Encore At Wilmington
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, Delaware.
- Location
- 2723 Shipley Road, Wilmington, Delaware 19810
- CMS Provider Number
- 085031
- Inspections on file
- 18
- Latest survey
- August 26, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Encore At Wilmington during CMS and state inspections, most recent first.
Surveyors found that the facility’s infection prevention and control program lacked a complete water management plan to address Legionella and other waterborne pathogens. During document review and interviews with the DPO and later with the NHA, DON, ADON, and regional staff, the surveyor identified that the plan did not include a description and diagram of facility water flow, did not identify potential infection sites, and did not specify prevention and treatment measures.
A resident with multiple sclerosis and dementia received two sets of pneumococcal, influenza, and COVID-19 vaccines within twelve hours due to a failure by an RN to document the initial administration in the MAR. An LPN, unaware of the earlier doses, administered the vaccines again, resulting in the resident developing a fever and requiring hospital evaluation.
A resident with a nephrostomy tube experienced multiple hospitalizations related to tube dislodgement and pain with a UTI diagnosis. Facility progress notes showed that the resident’s POA was notified of each hospital transfer, and transfer paperwork documented the hospitalizations. However, review of monthly Ombudsman reports and transfer records showed that the Ombudsman was not notified of these hospital transfers, and the resident’s name was absent from the relevant monthly Ombudsman reports. The NHA confirmed that the resident was not listed on those reports, and these findings were reviewed with facility leadership during the survey.
A resident with intact cognition was documented as always incontinent of bowel and bladder and initially dependent on staff for toileting, later changing to requiring partial to moderate assistance to get on and off the toilet with a promoted continence approach. Despite this change in toileting and transfer status, the resident’s toileting care plan was not reviewed or revised to reflect the new level of assistance and continence promotion. The NHA confirmed that the care plan had not been updated, and surveyors discussed these findings with facility and regional leadership.
Two cognitively intact residents who expressed a desire to use the toilet and reduce diaper use did not receive person-centered toileting programs despite being able to transfer with partial to moderate assistance. Care plans and MDS assessments identified incontinence and the need for toileting assessment, including 3‑day voiding diaries, but there was no evidence that the diaries were evaluated or that individualized toileting interventions were implemented. CNAs reported routinely changing both residents in bed when wet and were unaware of any toileting programs, even though one resident used a walker to stand and both were frequently or always incontinent, as documented by numerous incontinence episodes in their clinical records. The DON acknowledged that while voiding diaries were completed, toileting interventions were not put in place because the residents were incontinent on admission.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with multi-drug resistant organisms, as evidenced by the absence of EBP signage and PPE use. Additionally, urinary catheter care was inadequate, with collection bags left uncovered and in contact with the floor. Staff interviews and observations confirmed these deficiencies.
The facility failed to document the administration of pneumococcal and influenza vaccines in the medical records of several residents, despite the vaccines being recorded in the DELVAX system. Additionally, one resident was not offered an updated pneumococcal vaccine as per CDC guidelines. The Clinical Specialist acknowledged the oversight, noting that the vaccines were entered into DELVAX but not updated in the facility's EMR system.
The facility failed to maintain a dignified existence for three residents by improperly managing urinary catheter bags. One resident's catheter bag was uncovered and visible from the entrance, and another's was seen dragging on the floor. Two other residents with neurogenic bladder had uncovered urinary bags on the floor, contrary to their care plans. These deficiencies were confirmed by facility staff.
A facility failed to involve a resident in care planning and did not notify a POA about medication changes for another resident. One resident did not participate in subsequent care plan conferences after admission, and another resident's POA was not informed of medication discontinuations, with incorrect diagnoses listed. These issues were acknowledged by facility staff.
The facility failed to ensure call bells were within reach for three residents, including one with severe cognitive impairment. Observations showed call bells on the floor, inaccessible to residents who confirmed their use for assistance. This deficiency was confirmed with facility leadership.
A facility failed to provide written notification to a resident and their representative regarding a hospital transfer due to chest pain. The facility's process involved only verbal communication, resulting in the representative not receiving written notification of the transfer and its reason.
A facility failed to update a resident's assessment every three months as required. After the resident's admission and subsequent readmission following hospitalization, no further MDS assessments were conducted for over 141 days. The MDS coordinator confirmed the oversight, noting the system did not flag the resident for a quarterly assessment. This issue was reviewed with facility leadership and state ombudsmen.
The facility failed to ensure accurate assessments for two residents. One resident's MDS assessment omitted Parkinson's disease, while another's incorrectly included pneumonia as an active diagnosis. The errors were confirmed by facility staff.
A facility failed to secure the PASARR documentation for a resident admitted with Parkinson's, diabetes, and bipolar disorder. Despite attempts to locate the document, it remained missing, as confirmed by the DON. The issue was discussed during an exit conference with facility staff and state ombudsmen.
The facility failed to develop and implement person-centered care plans for two residents. One resident's care plan lacked documentation for a prescribed hand splint, while another resident's care plan and Kardex did not specify the number of staff needed for turning and repositioning, despite severe cognitive impairment and complete dependence on staff. Interviews confirmed these omissions, highlighting issues in communication and documentation.
The interdisciplinary team at a facility failed to update a resident's care plan to include dehydration after it was identified in a comprehensive assessment. Despite a care plan meeting, the electronic medical record lacked a problem for dehydration, as confirmed by the MDS Coordinator. This issue was discussed with facility leadership and a State of DE Ombudsman.
The facility did not comply with the Delaware Board of Nursing Scope of Practice by allowing LPNs to conduct admission assessments and progress notes for new residents. This was confirmed by the ADON and involved various evaluations, including the Braden scale for pressure ulcer risk. The issue was discussed in an exit conference with facility leadership and the State Ombudsman.
A resident with severe cognitive impairment and dependent on staff for grooming was observed multiple times with long, dirty fingernails, despite a care plan requiring regular nail maintenance. The resident, who was admitted with heart disease and muscle weakness, was seen feeding herself and putting items in her mouth with unclean nails. The deficiency was confirmed by facility staff and discussed during an exit conference.
A resident with severe hearing difficulties did not receive a referral for audiology services despite an order in their medical record. Staff interviews confirmed the resident's hearing issues, which led to disturbances for other residents due to high TV volume. The facility lacked documentation of any treatment or referral for the resident's hearing deficit.
The facility did not complete an annual performance review for a CNA hired in February 2023. As of July 2024, there was no documentation of a 2024 performance evaluation. This was confirmed by HR during an interview and discussed in an exit conference with facility staff and a state ombudsman.
A resident with multiple sclerosis and stroke was prescribed Clopidogrel and Protonix, both administered via G-tube. The facility failed to use the correct formulation of Protonix and did not adjust the medication schedule to prevent interactions. Despite warnings, the medications were administered too closely together, and the consultant pharmacist's reviews did not identify these issues.
A resident's medical records contained conflicting documentation regarding their code status, with both full code and DNR statuses noted. Despite the resident's expressed wish for CPR and the DMOST indicating full code, progress notes by a doctor contained contradictory information, leading to confusion among staff.
The facility failed to designate a qualified infection preventionist with specialized training. Initially, the ADON was listed as the Infection Preventionist, but staff interviews revealed confusion about the role. The DON, ADON, and RN/MDS Coordinator were managing infection control collectively. The facility could not provide the DON's certification, but later updated the Facility Assessment to list the certified RN/MDS Coordinator as the Infection Preventionist.
The facility did not provide the required 12 hours of annual in-service training, including abuse prevention, for five CNAs. Documentation was lacking, and the DON confirmed the inability to provide evidence of completed training hours. These issues were discussed with facility leadership and a state ombudsman.
The facility's Facility Assessment Tool inaccurately listed the ADON as the Infection Preventionist, despite her lack of certification. The Clinical Specialist clarified that the DON was the actual Infection Preventionist. Infection control duties were shared among the DON, ADON, and RN/MDS Coordinator due to a last-minute withdrawal of a candidate for the role. The facility provided proof of the RN/MDS Coordinator's certification.
Incomplete Water Management Plan for Legionella and Waterborne Pathogens
Penalty
Summary
The facility failed to provide a satisfactory water management plan to prevent the growth of Legionella and other waterborne pathogens. During document review and interview with the DPO (E3), the surveyor determined that the existing water management plan did not include a description and diagram of water flow in the facility, did not identify potential infection sites, and did not outline prevention and treatment plans. These deficiencies in the written plan were confirmed with E3. The survey findings were subsequently reviewed with the NHA (E1) on the same day, and later with the NHA (E1), DON (E2), ADON (E3), a regional nurse (E8), and regional reimbursement staff (E9, via phone) during the exit conference.
Resident Received Duplicate Doses of Vaccines Due to Documentation Failure
Penalty
Summary
A resident with multiple sclerosis and dementia was admitted to the facility and had physician orders for annual influenza vaccination, pneumococcal vaccination every five years, and COVID-19 vaccination. On a single day, the resident was administered two sets of the same three vaccines—pneumococcal conjugate PCV20, high-dose influenza, and COVID-19—within a twelve-hour period. The first set was given in the morning by an RN, and the second set was administered in the evening by an LPN, both documented in the resident's medical record. The LPN discovered the earlier administration only after giving the second set and attempted to document the vaccines, at which point the duplication was identified. The facility's policy required that the individual administering medication document each administration in the Medication Administration Record (MAR) before proceeding to the next. However, the RN failed to document the morning administration in the MAR, leading to the LPN unknowingly administering duplicate doses later that day. This resulted in the resident, who was bedbound and medically frail, receiving double doses of all three vaccines in violation of CDC recommendations for vaccine scheduling. The resident subsequently developed a fever and was sent to the hospital for evaluation.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
Surveyors determined that the facility failed to notify the Ombudsman of a resident’s hospital transfers as required. The resident, admitted on 1/6/22, had a nephrostomy tube and experienced multiple hospitalizations related to that device. Progress notes showed that the resident’s POA was notified when the resident was hospitalized on 11/13/24 after the nephrostomy tube was dislodged, again on 12/26/24 for pain at the nephrostomy site and a UTI diagnosis, and on 5/11/25 for another dislodgement of the nephrostomy tube. However, review of the resident’s hospital transfer paperwork and the facility’s monthly Ombudsman reports revealed that the Ombudsman was not notified of these three hospital transfers, and the resident’s name did not appear on the Ombudsman reports for November 2024, December 2024, or May 2025. These findings were confirmed with the NHA during the survey and discussed with facility leadership at the exit conference. The deficiency centers on the facility’s omission of required Ombudsman notification for the resident’s repeated hospitalizations, despite documentation that the POA had been informed and that the transfers were recorded in the medical record and transfer paperwork.
Failure to Revise Toileting Care Plan After Change in Resident Status
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to revise a resident’s toileting care plan when the resident’s toileting and transfer status changed. The resident, identified as R44, had quarterly MDS assessments on 12/18/24 and 3/12/25 that both documented a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact status. On 12/18/24, the clinical record documented that the resident was always incontinent of bowel and bladder and dependent on staff for toileting. By 3/12/25, the clinical record documented that the resident remained always incontinent of bowel and bladder but now required partial to moderate assistance from staff to get on and off the toilet, reflecting a change from dependent to partial/moderate assistance and a promotion of continence. On 6/6/25 at 9:00 AM, record review showed the facility had not reviewed or revised the resident’s toileting care plan to reflect this change in transfer status and toileting approach. During an interview at 10:00 AM on the same day, the Nursing Home Administrator confirmed that the care plan had not been reviewed or revised, and these findings were later discussed with facility and regional leadership at the exit conference.
Failure to Implement Person-Centered Toileting Programs for Cognitively Intact Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, person-centered services and treatment to promote bowel and bladder continence for two cognitively intact residents. One resident was admitted with acute respiratory failure and muscle weakness and had a care plan identifying risk for altered bladder elimination, with goals for regaining prior elimination status and an intervention for a 3‑day voiding diary to establish the need for bladder training. The admission MDS showed this resident required partial to moderate assistance for transfers and was occasionally incontinent of bladder and frequently incontinent of bowel. Despite this, the Kardex lacked evidence of a formulated toileting program, and the resident reported not knowing about any toileting program, stating that staff only changed her when she was wet and that she was wet at the time of the interview. CNAs confirmed they changed her in bed when she was wet and did not assist her to the toilet, despite describing her as needing only minimal assistance with transfers. Record review showed 41 episodes of urinary incontinence out of 51 opportunities for continence, and although the facility stated a voiding diary was done on admission, they could not provide evidence that it was assessed. The second resident was admitted with a left lower extremity fracture and congestive heart disease and had quarterly MDS assessments documenting a BIMS score of 15. Initially, the record documented that the resident was always incontinent of bowel and bladder and dependent on staff for toileting, but a later MDS documented that the resident remained always incontinent while now requiring only partial to moderate assistance to get on and off the toilet. The clinical record lacked evidence of any assessment or interventions for a toileting program when the resident’s transfer status improved. The resident stated a desire to use the toilet, to stop using diapers, and to possibly move back to assisted living if able to toilet, and reported being wet at the time of the interview. CNAs reported they did not know if the resident was on a toileting program, stated they changed the resident in bed when wet, and one CNA described the resident as easy to care for, using a walker to stand while being changed. Record review showed 79 episodes of urinary incontinence out of 90 opportunities for continence. The DON stated that 3‑day voiding diaries were completed for both residents but that person-centered toileting interventions were not implemented because the residents were incontinent on admission.
Inadequate Infection Control and Urinary Catheter Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for residents with multi-drug resistant organisms (MDROs). For several residents, including those with documented infections such as extended spectrum beta-lactamase (ESBL) and methicillin-resistant Staphylococcus aureus (MRSA), there was no evidence of EBP signage or personal protective equipment (PPE) outside their rooms. Observations revealed that staff did not consistently use gowns and gloves during high-contact care activities, as required by the facility's EBP policy. In addition to the lack of EBP implementation, the facility also failed to ensure a safe and sanitary process for urinary catheter care. Observations of residents with indwelling foley catheters showed that urinary collection bags were often left uncovered, undated, and in contact with the floor, posing a risk of contamination. Staff interviews confirmed that protective clothing was not consistently used when handling urinary catheters, and there was a lack of proper signage indicating the need for precautions. The deficiencies were confirmed through multiple observations and interviews with facility staff, including the Assistant Director of Nursing (ADON) and Clinical Specialist. Despite the presence of MDROs and medical devices that warranted EBP, the facility did not adequately communicate or enforce these precautions, as evidenced by the absence of EBP orders in the electronic medical records and the lack of visible precautionary measures during the survey period.
Failure to Document Vaccinations in Resident Records
Penalty
Summary
The facility failed to document the administration of pneumococcal and influenza vaccines in the medical records of nine residents. Despite the vaccines being recorded in the DELVAX system, the electronic medical records (EMR) of these residents did not reflect the administration of the PCV20 pneumococcal vaccine. Additionally, there was no documentation of the influenza vaccine or its declination for five residents. This lack of documentation was identified during a review of the residents' clinical records. The facility's policy requires that all residents be offered vaccines to prevent infectious diseases, with documentation of the vaccine administration details in the resident's medical record. However, the review revealed that the facility did not adhere to this policy, as evidenced by the missing documentation in the EMRs. The Clinical Specialist acknowledged that the vaccines were entered into DELVAX by a pharmacy clinical team but were not updated in the facility's EMR system. Furthermore, the facility failed to offer an updated pneumococcal vaccine to one resident, as per the CDC guidelines. The resident's record showed no documentation of a recent pneumococcal vaccination, medical contraindication, or declination. This oversight was discussed during an exit conference with facility administrators and state ombudsmen.
Failure to Maintain Dignity in Catheter Bag Management
Penalty
Summary
The facility failed to ensure a dignified existence for three residents, as evidenced by improper management of urinary catheter bags. One resident, admitted with obstructive uropathy, had a care plan specifying that the catheter bag should be placed away from the entrance door. However, observations revealed the catheter bag was uncovered and visible from the entrance, and on one occasion, it was seen dragging on the floor as the resident was wheeled to the shower room. These observations were confirmed by the Assistant Director of Nursing and a Clinical Specialist. Another resident, admitted with neurogenic bladder, had a care plan that required the urinary collection bag to be kept off the floor and covered. Despite this, the resident was repeatedly observed with an uncovered urinary bag on the floor. Similarly, a third resident with neurogenic bladder was observed with an uncovered urinary bag touching the floor and visible from the doorway. These findings were confirmed with facility staff and reviewed during an exit conference with the Nursing Home Administrator, Director of Nursing, and other relevant personnel.
Deficiencies in Resident Care Planning and Medication Notification
Penalty
Summary
The facility failed to ensure that a resident, identified as R4, participated in the development and implementation of his person-centered plan of care. R4 was admitted to the facility and initially participated in a care plan conference, signing the Care Plan Conference Summary. However, there was no documentation of R4's participation in any subsequent care plan conferences, including the one that should have occurred in April. The Corporate Clinical Nurse Specialist acknowledged that a care plan meeting was not conducted in April and that the care plan was not updated due to the absence of a care conference. Additionally, the facility did not notify the Power of Attorney (POA) for another resident, R13, about changes in medication. R13, who had a moderate cognitive impairment, had two medications discontinued by a nurse practitioner, with incorrect diagnoses listed for each. There was no evidence that R13's POA was informed of these changes. The POA confirmed not being notified about the discontinuation of Flomax, prescribed for urinary retention, and Primidone, prescribed for tremors. These findings were reviewed with the Director of Nursing, Assistant Director of Nursing, and other relevant staff members.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call bells were within reach for three residents, leading to a deficiency in accommodating their needs and preferences. Resident 19, who was admitted with diagnoses including shortness of breath, asthma, and congestive heart failure, was observed multiple times with the call bell on the floor near the head of the bed, despite having no cognitive impairment as indicated by a BIMS score of 14. When asked by the surveyor, Resident 19 confirmed the use of the call bell for assistance, highlighting the inaccessibility issue. Similarly, Resident 33, with acute respiratory failure, congestive heart failure, and chronic pain, was observed in a wheelchair with the call bell on the floor behind her, also having a BIMS score of 14. Resident 45, with severe cognitive impairment and a BIMS score of 00, was observed with the call bell on the floor behind the bed. Despite the cognitive impairment, Resident 45 acknowledged using the call bell for assistance. These observations were confirmed with the Assistant Director of Nursing (ADON) and reviewed during the exit conference with facility leadership and the State Ombudsman.
Failure to Provide Written Notification of Hospital Transfer
Penalty
Summary
The facility failed to provide written notification to a resident and the resident's representative regarding the resident's transfer to the hospital. The resident, who was admitted to the facility on June 13, 2023, was transferred to the hospital on May 15, 2024, due to chest pain and was subsequently admitted to the hospital. During an interview, a staff member stated that the facility's process for hospital transfer communications involved only verbal communication to resident representatives, not written communication. As a result, the resident's representative did not receive written notification of the transfer, including the reason for the transfer.
Failure to Update Resident Assessment Every Three Months
Penalty
Summary
The facility failed to update a resident's assessment at least once every three months, as required. The resident was admitted to the facility and had their admission Minimum Data Set (MDS) assessment completed shortly after. Following a hospitalization and readmission, another admission MDS was completed. However, no further MDS assessments were conducted for the resident for over 141 days, exceeding the three-month requirement. During an interview, the MDS coordinator confirmed the oversight and expressed uncertainty as to why the system did not flag the resident for a quarterly assessment. This deficiency was discussed during an exit conference with facility leadership and state ombudsmen.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for two residents. One resident, admitted with diagnoses including Parkinsonism, epilepsy, and hypertension, had a quarterly Minimum Data Set (MDS) assessment that did not document Parkinson's disease as a diagnosis, despite it being confirmed by the MDS Coordinator that it should have been included. Another resident, admitted with atrial fibrillation, heart failure, and dementia, had an annual MDS assessment that incorrectly documented pneumonia as an active diagnosis. The facility could not provide evidence to support this diagnosis, and a Clinical Specialist confirmed it was a mistake, acknowledging that the resident did not have pneumonia during that period.
Failure to Secure PASARR Documentation
Penalty
Summary
The facility failed to secure the PASARR (Preadmission Screening and Resident Review) documentation for a resident upon their admission on April 8, 2024. The resident was admitted with diagnoses including Parkinson's disease, diabetes, and bipolar disorder. The Minimum Data Set (MDS) assessment conducted on April 21, 2024, confirmed bipolar disorder as one of the resident's diagnoses. Despite efforts to locate the PASARR document, the Director of Nursing (DON) reported on June 27, 2024, that the document could not be found and was still missing as of July 2, 2024. The DON mentioned plans to request a duplicate online. The deficiency was discussed during an exit conference on July 2, 2024, with facility staff and state ombudsmen.
Deficiencies in Care Plan Documentation for Residents
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for two residents, leading to deficiencies in their care. For one resident, who was admitted with multiple sclerosis and a stroke affecting the right side, the care plan did not include any interventions or tasks regarding the use of a prescribed resting hand splint. Despite an order from a doctor to apply the splint during specific shifts, the care plan lacked documentation of this intervention, and the Director of Nursing confirmed the omission during an interview. For another resident, who was completely dependent on staff for all activities of daily living and had severe cognitive impairment, the facility failed to document the number of staff members required for turning and repositioning in bed. Although the Physical Therapy department was responsible for determining and communicating this information, there was no documentation in the resident's care plan or Kardex. Interviews with staff revealed reliance on the Kardex for care instructions, but the necessary information was missing, indicating a breakdown in communication and documentation processes.
Failure to Update Care Plan for Dehydration
Penalty
Summary
The facility's interdisciplinary team failed to review and revise the care plan for a resident after a comprehensive assessment identified a new care area for dehydration. The resident was admitted to the facility on June 13, 2023, and a Minimum Data Set (MDS) comprehensive assessment was documented on May 28, 2024, which included dehydration as a newly assessed care area. A care plan meeting was held on June 13, 2024, to review the resident's care needs. However, a subsequent review of the resident's electronic medical record on June 25, 2024, revealed that the care plan did not include a problem for dehydration. This oversight was confirmed during an interview with the MDS Coordinator on June 28, 2024. The findings were discussed during an exit conference on July 2, 2024, with facility leadership and a State of DE Ombudsman.
Non-Compliance with Nursing Scope of Practice for Admission Assessments
Penalty
Summary
The facility failed to meet professional standards of the Delaware Board of Nursing Scope of Practice by allowing LPNs to complete admission assessments and progress notes for new residents. This deficiency was identified for three residents out of twenty-one reviewed. Specifically, the clinical records of these residents showed that LPNs conducted various admission assessments, including evaluations for wander risk, pain, bladder and bowel continence, trauma-informed screening, functional abilities and goals, baseline care plans, and Braden scale evaluations for predicting pressure ulcer risk. Additionally, the admission progress notes for these residents were also completed by LPNs. During an interview, the Assistant Director of Nursing (ADON) confirmed that LPNs are responsible for conducting admission assessments on new residents. This practice is not in compliance with the Delaware State Board of Nursing guidelines, which stipulate that Registered Nurses (RNs) should perform admission assessments. The findings were discussed during an exit conference with the Nursing Home Administrator (NHA), Director of Nursing (DON), ADON, Clinical Specialist, and the State of Delaware Ombudsman.
Failure to Maintain Resident Grooming
Penalty
Summary
The facility failed to provide appropriate care for a resident, identified as R45, to maintain good grooming. R45 was admitted with diagnoses including heart disease and muscle weakness and had a care plan that required staff to check, clean, and trim her nails on bath days and as necessary. Despite this, observations on multiple occasions revealed that R45 had long and dirty fingernails. R45 was noted to have severe cognitive impairment and was dependent on staff for bathing, grooming, and hygiene. On several occasions, R45 was observed with long, dirty fingernails while feeding herself and picking up items to put in her mouth. When asked by a surveyor, R45 agreed to have her nails cleaned and trimmed. These findings were confirmed with the Assistant Director of Nursing (ADON) and a Clinical Specialist, and reviewed during an exit conference with facility leadership and a State Ombudsman.
Failure to Provide Hearing Services for Resident
Penalty
Summary
The facility failed to ensure a resident received proper treatment to assist and maintain hearing abilities. The resident, who was admitted to the facility on January 21, 2024, was noted to be severely hard of hearing. Despite an order in the electronic medical record allowing for audiology consults, no referral was submitted for the resident's hearing issues. Interviews with staff revealed that the resident had significant hearing difficulties, requiring the volume on their television to be set at a high level, which disturbed other residents. The facility was unable to provide documentation of any treatment or referral for the resident's hearing deficit. During an interview, a corporate physical therapist mentioned the resident would be put on the list for audiology, but no action had been taken by the time of the survey.
Failure to Conduct Annual Performance Review for CNA
Penalty
Summary
The facility failed to conduct a performance review every twelve months for one of its certified nurse aides (CNAs), identified as E16. E16 was hired on February 22, 2023, and as of July 1, 2024, there was no documentation of an annual performance evaluation for the year 2024. This deficiency was confirmed during an interview with E21 from Human Resources, who acknowledged that E16 had not received the required annual performance evaluation since their hiring date. The findings were discussed during an exit conference with key facility personnel and a State of Delaware Ombudsman.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure safe and effective medication use for a resident with multiple sclerosis and a stroke affecting the right side. The resident was prescribed Clopidogrel and Protonix, both administered via a G-tube. The facility did not ensure the correct formulation of Protonix was used, as delayed-release tablets should not be crushed and administered through a G-tube. Despite monthly Medication Regimen Reviews (MRR) by the consultant pharmacist, no irregularities were identified, indicating a lapse in the thoroughness of the reviews. Additionally, the facility did not define a medication administration schedule that prevented potential significant interactions between Clopidogrel and Protonix. The resident's Medication Administration Record showed that these medications were scheduled too closely together, increasing the risk of major adverse cardiovascular events. A pharmacy warning was noted in the resident's order set, but the medications continued to be administered without adjusting the timing or formulation, as confirmed by a clinical specialist.
Inconsistent Documentation of Resident's Code Status
Penalty
Summary
The facility failed to maintain accurately documented medical records for a resident, identified as R22, regarding their code status. R22 was admitted with diagnoses including atrial fibrillation, heart failure, and dementia. A Delaware Medical Orders for Scope of Treatment (DMOST) was completed with R22's son, who is also the power of attorney, indicating that R22 was to have CPR and attempt resuscitation. However, conflicting documentation was found in the electronic medical records (EMR) where a progress note by E36 (DO) stated both a full code status and a DNR status for R22. This inconsistency was noted in two separate progress notes, creating confusion about R22's actual code status. During an interview, R22 expressed a desire for CPR and all possible interventions, which was consistent with the DMOST and the order in the EMR that stated R22 was a full code. However, the conflicting documentation in the progress notes led to confusion among the staff, as acknowledged by E4 (Clinical Specialist) during an interview. The issue was discussed during an exit conference with facility administrators and state ombudsmen, highlighting the need for clarity and accuracy in documenting residents' code statuses.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to have a designated infection preventionist with specialized training in infection prevention and control. The Facility Assessment dated May 2024 identified the Assistant Director of Nursing (ADON) as the Infection Preventionist. However, during interviews, there was confusion among staff about who held this role. The RN/MDS Coordinator stated that the ADON was the Infection Preventionist, while the Clinical Specialist indicated that the Director of Nursing (DON) was responsible for infection prevention, but the ADON was not certified for the role. Further interviews revealed that the facility was attempting to fill the Infection Preventionist role after a last-minute withdrawal by a candidate. The DON, ADON, and RN/MDS Coordinator were collectively managing infection control efforts. The facility was unable to provide a copy of the DON's Infection Preventionist training certificate, as it was sent to her previous employment's email. Eventually, the facility updated the Facility Assessment to list the RN/MDS Coordinator, who is certified, as the Infection Preventionist. These findings were discussed during an exit conference with facility leadership and state ombudsmen.
Failure to Provide Required CNA Training
Penalty
Summary
The facility failed to provide the required in-service training for five Certified Nursing Assistants (CNAs), as mandated by regulations. Specifically, the facility did not ensure that these CNAs received the necessary 12 hours of annual in-service training, which includes education on resident abuse prevention. During a review of facility documentation, it was found that there was no evidence to confirm that CNAs E16, E17, E18, E19, and E20 completed the required training hours. Furthermore, during an interview, the Director of Nursing (DON) admitted that the facility could not provide documentation of the total number of training hours, including those related to abuse prevention, for the CNAs in question. These findings were discussed during an exit conference with facility leadership and a state ombudsman.
Inaccurate Facility Assessment for Infection Preventionist Role
Penalty
Summary
The facility failed to accurately update its Facility Assessment Tool with the correct name of the Infection Preventionist. The assessment, dated May 2024, incorrectly listed the Assistant Director of Nursing (ADON) as the Infection Preventionist. However, during an interview, the Clinical Specialist clarified that the Director of Nursing (DON) was the actual Infection Preventionist, as the ADON was not certified for the role. Further interviews revealed that infection control responsibilities were being shared among the DON, ADON, and the RN/MDS Coordinator due to a last-minute withdrawal of a candidate for the Infection Preventionist role. The facility provided evidence of the RN/MDS Coordinator's training and certification for the role.
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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