, and threatened to have staff refuse to buzz him back into the building. A CNA corroborated that the RN was upset about being called in to work and used curse words toward the resident, but did not report the incident at the time because the RN was the night supervisor. The resident reported the event to the Social Services Director the next day, yet the facility initially treated it as a grievance rather than abuse and delayed submitting a report to the State Survey Agency until weeks later, after determining it was a reportable abuse incident.
Two residents did not receive required ADL and hygiene care as care planned. One resident with dementia and osteoarthritis, dependent for toileting and personal hygiene, was not toileted during an evening shift, with CNA documentation showing no toileting and the oncoming CNA finding the resident’s clothing, linens, and mattress saturated with urine; the assigned CNA reported care resistance but did not notify an RN or LPN. Another resident with dementia and stroke, requiring assistance with dressing and personal hygiene, remained in bed in pajamas into the afternoon without having received morning care, despite CNA documentation indicating dressing was completed; the CNA later confirmed that care was only provided after being questioned by an RN supervisor following a family complaint.
A resident with left-sided weakness after a stroke, high fall risk, and total dependence for ADLs and bed mobility was being turned onto their side for peri care by an aide when they fell from the bed to the floor, sustaining head trauma and a scalp laceration while on blood thinners. The care plan required extensive to total assistance with two-person support for bed mobility, but the fall occurred during care without documentation of the required level of assistance, indicating the facility did not provide adequate supervision and assistance to prevent accidents as outlined in its own fall prevention practices.
A resident with significant upper extremity weakness and recent surgery was discharged home to a multi-story residence without confirmed DME delivery, home health services, or caregiver support. Although referrals for home health, skilled nursing, and DME were made and family attended a discharge care plan meeting, staff did not verify that services were active, did not set or confirm a start-of-care date with the agency, and did not confirm delivery of a hospital bed. The resident, who lived alone and could not manage fine motor tasks, arrived home without in-home assistance, reported difficulty with eating and self-care, and was later found by an HHA RN in unsafe conditions, unable to access food or medications, leading to emergency transport back to the hospital.
A resident with dementia, Parkinson’s disease, CHF, and a history of AKI had documented fluid goals and was identified as at risk for dehydration and malnutrition, yet daily intake records repeatedly showed fluid consumption well below the recommended amounts. Despite severely impaired cognition, poor oral intake, and documented changes in mentation, lethargy, falls, and restlessness, the facility did not consistently implement or document enhanced monitoring, assistive feeding measures, or timely provider consultation focused on hydration. The resident was hospitalized twice with AKI, dehydration, hypotension, and anemia, and staff interviews confirmed that while expectations existed to encourage fluids and notify providers when goals were not met, there was no clear evidence that these expectations were carried out for this resident.
A resident with cardiac conditions was discharged home with a documented post-discharge plan for home health aide, home health RN/LPN, and PT/OT, but the facility did not complete the home health referral before discharge. The resident went home with a family member and, according to a complaint, did not receive PT, OT, or a nursing wellness check for about a week. The SW later confirmed the referral for home health and therapy services was not requested until several days after discharge, and services did not begin until even later, despite therapy recommendations that are typically communicated to social services to arrange home care.
The facility failed to consistently revise care plans to reflect residents’ current needs and behaviors and did not ensure a cognitively intact resident was involved in ongoing care planning. One resident participated in an initial care conference but was not included in later care plan updates. Another resident with an order for a palm protector was frequently observed without it and often refused it, yet the care plan did not address refusals. Two cognitively impaired residents whose MDS assessments showed dependence for bathing had care plans that still listed only setup or one‑person assist. A cognitively impaired resident with combative behaviors and an incident of striking another resident had a behavior care plan that was not updated to include attempts to hit other residents or the risk of resident‑to‑resident altercations.
Failure to Prevent Resident‑to‑Resident Physical Abuse Among Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from resident‑to‑resident physical abuse. One resident with dementia, agitation, depression, anxiety, and PTSD, and a BIMS score indicating moderate cognitive impairment, was pushed to the floor by another resident after that resident entered his room and followed him into the hallway. Staff initially documented the event as an unwitnessed fall after hearing loud screaming and finding the resident on the floor with complaints of right shoulder and left wrist pain, active bleeding from facial lacerations, and clamminess. Subsequent review of surveillance footage showed that another resident walked into the victim’s room, then followed him out and pushed him, causing the fall that resulted in multiple fractures, including a closed left distal radius fracture, a closed, displaced comminuted right proximal humerus fracture, and a closed, displaced distal clavicle fracture. The resident who pushed him had dementia with mood disturbances, bipolar disorder with psychotic features, PTSD, insomnia, and depression, and a BIMS score indicating severe cognitive impairment. His care plan identified a behavior problem related to bipolar disorder and dementia, including wandering, refusal of care, and physical aggression toward staff and others, such as biting a CNA and swinging a walker at a CNA. The care plan directed staff to anticipate and meet his needs, divert him with alternative objects or activities, intervene to protect the rights and safety of others, and conduct safety checks. Despite these identified risks and interventions, he was able to enter another resident’s room and subsequently push that resident in the hallway, resulting in serious injury. Another incident involved two residents with significant cognitive impairment and behavioral symptoms, including delusions, physical behaviors toward others, agitation, and a tendency to invade others’ personal space. One resident, who was described as aggressive toward others, easily agitated, and prone to getting into others’ personal space, walked next to another resident sitting in a dayroom chair and placed his hand on that resident’s chest. The seated resident responded by punching him in the face with the back of his fist, and the first resident then punched back. Staff and psychiatric documentation noted this altercation and ongoing behavioral concerns such as combativeness with care, agitation, and wandering, but the record contained no additional progress notes describing the incident itself beyond the brief psychiatric follow‑up entry. A further incident occurred when a resident with anxiety, major depressive disorder, dementia with behavioral disturbances, agitation, and severe cognitive impairment entered another resident’s room on the memory care unit. The resident in the room, who had depression, anxiety, dementia without behavioral disturbances, PTSD, insomnia, hallucinations, verbal behaviors toward others, other behavioral symptoms, and wandering, reported that he was hit in the face. Staff heard yelling and found the intruding resident pulling covers at the foot of the bed and yelling that the room was his house, while the other resident sat on the side of the bed and stated that he had been hit and told staff to get a gun and shoot the other resident. Slight puffiness was noted around the reporting resident’s left eye. The intruding resident’s care plan documented compulsiveness, invading others’ personal space, yelling, restlessness, physical aggression, and attempts to assist other residents he believed needed help, with interventions to divert him, familiarize him with his surroundings, and intervene to protect the rights and safety of others. Despite these identified behaviors and interventions, he was able to enter another resident’s room, engage in a confrontation, and allegedly strike the resident.
Resident Injury from Improper Hoyer Lift Operation During Transfer
Penalty
Summary
The deficiency involves the facility’s failure to prevent an accident during a Hoyer lift transfer, resulting in a fall and skin tear injury to a resident. The resident had diagnoses including spinal stenosis, Alzheimer’s disease, vascular dementia with behavioral disturbance, bipolar disorder, and pain, and was documented on the MDS as dependent on staff for transfers from bed to chair. The care plan and physician orders specified that the resident required a Hoyer lift with assistance of two staff for transfers. On the day of the incident, the resident was being transferred via Hoyer lift after a shower, from a shower bed back to a Geri-chair. Progress notes and the post-fall evaluation documented that the fall occurred in the bathroom during a Hoyer transfer with staff assistance of two, and that the Hoyer lift tipped sideways. The resident was found on the floor in the sling, with staff reporting that the Hoyer lift’s legs were widened and that as the resident was being positioned over the chair, the lift tipped to the side. Staff held the sling on each side of the resident’s head and lowered the resident to the floor, after which a skin tear measuring 1.0 cm x 0.1 cm was noted on the elbow. The facility’s investigation determined that the Hoyer tipped because one CNA pushed the lift’s feet apart manually instead of using the designated button to open the legs. Interviews indicated that the manual mechanical lift used at the time was considered less steady and required manual operation of a foot pedal to open the legs, and that the straps may have been more to one side than the other. The DON reported that three CNAs were involved with operating the lift at the time of the incident, including one CNA on light duty who was not supposed to be using the Hoyer lift, and that the lift itself was later found to have no mechanical problems. As a result of the tipping incident, the resident sustained a skin tear to the elbow and required diagnostic imaging to rule out fractures.
Incomplete Investigations of Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of verbal or potential physical abuse as required by its abuse, neglect, and exploitation policy. One cognitively intact resident with hemiplegia following a stroke reported a verbal altercation with a CNA after sliding to the floor while being assisted back to bed. The resident requested use of a Hoyer lift, the CNA told him he could get himself up, and an argument ensued in which the CNA told the resident it was not his room and did not leave until directed by an LPN. The facility’s investigation file for this incident contained only the resident’s interview and no interviews with other residents on the unit who might have had knowledge of similar verbal abuse by the CNA. Another cognitively intact resident with rheumatoid arthritis, hypertension, and peripheral vascular disease reported that her roommate’s daughter came into her room and verbally abused her after the roommate had been relocated due to aggression. The daughter allegedly cursed at the resident, calling her an offensive name and telling her she was going to hell. The investigation file for this incident contained no interviews with other residents on the unit to determine whether they had experienced verbal abuse by this family member or had knowledge of the event. The DON acknowledged that no such interviews were conducted. A third cognitively intact resident with type 2 diabetes and epilepsy reported, through her daughter, that a male CNA wearing a red shirt was too rough with her and appeared upset about having to change her linens. The facility’s investigation into this potential staff-to-resident abuse included an interview with the resident but did not include interviews with other interviewable residents in the same area who might have had knowledge of the incident. A fourth cognitively intact resident with type 2 diabetes and heart disease, later discharged, reported that a staff member entered her room, called her a poor excuse for a human being, and refused to assist with changing her brief. The investigation documentation for this allegation lacked interviews with additional residents or staff, did not show that the resident was promptly assessed physically and psychosocially in relation to the allegation, and did not include a review of the accused staff member’s employee record, resulting in an incomplete investigation contrary to facility policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
Failure to Protect Resident From Verbal Abuse and Delay in Reporting Incident
Penalty
Summary
The facility failed to protect a cognitively intact resident from verbal abuse by a staff member. The resident, admitted with rectal cancer and independently ambulatory with a rolling walker, reported that during an overnight shift he left the campus to smoke and, upon returning and walking toward the nursing station, was confronted by an RN. According to the resident’s report, the RN told him that when she was on the night shift he was not allowed to go outside, using profanity toward him, and further stated that if he went out the door she would instruct staff not to buzz him back into the building. A CNA later confirmed that the RN had been upset about being called in to work, spoke loudly to the resident about his smoking, and used curse words when he responded to her. The incident was not promptly reported to facility administration despite occurring during the night shift, with the CNA stating that the RN involved was the supervisor at the time. The resident reported the incident the following day to the Social Services Director, but the facility did not immediately recognize or treat the allegation as reportable abuse. Instead, the administration initially considered it a grievance and investigated it in that manner. The incident report was not submitted to the State Survey Agency until several weeks after the resident’s report, and only after the facility later determined that the event constituted a reportable abuse incident.
Failure to Provide Required ADL and Hygiene Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL assistance to maintain grooming and personal hygiene for two dependent residents. One resident with dementia, osteoarthritis, and moderately impaired cognition was care planned to receive partial to substantial assistance with personal and oral care, scheduled toileting every two hours, and assistance with toilet transfers. CNA documentation for an evening shift showed “N/A” for all scheduled toileting times, and a facility incident report stated that the CNA assigned to this resident failed to provide incontinence care during that shift. The oncoming night-shift CNA later found the resident’s clothing, linens, and mattress saturated and soaked with urine and provided the needed care, with the prior-shift LPN confirming the condition when notified. The assigned CNA reported the resident was resistant to care but did not notify the LPN or RN for assistance or document the issue. The second resident, with dementia, stroke, weakness, and moderately impaired cognition, was care planned for an ADL self-care deficit requiring setup or cleanup assistance with eating, partial to substantial assistance with personal hygiene and oral care, and substantial assistance with toileting, showering/bathing, and lower body dressing. On a morning shift, the resident’s daughter-in-law reported to the LSW that she did not believe the resident had received morning care because he was still in bed wearing pajamas and had not yet received his lunch tray. A CNA statement indicated the resident had eaten breakfast and was later found asleep in bed, and CNA documentation for that shift showed the dressing task as completed. However, the facility’s follow-up summary documented that the CNA confirmed care had not been provided to the resident prior to being questioned by the RN supervisor, and the LSW confirmed that the CNA changed the resident only after the family reported the concern and nursing was notified.
Failure to Provide Adequate Supervision and Assistance During Bed Mobility for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for a resident with significant functional and cognitive impairments. The resident was admitted with left-sided weakness after a stroke and was care planned as extensively to totally dependent for bed mobility, requiring the support of two persons. A fall risk evaluation documented a score of 10, indicating high fall risk, and a quarterly MDS assessment showed the resident was unable to participate in a cognitive assessment and was completely dependent on staff for all ADLs. Despite these identified needs and risks, the resident was being turned onto their side for peri care by an aide when they fell from the bed to the floor. During this incident, the resident sustained head trauma and a small scalp laceration, and was on blood thinners at the time of the fall. The fall occurred while the aide was providing peri care and turning the resident, but the report does not document the presence of a second staff member, despite the care plan indicating the need for two-person assistance for bed mobility. The facility’s own policy on falls emphasized instituting individualized practices to minimize fall risk and maximize safety for residents identified as high risk, but the resident’s documented high fall risk and total dependence were not adequately addressed in the supervision and assistance provided at the time of the fall.
Failure to Ensure Safe Discharge with Confirmed Home Services and Support
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s discharge home included confirmed durable medical equipment (DME), home health services, and adequate caregiver support. The resident was admitted with spinal stenosis, cervical disc disorder, muscle weakness, carpal tunnel syndrome, and a recent post-fasciotomy to the right arm, and was documented as cognitively intact with a BIMS score of 14/15. Despite these physical limitations, the facility discharged the resident home in the evening via medical transport to a three-story residence, where no caregiver support was present. The facility’s own policy required a post-discharge plan of care developed with the resident and representative, and orientation to ensure a safe and orderly transfer or discharge, but the record lacked evidence that services were confirmed as in place prior to discharge. Prior to discharge, the social worker documented that the resident would have a safe discharge home with services and supports in place, and that referrals for home health care, skilled nursing services, and DME had been made, with family members in attendance at the discharge care plan. However, the clinical record did not contain confirmation that these services were actually arranged and active before the resident left the facility. The resident was discharged with medications called to the pharmacy for home delivery, but there was no documentation that the hospital bed had been delivered or that home health nursing, therapy, or home health aide services were scheduled to start at the time of discharge. The social worker later acknowledged not informing the agency of a specific start-of-care date, assuming the agency and VA would contact the resident, and confirmed not calling to verify delivery of the hospital bed. After discharge, it was discovered that the hospital bed ordered days earlier was not delivered until the morning after the resident arrived home, and that therapy, RN, and HHA services had not yet begun or contacted the resident by the time the facility followed up. The resident reported living alone, being unable to use their hands, needing a caretaker, and having to rely on a sister-in-law for limited assistance with hygiene, meals, and rearranging furniture for the bed that arrived later. The significant other confirmed that no one lived with the resident, that they had their own health issues, and that neither they nor their son stayed with the resident after discharge. When a home health RN eventually visited, the resident was found sitting on a couch in minimal clothing, reporting not having eaten adequately for two days, having little or no accessible food, and being unable to open medications or bottles due to impaired fine motor skills. The RN observed the resident’s inability to grip or perform fine motor tasks, assisted with toileting, and then contacted the agency director and emergency services due to the unsafe conditions in which the resident had been left. These events led surveyors to determine that the facility failed to ensure services and caregiver support were in place prior to discharge, resulting in an immediate jeopardy situation.
Removal Plan
- Audited discharge documentation related to home health services, appropriate caregiver/family support, and any necessary services to meet residents' care needs to determine if any residents were affected.
- Reviewed planned discharges by the Administrator, DON, Director of Social Services, and Director of Rehabilitation to ensure home health services, appropriate caregiver/family support, and necessary services to meet the resident's care needs are in place before discharge.
- Completed a root cause analysis identifying failure to have a robust discharge care plan meeting with the interdisciplinary team (IDT), resident, and resident representative.
- Reviewed the procedure for safe and effective discharge planning with the IDT.
- Re-educated the discharge planning IDT on the discharge policy and procedure to ensure sufficient preparation and orientation for a safe discharge.
- Implemented review of residents scheduled to be discharged to ensure appropriate discharge planning is in place.
- Implemented review of residents scheduled for discharge to ensure ADL support is in place, durable medical equipment is available prior to or on the discharge date, medications are available upon discharge, and identified needs/support are available.
- Implemented review of residents scheduled for discharge to ensure safe discharge planning is in place and to address any issues identified.
- Implemented oversight during utilization review by the NHA/designee to ensure discharge planning preparation and services are in place prior to discharge.
- Initiated audits and educational in-services to the IDT team and conducted staff interviews to confirm education received regarding discharge to the community and/or transfers to other facilities.
Failure to Maintain Adequate Hydration Resulting in Recurrent AKI and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate hydration for a resident with significant medical conditions, including acute kidney injury (AKI), congestive heart failure (CHF), dementia, and Parkinson’s disease. Upon admission, the resident’s care plan identified potential for altered nutrition and included interventions such as assisting at meals, encouraging oral fluids, and monitoring for additional nutrition interventions. A nutrition assessment established an initial fluid goal of 1943–2098 mL/day and documented that the resident was at risk for dehydration and malnutrition, with early labs showing a BUN of 29, creatinine of 1.4, and eGFR of 53. The admission MDS documented that the resident was severely cognitively impaired and required setup assistance for feeding and hydration. Daily fluid intake records from CNA task flow sheets and the MAR showed that the resident’s intake frequently fell below the recommended fluid goals, with multiple days of intake under 1200 mL and some days as low as 360–720 mL. A malnutrition risk assessment identified the resident as at risk for malnutrition due to severe dementia and tremors. A subsequent nutrition note on 5/12/25 documented that the resident’s average fluid intake was 330 mL/day, recommended discontinuing a prescribed hydration pass due to CHF, and set a new fluid goal of 1635–1766 mL/day, while continuing to recommend encouraging oral fluids. Despite these documented risks and low intakes, there is no evidence in the record of intensified monitoring or additional interventions to ensure the resident met the revised fluid goals. The resident experienced multiple clinical deteriorations associated with poor intake and changes in condition. On 6/1/25, after a day with only 360 mL of recorded intake, the resident was transferred to the hospital following falls, hypotension, and confusion, and was admitted with AKI and dehydration. After readmission to the facility, nursing documentation noted low oral intake and a plan to discuss adding the resident to an assist-to-feeding list, but the record lacked evidence that this occurred. Subsequent notes documented lethargy, increased confusion, agitation, restlessness, and continued poor intake, yet a physician progress note following two unwitnessed falls did not include an assessment of hydration status or interventions to improve hydration. On 6/19/25, labs showed a BUN of 62 mg/dL and creatinine of 1.7 mg/dL, and the resident was again sent to the hospital and admitted with AKI, hypotension, and anemia, requiring IV fluid resuscitation. Staff interviews confirmed expectations to monitor intake, encourage fluids, and notify providers when fluid goals were not met, but there was no documentation that the provider was consistently notified or that appropriate interventions were implemented in response to the resident’s ongoing inadequate fluid intake and changes in condition.
Failure to Arrange Timely Home Health Services Prior to Discharge
Penalty
Summary
The facility failed to ensure a timely referral for home health care services prior to discharge for one resident. Facility policy dated 5/1/25 required sufficient preparation and orientation to residents to ensure an orderly transfer or discharge. The resident was admitted on 7/28/25 with diagnoses including aortic valve replacement, aortic regurgitation, and congestive heart failure. A discharge summary dated 8/11/25 documented a post-discharge plan for home health aide, home health RN/LPN, and occupational and physical therapy. The resident was discharged home with a family member on 8/12/25. A complaint received by the Division on 9/30/25 stated that the resident was discharged to a family member's home without a home health care agency referral and that, after one week at home, the resident had not received any physical or occupational therapy or a wellness check from a nurse. During an interview on 2/16/26, the social worker reported needing to check if a referral was made and later confirmed that the referral for home health and therapy services was not requested until 8/15/25, with services opened on 8/20/25. The director of therapy confirmed that physical and occupational therapy were recommended for the resident and stated that such recommendations are typically communicated to social services to set up home care. Findings were reviewed with facility leadership during the exit conference.
Failure to Revise Care Plans and Involve Resident in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise person‑centered care plans and to involve a cognitively intact resident and/or representative in the care planning process. One resident with an intact BIMS score of 15 was admitted and had a documented care conference shortly after admission, but there was no evidence of any subsequent care conferences during the following year despite multiple care plan updates. The resident reported not recalling quarterly care plan meetings, and staff confirmed that no care conferences occurred after the initial one, with no documentation that the resident or representative participated in the later care plan revisions. Additional residents’ care plans were not revised to reflect current, individualized needs and behaviors. One resident had a physician’s order for a right palm protector or substitute, was repeatedly observed without it in place, and routinely refused it according to nursing and CNA interviews, yet the care plan did not address potential refusals. Two cognitively impaired residents whose MDS assessments documented dependence for bathing had care plans that continued to list only setup assistance or one‑person assist, without updating to reflect full dependence. Another cognitively impaired resident with documented combative behaviors toward staff and a reported incident of striking another resident with a remote had a behavior care plan that was not revised to include the new behavior of attempting to hit other residents or the potential for resident‑to‑resident altercations.
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