Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Evergreen Post Acute during CMS and state inspections, most recent first.
A resident with seizures, trach, G-tube, muscle spasms, and MS who was dependent for bed mobility and required 2-person assist fell from bed during incontinent care when one CNA stepped away to get supplies and the other turned away to retrieve clothing. The resident struck her head on a nightstand drawer, sustained a deep forehead/temple laceration, was sent to the ED, and received sutures.
A resident with dementia, aphasia, hemiparesis, hemiplegia, and CVA was identified as being at risk for hydration problems and had a recommended fluid intake of 2050 mL/day. CNA records showed repeated low fluid intake and one day with no intake recorded. After the resident became fatigued and slow to respond, labs showed hypernatremia, elevated BUN, and AKI, and the resident was transferred to the hospital with diagnoses of dehydration, AKI, hypernatremia, and hypokalemia.
Failure to timely report an injury of unknown source: A resident with a fractured right hip had a facility incident documented after an x-ray showed the injury, but the report was not submitted to the State Agency within the required timeframe. The DON confirmed the late reporting during interview.
A resident with right hip discomfort, swelling, pain, grimacing, and uneven hip positioning was observed by staff, and an x-ray later showed an acute right hip fracture. Although the provider was notified and imaging was completed, the resident was not sent to the hospital until hours after the change in condition was first noted, and the DON confirmed the delay was unclear.
A resident’s IV antibiotic orders were not fully met because nafcillin and later cefazolin were not available from pharmacy when due. The MAR showed held doses, including doses for pneumonia and for endocarditis and bacteremia prophylaxis, and a progress note documented the cefazolin was still on order from pharmacy.
A resident with heart failure and COPD was mistakenly given her roommate's medications by an LPN who failed to properly verify the resident's identity. The error led to severe hypotension, requiring emergency transfer and hospital treatment with IV fluids and monitoring before the resident returned to the facility.
A resident with moderate cognitive impairment, as indicated by a BIMS score of 11 and an existing POA for medical decisions, completed an Advance Directive Acknowledgment form without the involvement of their designated POA. The resident signed the form incorrectly, and staff interviews revealed inconsistent practices regarding when to involve family or POA in such decisions.
A resident and their responsible party were not informed in advance of a change in Medicaid/Medicare coverage, resulting in them being billed for services not covered by insurance before receiving notification. Facility staff confirmed that notification was provided only after billing for uncovered services had already begun.
A resident was placed on extended contact isolation for a suspected scabies outbreak, despite ongoing treatment and changes in the rash's presentation. Providers did not reference CDC guidelines, and the facility determined the isolation duration. The resident remained secluded for 78 days until a dermatology consult revealed the rash was not scabies, leading to the discontinuation of isolation precautions.
A resident was admitted to hospice care, but the required significant change MDS assessment was not completed within the mandated timeframe. The assessment was delayed until the MDS office was notified of the hospice admission, despite documentation of the change in the clinical record and transfer/discharge list.
A resident with Alzheimer's disease and moderate cognitive impairment was the subject of an abuse allegation reported by a family member to a CNA. The information was passed to a supervisor and a written statement was collected, but the statement was not promptly escalated to facility leadership, and neither the ADON nor the NHA were aware of the allegation. The facility failed to report the abuse allegation to the appropriate authorities as required by policy.
A resident with Alzheimer's disease, who was moderately cognitively impaired, was the subject of an abuse allegation reported by a family member. Staff confirmed the concern was reported to a supervisor, but no investigation or staff interviews were conducted, and the incident was not reported to the state agency. The facility's policy requiring immediate investigation of abuse allegations was not followed.
A resident at risk for skin integrity issues developed a pressure-related deep tissue injury due to improper wound care management. Despite a care plan to prevent such injuries, staff wrapped the resident's foot too tightly with kling gauze, contrary to treatment orders, resulting in a wound on the top of the foot. The wound was initially misclassified and later confirmed to be caused by the tight wrapping, as acknowledged by the facility's clinical staff.
A resident with cognitive impairment and an enlarged prostate experienced a significant increase in incontinence episodes, yet the facility failed to implement an individualized toileting program. Despite the facility's awareness of the resident's mixed continence status, appropriate interventions were not established, leading to a decline in bladder function. The facility did not perform a thorough bladder assessment or follow its policy for periodic re-evaluation of continence levels.
The facility failed to properly store, prepare, and serve food, risking foodborne illness. The Dietary Services Manager found insufficient sanitizer levels in buckets, a rice spill was left unattended, and opened food items in nourishment refrigerators were undated or expired. These issues were confirmed with the NHA and reviewed with the DON and other staff.
The facility failed to ensure comprehensive care plans were developed with input from all required interdisciplinary team members for several residents. Reviews of clinical records showed missing input from physicians, CNAs, and other staff in care plan meetings. Interviews with staff confirmed a lack of awareness about mandatory IDT members, leading to deficiencies in care plan development.
The facility failed to maintain an effective infection prevention and control program. A laundry aide was observed handling soiled laundry without gloves, and a resident reported a CNA cleaning a bedside commode bucket over the sink in their room. These incidents indicate lapses in infection control practices.
A facility failed to maintain a resident's dignity by not ensuring their urinary collection bag was kept in a privacy bag. The resident had an indwelling urinary catheter, and observations over several days showed the urine collection bag was uncovered while the resident was sitting by the nurses' station. It was only after several days that the bag was covered, as confirmed by a CNA.
A resident's preference for showers was not accommodated due to a broken bariatric shower bed, resulting in the resident only receiving bed baths for several months. The resident's dependency for transfers and showering was documented, but staff were unaware of the preference and equipment issues.
The facility failed to offer an opportunity to formulate an advance directive for three cognitively intact residents. Despite being admitted over a period of years, none of the residents had an advance directive on file, and interviews confirmed they were not offered assistance upon admission. These findings were confirmed by the NHA and reviewed with the DON and other staff.
A resident with end-stage renal disease and other conditions reported missing personal items after hospital transfers. The facility failed to document the grievance or provide evidence of resolution. The grievance policy lacked a process for informing residents or families of investigation results, and the grievance was not logged. The resident's daughter found some items in storage, but the facility could not provide a written decision on the grievance.
The facility failed to ensure accurate MDS assessments for multiple residents, leading to discrepancies in dental status, behavioral occurrences, and bladder continence documentation. Interviews with staff confirmed these inaccuracies, highlighting issues in communication and responsibility for MDS documentation.
The facility failed to complete necessary PASARR referrals for four residents, resulting in deficiencies. One resident with a new diagnosis of major depressive disorder did not receive an updated PASARR. Another resident was deemed to have an intellectual disability, but no new evaluation was conducted. A third resident had an updated PASARR submitted, while a fourth resident with mood disorders did not receive an updated PASARR after admission. These issues were confirmed through staff interviews.
A resident was admitted to the facility without evidence of a Delaware State PASARR, despite having diagnoses of major depressive disorder, delusional disorder, anxiety disorder, and mood disorder. A review of clinical records showed no level I PASARR or referral for an update. A social worker confirmed the absence of a PASARR review and contacted the State PASARR authority, which had no record on file. These findings were discussed with the DON, a consultant, and a corporate clinical nurse.
The facility failed to develop person-centered care plans for two residents to address their incontinence needs. One resident, cognitively intact, was always incontinent of bowel and bladder, yet lacked a care plan with interventions. Another resident, cognitively impaired, progressed from occasional to consistent bladder incontinence without a toileting program. Staff confirmed the absence of appropriate care plans, and these findings were discussed with facility leadership.
A resident with a PEG tube was documented as receiving medications orally, despite being NPO. Nursing staff administered medications via the PEG tube but inaccurately recorded them as given by mouth, violating professional standards of medication administration.
The facility failed to provide adequate assistance with ADLs for four dependent residents. One resident was left in a chair without continence care, another was left in a geri-chair with wet clothing, a third had not received a shower or hair wash due to a broken shower bed, and a fourth had overgrown nails due to lack of care. These deficiencies were confirmed through staff interviews and observations.
The facility failed to provide appropriate care for three residents, leading to deficiencies. One resident did not receive proper wound care for a surgical neck wound, resulting in a significant dehiscence. Another resident lacked a documented neurology follow-up, and a third resident received insulin without proper assessment, leading to hypoglycemia and hospitalization.
A resident with a PEG tube and documented as NPO was prescribed oral medications, and the facility failed to conduct a proper medication regimen review. The pharmacist did not identify the discrepancy, and the issue was later discussed with facility administrators.
The facility failed to monitor adverse effects for residents on medications like trazodone and Pradaxa, and did not discontinue Seroquel for a resident as recommended. Communication breakdowns and lack of documentation contributed to these deficiencies, as confirmed by staff interviews.
A facility failed to document the receipt of narcotic medications according to professional standards. A resident had a physician's order for oxycodone, but the narcotic count verification sheets for several months lacked necessary documentation, such as dates, times, and nurse signatures. This issue was confirmed by an RN UM and reviewed with the DON and other staff.
A resident experienced a delay in treatment for a urinary tract infection due to the facility's failure to promptly notify the ordering practitioner of abnormal lab results. The resident reported pain during urination, and lab results confirmed an infection. However, the physician was not informed until two days later, delaying the prescription of antibiotics. An LPN confirmed that abnormal results should be reported to the on-call provider, but this was not done.
The facility failed to maintain accurate medical records for two residents. One resident's EMR showed conflicting Risperdal dosages without a diagnosis, while another resident's 1:1 supervision and toileting program were not documented accurately. These issues were confirmed through staff interviews.
Failure to Maintain Safe Bed Mobility During Incontinent Care
Penalty
Summary
The facility failed to provide adequate supervision and safe bed mobility practices for a resident who required two-person assistance. The resident had diagnoses including seizures, gastrostomy tube, tracheostomy, anxiety, muscle spasms, and later multiple sclerosis, and was documented as dependent for multiple activities of daily living and bed mobility. The care plan identified the resident as needing two-person assist for transfers and bed mobility and as being at risk for falls due to poor safety awareness, seizures, and adjustment to a new environment. During incontinent care, two CNAs were assisting the resident with a large liquid bowel movement and ongoing diarrhea. One CNA rolled the resident and cleaned her while the other stepped away to place soiled linen in the linen cart near the doorway and then turned to retrieve a gown and brief from a chair. The resident remained in bed at waist height and was unable to reposition herself or assist with movement. While staff were occupied with obtaining supplies and handling linen, the resident fell from the bed and struck her head on the nightstand drawer. After the fall, the resident was found on the floor with a deep laceration to the left temple/forehead and minimal red drainage. She was unable to verbalize what happened, was sent to the ED, and received six sutures. Facility statements and interviews confirmed that the resident was still receiving incontinent care when the fall occurred, that she required two-person assistance, and that staff were not able to physically prevent her from rolling out of bed while care was ongoing.
Failure to Provide Adequate Fluids Resulted in Dehydration and AKI
Penalty
Summary
The facility failed to ensure that one resident at risk for nutrition and hydration problems was offered sufficient fluids to maintain proper hydration. The resident was admitted with a history that included dementia, aphasia, hemiparesis, hemiplegia, and CVA, and the care plan identified the resident as being at risk for nutrition/hydration issues. A nutrition assessment documented a recommended fluid intake of 2050 mL/day and noted risk for malnutrition and dehydration, with lab results showing elevated sodium and low potassium and an order for additional oral fluids for two weeks related to the electrolyte imbalance. CNA task flow sheets showed multiple days of fluid intake below the recommended amount, including several days with very low totals and one day with no recorded intake. On 10/20/25, a provider evaluated the resident for increased fatigue and slow response and documented a plan to check labs and encourage fluids. The record stated that the facility failed to implement the provider recommendation and lacked evidence of increased monitoring or approaches to increase hydration. The next day, labs showed BUN 42 mg/dL, creatinine 1.50 mg/dL, and sodium 159 mmol/L. A provider documented that the results were indicative of hypernatremia and AKI, that fluid resuscitation was unsuccessful, and that the resident was sent to the hospital. The hospital documented admission diagnoses of AKI, hypernatremia, hypokalemia, and dehydration. Staff interviews later confirmed that fluids were expected to be recorded and that residents not meeting fluid goals were to be reported to nursing leadership for further evaluation.
Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of unknown source to the State Agency within the required timeframe for one resident reviewed for abuse. The resident was admitted to the facility on 4/1/23, and on 3/8/26 at 1:00 PM a facility reported incident documented that the resident had an injury of unknown origin based on a positive x-ray showing a fractured right hip. A Radiology Results Report later that day at 8:35 PM documented an acute fracture to the resident’s right hip. The facility reported incident was submitted to the State Agency at 12:59 AM on 3/9/26, 12 hours after the incident occurred. During an interview on 5/8/26, the DON confirmed that the report was not submitted to the State Agency within the appropriate timeframe.
Delayed Response to Resident’s Right Hip Fracture
Penalty
Summary
The facility failed to ensure care and treatment were provided in accordance with professional standards of practice for one resident, R30, who was admitted to the facility on 4/1/23. On 3/8/26 at 10:48 AM, an SBAR documented that R30 was observed with right hip discomfort and swelling, and that the provider was notified and a return call was pending. At 3:22 PM, a telephone physician order was entered for x-ray imaging of both hips with two views, and the radiology report later documented that the x-ray was completed at 5:03 PM and showed an acute fracture of the right hip. A nursing progress note at 11:09 PM documented that R30 had a positive fracture to the right hip and was sent to the hospital for further evaluation. During interviews, a CNA stated she observed pain, grimacing, and that the right hip was not sitting evenly with the left hip during incontinence care, and that she reported these observations to the nurse after care was completed. A technician confirmed the x-ray order was received at 3:22 PM, the x-ray was completed at 5:03 PM, and results were sent to the facility at 8:35 PM. The DON confirmed the positive x-ray for right hip fracture and that R30 was sent to the hospital, and it was unclear why the facility sent R30 to the hospital 15 hours after the change in condition was observed.
Delayed IV Antibiotic Availability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of one resident, R153, who was admitted on 1/9/26. A physician ordered nafcillin sodium 2 grams IV every 8 hours for pneumonia for 15 days, but the January MAR showed the 12:00 AM and 8:00 AM doses were held because the medication was not available from pharmacy. The MAR did not show a hold order for the 4:00 PM dose on 1/9/26. A later physician order for cefazolin sodium 2 grams IV three times a day for endocarditis and bacteremia prophylaxis was also affected when the MAR documented the 10:00 PM dose as held, and a progress note stated cefazolin was on order from the pharmacy.
Medication Error Resulting in Hospitalization Due to Staff Misidentification
Penalty
Summary
A medication error occurred involving a resident who was admitted with diagnoses including heart failure and chronic obstructive pulmonary disease. On the morning following admission, a staff LPN mistakenly administered the medications intended for the resident's roommate, which included amlodipine 10mg, benazepril 40mg, Coreg 25mg, and sevelamer 800mg. The error was made when the LPN identified the resident incorrectly, relying on the name in the room and not verifying the resident's identity with the armband or photo in the medication administration record. The resident, who was hard of hearing, received the wrong medications after confirming she needed her medication in pudding, further contributing to the misidentification. Following the administration of the incorrect medications, the resident's blood pressure dropped significantly, with documented readings as low as 50/20. The staff recognized the error after rechecking the resident's blood pressure and reviewing the medication administration. Emergency services were called, and the resident was sent to the hospital for evaluation and treatment, where she received IV fluids and monitoring for hypotension. The resident spent approximately 16 hours in the emergency room before returning to the facility. The incident was confirmed through staff interviews and documentation review.
Failure to Involve POA in Advance Directive for Cognitively Impaired Resident
Penalty
Summary
A deficiency was identified when a resident with moderate cognitive impairment was admitted to the facility. The resident's admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The resident's electronic medical record (EMR) listed their daughter as the primary emergency contact and included a notarized Power of Attorney (POA) document naming the daughter as the sole POA for both medical and financial matters. Despite this, the facility's social worker completed the Advance Directive Acknowledgment form with the resident alone, who printed her name incorrectly on the signature line, using a different first name and misspelling her last name. Interviews with facility staff revealed inconsistent practices regarding the involvement of family representatives or POAs in the completion of advance directive paperwork for residents with cognitive impairment. The social work director stated that there was no formal cutoff BIMS score for determining decision-making capacity and that the process was based on judgment. The DON indicated that typically, if a resident's BIMS score is below 12, the family or POA is involved in signing paperwork. However, in this case, the POA was not included in the acknowledgment process, despite the resident's documented cognitive impairment and existing POA documentation.
Failure to Provide Advance Notice of Change in Billing for Non-Covered Services
Penalty
Summary
A resident was admitted to the facility and subsequently exhausted their insurance coverage for nursing home stay, as indicated by an Eligibility Verification Notice received by the facility. The facility became aware of the change in coverage and, on the same day, read a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) over the phone to the resident's responsible party, informing them that they would be responsible for payment starting the following day. However, the facility began billing the resident and responsible party for services from the last date of coverage, prior to providing notification of the change in billing status. Facility staff confirmed that the resident and responsible party were not informed in advance of the change in billing, and billing for uncovered services occurred before notification was given.
Resident Subjected to Prolonged Involuntary Seclusion Due to Misdiagnosed Rash
Penalty
Summary
A resident was admitted to the facility and subsequently developed a rash, which was initially documented on both arms and upper thighs. The resident was placed on contact isolation precautions for suspected scabies, as documented in the care plan and physician's orders. Despite treatment with Ivermectin and Permethrin, and ongoing provider assessments, the resident remained on isolation for an extended period. Progress notes indicated that the rash persisted and changed locations, but providers did not consult CDC guidelines for scabies treatment, and the isolation precautions continued based on facility protocol rather than updated clinical assessment. The resident remained on isolation for a total of 78 days, during which time he reported feeling confined and unable to receive showers for a significant portion of the isolation period. It was only after a dermatology consult that the rash was diagnosed as atopic dermatitis, unrelated to scabies, and isolation precautions were discontinued. Interviews with staff confirmed that the decision to maintain isolation was a collaborative process, but providers acknowledged not referencing CDC guidelines and that the facility determined the duration of isolation. The prolonged and unnecessary isolation resulted in the resident being involuntarily secluded due to a misdiagnosis.
Failure to Complete Timely Significant Change Assessment After Hospice Admission
Penalty
Summary
A deficiency occurred when the facility failed to complete a comprehensive assessment for a resident who experienced a significant change in condition, specifically upon admission to hospice care. The resident was admitted to the facility and later to hospice services, but a significant change Minimum Data Set (MDS) assessment was not completed within the required fourteen days of the hospice admission. Documentation and interviews confirmed that the MDS for the significant change was only completed nearly a month later, after the MDS office became aware of the resident's hospice status. The delay was attributed to a lack of timely notification to the MDS office regarding the resident's change in status, despite the hospice admission being documented in the clinical record and on the Ombudsman Transfer/Discharge list.
Failure to Timely Report Alleged Abuse
Penalty
Summary
A deficiency occurred when the facility failed to report an allegation of abuse involving a resident with Alzheimer's disease and moderate cognitive impairment. On the day in question, a family member reported to a CNA that a staff member was being mean and rude to the resident. The CNA relayed this information to a supervisor, who instructed the family member to write a statement. The statement was then placed under the door of the social worker's office because it was the weekend. The following day, the social worker found the statement and gave it to the assistant director of nursing (ADON), but the ADON was unaware of the allegation. The nursing home administrator (NHA) was also unaware of the statement or the abuse allegation. There was no evidence that the facility reported the allegation of abuse as required by their policy, which mandates immediate reporting to the administrator and state agencies within specified timeframes.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident with Alzheimer's disease, who was moderately cognitively impaired, from abuse and did not properly investigate an allegation of abuse. On the date of the incident, a family member reported to staff that a staff member was being inappropriate and mean to the resident. Multiple staff members, including an LPN and a CNA, confirmed that the concern was reported to a supervisor, but neither were interviewed nor asked to provide statements about the incident. The supervisor had the family member write a statement and left it for the social worker, but did not conduct further investigation or interviews. The social worker found the statement the next day and passed it to the Assistant Director of Nursing, but the Nursing Home Administrator was not made aware of the allegation, and no formal investigation was initiated. The resident was discharged the following day, and there was no evidence that the allegation was reported to the state agency or that an investigation was completed. The facility's policy required immediate investigation of abuse allegations, but this was not followed in this case.
Improper Wound Care Leads to Pressure Injury
Penalty
Summary
The facility failed to provide adequate care and services to prevent an avoidable deep tissue injury from developing in a resident, identified as R110, who was at risk for skin integrity issues due to multiple health conditions including diabetes, dementia, and impaired mobility. Upon admission, a care plan was established to mitigate these risks, which included regular skin checks and repositioning. Despite these measures, a new pressure-related deep tissue injury was documented on the resident's right foot, which was not initially present. The deficiency arose from improper wound care management, specifically related to the use of kling gauze. A treatment order for a diabetic foot ulcer on the resident's right heel did not include wrapping with kling gauze, yet staff wrapped the foot too tightly, leading to the development of a pressure-related wound on the top of the right foot. This wound was initially documented as a deep tissue injury and later inaccurately staged as a stage 2 pressure ulcer, before being classified as unstageable with slough present in the wound bed. Interviews with staff, including an LPN and a wound NP, confirmed that the wound resulted from the foot being wrapped too tightly, contrary to the treatment orders. The wound NP had instructed staff not to wrap the foot, but the directive was not followed, leading to the development of the wound. The facility's Director of Nursing and other clinical staff were made aware of these findings, highlighting a lapse in adherence to prescribed wound care protocols.
Failure to Implement Individualized Toileting Program for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or restore bladder function for a resident, identified as R106, who was initially continent of urine upon admission. Despite the resident's cognitive impairment and diagnoses of an enlarged prostate and dementia, the facility did not implement an individualized toileting program even as the resident's episodes of incontinence increased significantly over time. The resident's care plan initially included interventions for skin integrity and fall risk, but these did not adequately address the resident's changing continence status. The resident's clinical records and interviews with staff revealed a pattern of increasing incontinence episodes, yet there was no evidence of a comprehensive bladder assessment or a personalized toileting program being established. The facility's policy required periodic re-evaluation of continence levels, but this was not consistently followed, as evidenced by the lack of a quarterly bladder and bowel evaluation in December 2023. Staff interviews indicated that the resident was checked every two hours, but this approach was not based on a thorough assessment of the resident's needs. Despite the facility's awareness of the resident's mixed continence status, appropriate interventions were not implemented. The resident's continence declined from frequently incontinent in August to always incontinent by December 2023. The facility's failure to perform a thorough bladder assessment and establish a person-centered toileting program contributed to the deficiency, as the resident did not receive the necessary treatment and services to maintain or restore bladder function.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in a manner that prevents foodborne illness to the residents. During a kitchen tour, the Dietary Services Manager was observed testing the sanitizer level in two red sanitizing buckets, and the test strips indicated insufficient chemical concentration for proper sanitization. Additionally, a container of dry rice was spilled on the floor near the sink and left unattended for over an hour. In the Aspen unit's nourishment refrigerator, an opened carton of Nutritional Shake was found undated, despite instructions indicating it should be discarded after four days once opened. Similarly, in the Seaside Unit, an opened bottle of thickened juice dated over a month prior was found, although it should have been discarded after ten days according to the instructions. These findings were confirmed with the Nursing Home Administrator and later reviewed with the Director of Nursing, a consultant, and a Corporate Clinical Nurse.
Deficiency in Interdisciplinary Team Input for Care Plans
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for five residents were developed and reviewed with input from all required interdisciplinary team (IDT) members. The facility's policy mandates that the care plan should be prepared by an IDT, including the attending physician, a registered nurse, a nurse aide, a member of the food and nutrition services staff, the resident and their representative, and other appropriate staff as needed. However, the review of clinical records for the residents revealed multiple instances where the care plan meetings lacked evidence of input from the physician, certified nursing assistant, and other required team members. For instance, one resident's care plan meetings on several occasions lacked input from the physician and certified nursing assistant. Another resident's records showed missing input from the full IDT, as sign-in sheets were not provided, and there was no evidence of a quarterly care plan meeting in a specific month. Additionally, interviews with facility staff, including the Social Services Director and Social Work Assistant, confirmed their lack of awareness regarding the mandatory IDT members required for care plan meetings. These deficiencies were reviewed with the Director of Nursing, a consultant, and a corporate clinical nurse.
Infection Control Lapses in Laundry and Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents. First, a laundry aide was observed handling soiled laundry without gloves, indicating a lack of awareness of safe handling practices for contaminated materials. This lapse in protocol was confirmed through an interview with the aide, who was not informed about the necessary precautions for handling laundry from residents under various illness-related precautions. Additionally, a resident reported an incident where a CNA was seen cleaning a bedside commode bucket over the sink in the resident's room. The resident captured this on video and reported it to the social worker and the state agency. The corporate clinical nurse confirmed awareness of the incident, and an investigation was conducted. However, the incident occurred several months prior to the investigation, suggesting a delay in addressing the issue.
Failure to Maintain Resident Dignity by Covering Urinary Collection Bag
Penalty
Summary
The facility failed to uphold a resident's dignity by not ensuring the urinary collection bag was kept in a privacy bag. The resident, identified as R18, was admitted to the facility on December 13, 2020, and had an indwelling urinary catheter as of March 26, 2024. Observations on May 9, 10, and 13, 2024, noted that R18 was sitting by the nurses' station with the urine collection bag uncovered. It was only on May 14, 2024, that a CNA confirmed the urinary collection bag was covered, indicating that the privacy bag was put in place that day. These observations and interviews highlight the facility's failure to consistently maintain the resident's dignity by not covering the urinary collection bag in a timely manner.
Failure to Accommodate Resident's Shower Preference
Penalty
Summary
The facility failed to accommodate a resident's preference for showers, as revealed through observations, interviews, and record reviews. The resident, who was admitted to the facility in June 2020, had a significant change MDS assessment in November 2023 indicating dependency for transfers and showering, and it was very important for the resident to choose between a bath or a shower. However, the resident reported not having had a shower or washed her hair since September 2023 due to a broken bariatric shower bed. CNA documentation from August 2023 to May 2024 showed the resident only received bed baths. An RN interviewed was unaware of the resident's preference for showers and could not confirm the availability of a bariatric shower bed.
Failure to Offer Advance Directives
Penalty
Summary
The facility failed to offer an opportunity to formulate an advance directive for three residents, identified as R18, R65, and R116, who were cognitively intact with a BIMs score of 15. R18 was admitted on 12/13/20, and during an interview on 5/9/24, confirmed that the facility did not assist in formulating an advance directive upon admission. A review of R18's electronic medical records on 5/13/24 showed no evidence of an advance directive on file. The Nursing Home Administrator (NHA) confirmed on 5/14/24 that R18 was not offered the opportunity to formulate an advance directive upon admission. Similarly, R65, admitted on 6/2/20, confirmed during an interview on 5/9/24 that the facility did not offer assistance in formulating an advance directive upon admission. A review of R65's electronic medical records on the same day showed no advance directive on file, which was confirmed by the NHA on 5/14/24. R116, admitted on 2/1/23, also confirmed on 5/9/24 that the facility did not offer to formulate an advance directive upon admission. A review of R116's records on the same day showed no advance directive, and this was confirmed by the NHA on 5/14/24. These findings were reviewed with the Director of Nursing (DON), a consultant, and a corporate clinical nurse on 5/20/24.
Failure to Document and Resolve Grievance for Missing Personal Items
Penalty
Summary
The facility failed to maintain evidence of resolving a grievance regarding a resident's missing personal items. The resident, who was admitted with end-stage renal disease, diabetes, and difficulty walking, reported missing items after being transferred to the hospital and returning to different rooms. The missing items included clothing, a bag of correspondence, toiletries, and coloring books. Despite informing Social Services, the resident did not recover all items. Interviews revealed that the facility's grievance policy lacked a documented process for informing residents or families of grievance investigation results. The Social Work assistant explained the process for handling missing items, which involves notifying the department director, searching for the items, and documenting grievances in a computer log. However, the grievance regarding the resident's missing items was not documented. The Director of Social Work confirmed awareness of the missing correspondence but did not document the grievance. The resident's daughter corroborated the missing items and found some items in a storage room. The facility could not provide evidence of a written grievance decision, including investigation steps or corrective actions.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for four residents, leading to deficiencies in their care documentation. For one resident, the MDS inaccurately recorded the presence of natural teeth despite dental reports confirming edentulism. This inaccuracy persisted across multiple assessments, and interviews with the resident and staff confirmed the error. Another resident's MDS failed to document behavioral occurrences, despite evidence from behavior flow sheets indicating verbal aggression. Interviews with staff revealed a lack of responsibility and communication regarding the documentation of behaviors in the MDS. Additionally, a third resident's MDS inaccurately reported no behavioral occurrences, contradicting documented evidence of verbal and physical aggression. The social services staff confirmed the inaccuracy. Lastly, the MDS for a fourth resident inaccurately coded bladder continence, despite documentation showing multiple incontinent episodes. The regional MDS consultant acknowledged the error, citing a lack of awareness of the voiding diary. These inaccuracies were confirmed through interviews with various staff members, including the Director of Nursing and corporate clinical personnel.
Failure to Complete PASARR Referrals for Residents
Penalty
Summary
The facility failed to ensure that referrals for Preadmission Screening and Resident Review (PASARR) were completed for four residents, leading to deficiencies in their care. For one resident, a new diagnosis of major depressive disorder with psychotic symptoms was added, but no updated PASARR was requested despite the change indicating a new primary mental illness. Another resident was deemed to have an intellectual disability due to aphasia and poor cognition following a stroke, yet no new PASARR evaluation was conducted. The physician involved was unaware of the PASARR process, and the Social Services Director was not informed of the new diagnosis. Additionally, a third resident had a history of anxiety and was later diagnosed with major depressive disorder and bipolar disorder, but the facility did submit an updated PASARR review for this resident. However, for a fourth resident, who was diagnosed with persistent mood disorder and mood disorder due to an unknown physiological condition, no updated PASARR was submitted after the initial screening prior to admission. These oversights were confirmed through interviews with facility staff, including the Social Services Director and medical personnel.
Failure to Obtain PASARR Prior to Admission
Penalty
Summary
The facility failed to provide evidence of a Delaware State PASARR for a resident prior to admission. The resident was admitted to the facility with a diagnosis of major depressive disorder and later diagnosed with delusional disorder, anxiety disorder, and mood disorder due to an unknown physiological condition. A review of the clinical records from 2023 to 2024 showed a lack of evidence for a level I PASARR and no referral for an update to the State PASARR authority. An interview with a social worker confirmed that the resident was admitted without a PASARR level I or any PASARR review. The social worker also confirmed that she contacted the State PASARR authority and found that a level I PASARR was not on file. These findings were reviewed with the Director of Nursing, a consultant, and a corporate clinical nurse.
Failure to Develop Person-Centered Incontinence Care Plans
Penalty
Summary
The facility failed to develop person-centered care plans for two residents, R40 and R106, to address their incontinence needs. R40 was admitted to the facility on January 23, 2020, and was documented as cognitively intact and always incontinent of bowel, with no toileting plan initiated. Despite a quarterly MDS assessment on April 30, 2024, confirming R40's incontinence of both bowel and bladder, the care plan lacked evidence of interventions to address these needs. Interviews with facility staff, including an LPN and an RN/UM, confirmed the absence of a person-centered care plan for R40's incontinence. Similarly, R106, admitted on June 23, 2023, was initially assessed as cognitively impaired and always continent of bladder. However, subsequent quarterly MDS assessments revealed a progression to occasional and then consistent bladder incontinence, with no toileting program in place. By March 26, 2024, R106 was documented as always incontinent of bladder, yet the care plan still lacked interventions for bladder incontinence. An LPN Supervisor confirmed the absence of a care plan for R106's bladder incontinence, and these findings were discussed with the Nursing Home Administrator, Director of Nursing, and Corporate Clinical Nurse.
Failure to Adhere to Medication Administration Standards
Penalty
Summary
The facility failed to ensure that the services provided by the nursing staff met professional standards of quality concerning the Five Rights of Medication Administration. A resident, identified as R3, was admitted to the facility with multiple sclerosis and later underwent a procedure to place a percutaneous endoscopic gastrostomy (PEG) tube due to malnutrition and failure to thrive. Despite being documented as NPO (nothing by mouth) by both a dietitian and a speech therapist, the nursing staff continued to administer medications via the PEG tube while inaccurately documenting them as given orally on the Medication Administration Record (MAR). The discrepancy was discovered when a surveyor attempted to observe a medication pass and found that the medications had already been administered via the PEG tube. Further investigation revealed that since the resident's readmission, the nursing staff had consistently administered medications through the PEG tube but recorded them as given orally. This practice was confirmed by an LPN and was not corrected until a physician was called to clarify the medication administration route. The facility's failure to adhere to the correct documentation and administration route violated the professional standards of medication administration.
Inadequate Assistance with ADLs for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for four residents who were dependent on staff for care. Resident R18, who was alert and oriented with a BIMS score of 15, was left in his chair from early morning until after lunch without receiving necessary continence care, despite being incontinent of urine and dependent for perineal care. Similarly, Resident R54, who was also alert and oriented, was left in a geri-chair for several hours with wet clothing, as staff cited being short-handed as the reason for the delay in care. Resident R65, dependent on staff for transfers and showering, had not received a shower or hair wash since September 2023 due to a broken bariatric shower bed, receiving only bed baths instead. Resident R79, requiring substantial assistance with showering, was observed with long, overgrown nails, indicating a lack of nail care, which was supposed to be part of the shower routine. These deficiencies were confirmed through interviews with staff and observations, highlighting a pattern of inadequate care for dependent residents.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and care for three residents, leading to deficiencies in their care. For one resident, R294, the facility did not follow up on wound care instructions for a surgical wound on the neck. Despite the resident's complaints of severe neck pain and the presence of a cervical collar, the facility did not remove the collar to inspect the wound regularly. The records show that the cervical collar was only removed once during the resident's 21-day stay, and the wound was not properly assessed, leading to a significant surgical dehiscence that required emergency hospital referral. Another resident, R106, was admitted with a recommendation for a neurology follow-up, which was not documented in the facility's records. The facility failed to ensure that the resident received the necessary neurology consult as per the hospital discharge summary. This oversight was confirmed during an interview with the facility's staff, who acknowledged the lack of documentation and follow-up on the neurology consult. For the third resident, R397, the facility administered insulin without proper assessment of the resident's blood glucose levels and meal intake. The resident had not consumed meals for four days, and despite a low blood glucose reading, insulin was administered without consulting a medical provider. This resulted in the resident being admitted to the hospital with hypoglycemia and acute kidney injury. The facility's documentation lacked evidence of appropriate nursing judgment and consultation with a medical provider before administering insulin.
Failure in Medication Regimen Review for NPO Resident
Penalty
Summary
The facility failed to ensure a monthly medication regimen review (MRR) was completed for a resident, identified as R3, who was admitted with multiple sclerosis and later hospitalized for altered mental status. Upon readmission to the facility, R3 had a percutaneous endoscopic gastrostomy (PEG) tube placed due to malnutrition and was documented as strictly NPO (nothing by mouth) by both a dietitian and a speech therapist. Despite this, orders for fourteen medications to be administered orally were entered by a nursing supervisor and co-signed by a medical doctor. The facility lacked evidence of a completed MRR for R3 for March 2024, and subsequent reviews in April and May by the registered pharmacist did not address the discrepancy of oral medication orders for a resident who was NPO. During an interview, the pharmacist admitted to not noticing the issue. The deficiency was discussed with the nursing home administrator and a corporate consultant, highlighting a failure in the medication review process.
Failure to Monitor Adverse Effects and Discontinue Unnecessary Medication
Penalty
Summary
The facility failed to ensure adequate monitoring of adverse effects for several residents and did not discontinue unnecessary medication for one resident. For one resident, the facility did not discontinue Seroquel as recommended during a Gradual Dose Reduction (GDR) meeting. Despite the psych doctor's recommendation to discontinue Seroquel and start Remeron, the medication was not discontinued, and the resident continued to receive it. This oversight was due to a communication breakdown during the GDR meeting, where the discontinuation of Seroquel was not noted by the staff present. Additionally, the facility did not adequately monitor adverse effects for three other residents. One resident, who was on trazodone for insomnia and mood, lacked documented monitoring of behavior changes such as tearfulness and sadness. Another resident on anticoagulant therapy with Pradaxa did not have documentation of monitoring for adverse effects like bleeding. Similarly, a resident prescribed trazodone for major depressive disorder also lacked monitoring for adverse effects. These failures were confirmed through interviews with facility staff, indicating a systemic issue in monitoring and documentation practices.
Failure to Document Narcotic Medication Receipt
Penalty
Summary
The facility failed to adhere to professional standards of care in the documentation and receipt of narcotic medications. A resident, identified as R65, was admitted to the facility and had a physician's order for oxycodone, a narcotic pain medication, to be administered every eight hours. However, a review of the narcotic count verification sheets for several months, from November 2023 to April 2024, revealed a lack of documentation, including missing dates, times, and nurse signatures of receipt. This deficiency was confirmed during an interview with a registered nurse unit manager (RN UM) and reviewed with the Director of Nursing (DON), a consultant, and a corporate clinical nurse.
Failure to Promptly Notify Practitioner of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify the ordering medical practitioner of laboratory results that were outside of clinical reference ranges for a resident. The resident, who was admitted to the facility on January 2, 2020, reported pain during urination on May 9, 2024, leading to the collection of a urine sample for analysis and culture. On May 10, 2024, lab results indicated a positive result for a urinary tract infection, with the culture still pending. By May 11, 2024, the lab results showed positive growth in the urine sample. However, it was not until May 13, 2024, that a physician's order for Bactrim DS, an antibiotic, was written for the urinary tract infection. An interview with an LPN confirmed that abnormal lab results posted during weekend hours should be reported to the on-call provider, but the facility lacked evidence of such prompt reporting in this case. The findings were reviewed with the Director of Nursing, a consultant, and a corporate clinical nurse on May 20, 2024.
Inaccurate Medical Records and Documentation Failures
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, R40 and R106, as per professional standards. For R40, the clinical record showed discrepancies in the documentation of Risperdal medication orders. Specifically, the electronic medical record (EMR) indicated conflicting dosages of Risperdal, with no associated diagnosis provided. This issue was confirmed during an interview with the Nursing Home Administrator (NHA). For R106, the facility did not document the required 1:1 supervision and toileting program accurately. Although the care plan was updated to include 1:1 supervision for fall risk, there was no evidence in the CNA flowsheets from September 2023 to January 2024 that this supervision was documented. Additionally, the facility's records showed inconsistencies in documenting R106's bladder and bowel evaluations, with discrepancies in the resident's continence status and lack of documentation for the voiding diary and toileting program. These issues were confirmed during interviews with the Corporate Clinical Nurse and other staff members.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 93 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Smyrna
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Delaware Hospital F/t Chronically Ill (dhci) | 2.1 mi | ★★★★★ | 10 | 2 |
| Westminster Village Health | 6.2 mi | ★★★★★ | 13 | 1 |
| Complete Care At Silver Lake Llc | 6.3 mi | ★★★★★ | 13 | 0 |
| Cadia Rehabilitation Capitol | 6.8 mi | ★★★★★ | 6 | 1 |
| Center At Eden Hill, Llc | 8 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.