Evergreen Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Smyrna, Delaware.
- Location
- 3034 South Dupont Blvd, Smyrna, Delaware 19977
- CMS Provider Number
- 085020
- Inspections on file
- 26
- Latest survey
- May 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Evergreen Post Acute during CMS and state inspections, most recent first.
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.
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.
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Multiple cognitively impaired residents with known behavioral issues, including wandering, agitation, and physical aggression, were not adequately protected from resident‑to‑resident abuse. In one case, a resident with dementia and PTSD was pushed to the floor by another resident who had a history of combative behavior, resulting in multiple fractures and facial lacerations after staff initially documented the event as an unwitnessed fall. In another case, two residents with dementia and psychotic features engaged in a physical altercation in a dayroom after one placed his hand on the other’s chest, leading to mutual punching. A separate incident occurred when a resident with dementia and behavioral disturbances entered another resident’s room, pulled at the bedcovers, yelled that the room was his house, and allegedly struck the other resident, who was later noted with puffiness around one eye. In all incidents, the involved residents had documented behavioral care plans and significant cognitive impairment, yet physical confrontations still occurred.
A resident with dementia, spinal stenosis, and total dependence for transfers, care-planned for Hoyer lift use with two-person assist, was being transferred from a shower bed to a Geri-chair when the Hoyer lift tipped sideways. Staff reported the lift’s legs had been widened and that one CNA manually pushed the feet apart instead of using the control, and straps may have been unevenly positioned. The resident was lowered to the floor while still in the sling and sustained a small skin tear to the elbow; imaging later showed no fractures. The DON stated that three CNAs were involved, including one on light duty who was not supposed to be using the lift, and that no mechanical defect was found with the lift.
The facility failed to thoroughly investigate several allegations of verbal and potential physical abuse involving four cognitively intact residents with conditions including hemiplegia, rheumatoid arthritis, type 2 DM, epilepsy, and heart disease. In each case, the facility’s investigations were limited, often including only the directly involved resident and omitting interviews with other potentially knowledgeable residents or staff. One resident reported a verbal altercation with a CNA after a fall to the floor, another reported being verbally abused by a roommate’s family member, a third reported a male CNA was too rough and upset while changing linens, and a fourth reported a staff member insulted her and refused brief care. Investigation files lacked broader resident and staff interviews, timely physical and psychosocial assessments, and review of the accused staff member’s employee record, contrary to the facility’s abuse policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
A resident with rectal cancer and intact cognition reported that an RN on night shift confronted him when he returned from smoking off campus, spoke to him loudly about his smoking, used profanity, and threatened to have staff refuse to buzz him back into the building. A CNA corroborated that the RN was upset about being called in to work and used curse words toward the resident, but did not report the incident at the time because the RN was the night supervisor. The resident reported the event to the Social Services Director the next day, yet the facility initially treated it as a grievance rather than abuse and delayed submitting a report to the State Survey Agency until weeks later, after determining it was a reportable abuse incident.
Two residents did not receive required ADL and hygiene care as care planned. One resident with dementia and osteoarthritis, dependent for toileting and personal hygiene, was not toileted during an evening shift, with CNA documentation showing no toileting and the oncoming CNA finding the resident’s clothing, linens, and mattress saturated with urine; the assigned CNA reported care resistance but did not notify an RN or LPN. Another resident with dementia and stroke, requiring assistance with dressing and personal hygiene, remained in bed in pajamas into the afternoon without having received morning care, despite CNA documentation indicating dressing was completed; the CNA later confirmed that care was only provided after being questioned by an RN supervisor following a family complaint.
A resident with left-sided weakness after a stroke, high fall risk, and total dependence for ADLs and bed mobility was being turned onto their side for peri care by an aide when they fell from the bed to the floor, sustaining head trauma and a scalp laceration while on blood thinners. The care plan required extensive to total assistance with two-person support for bed mobility, but the fall occurred during care without documentation of the required level of assistance, indicating the facility did not provide adequate supervision and assistance to prevent accidents as outlined in its own fall prevention practices.
A resident with significant upper extremity weakness and recent surgery was discharged home to a multi-story residence without confirmed DME delivery, home health services, or caregiver support. Although referrals for home health, skilled nursing, and DME were made and family attended a discharge care plan meeting, staff did not verify that services were active, did not set or confirm a start-of-care date with the agency, and did not confirm delivery of a hospital bed. The resident, who lived alone and could not manage fine motor tasks, arrived home without in-home assistance, reported difficulty with eating and self-care, and was later found by an HHA RN in unsafe conditions, unable to access food or medications, leading to emergency transport back to the hospital.
A resident with dementia, Parkinson’s disease, CHF, and a history of AKI had documented fluid goals and was identified as at risk for dehydration and malnutrition, yet daily intake records repeatedly showed fluid consumption well below the recommended amounts. Despite severely impaired cognition, poor oral intake, and documented changes in mentation, lethargy, falls, and restlessness, the facility did not consistently implement or document enhanced monitoring, assistive feeding measures, or timely provider consultation focused on hydration. The resident was hospitalized twice with AKI, dehydration, hypotension, and anemia, and staff interviews confirmed that while expectations existed to encourage fluids and notify providers when goals were not met, there was no clear evidence that these expectations were carried out for this resident.
A resident with cardiac conditions was discharged home with a documented post-discharge plan for home health aide, home health RN/LPN, and PT/OT, but the facility did not complete the home health referral before discharge. The resident went home with a family member and, according to a complaint, did not receive PT, OT, or a nursing wellness check for about a week. The SW later confirmed the referral for home health and therapy services was not requested until several days after discharge, and services did not begin until even later, despite therapy recommendations that are typically communicated to social services to arrange home care.
The facility failed to consistently revise care plans to reflect residents’ current needs and behaviors and did not ensure a cognitively intact resident was involved in ongoing care planning. One resident participated in an initial care conference but was not included in later care plan updates. Another resident with an order for a palm protector was frequently observed without it and often refused it, yet the care plan did not address refusals. Two cognitively impaired residents whose MDS assessments showed dependence for bathing had care plans that still listed only setup or one‑person assist. A cognitively impaired resident with combative behaviors and an incident of striking another resident had a behavior care plan that was not updated to include attempts to hit other residents or the risk of resident‑to‑resident altercations.
Failure to Prevent Resident‑to‑Resident Physical Abuse Among Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from resident‑to‑resident physical abuse. One resident with dementia, agitation, depression, anxiety, and PTSD, and a BIMS score indicating moderate cognitive impairment, was pushed to the floor by another resident after that resident entered his room and followed him into the hallway. Staff initially documented the event as an unwitnessed fall after hearing loud screaming and finding the resident on the floor with complaints of right shoulder and left wrist pain, active bleeding from facial lacerations, and clamminess. Subsequent review of surveillance footage showed that another resident walked into the victim’s room, then followed him out and pushed him, causing the fall that resulted in multiple fractures, including a closed left distal radius fracture, a closed, displaced comminuted right proximal humerus fracture, and a closed, displaced distal clavicle fracture. The resident who pushed him had dementia with mood disturbances, bipolar disorder with psychotic features, PTSD, insomnia, and depression, and a BIMS score indicating severe cognitive impairment. His care plan identified a behavior problem related to bipolar disorder and dementia, including wandering, refusal of care, and physical aggression toward staff and others, such as biting a CNA and swinging a walker at a CNA. The care plan directed staff to anticipate and meet his needs, divert him with alternative objects or activities, intervene to protect the rights and safety of others, and conduct safety checks. Despite these identified risks and interventions, he was able to enter another resident’s room and subsequently push that resident in the hallway, resulting in serious injury. Another incident involved two residents with significant cognitive impairment and behavioral symptoms, including delusions, physical behaviors toward others, agitation, and a tendency to invade others’ personal space. One resident, who was described as aggressive toward others, easily agitated, and prone to getting into others’ personal space, walked next to another resident sitting in a dayroom chair and placed his hand on that resident’s chest. The seated resident responded by punching him in the face with the back of his fist, and the first resident then punched back. Staff and psychiatric documentation noted this altercation and ongoing behavioral concerns such as combativeness with care, agitation, and wandering, but the record contained no additional progress notes describing the incident itself beyond the brief psychiatric follow‑up entry. A further incident occurred when a resident with anxiety, major depressive disorder, dementia with behavioral disturbances, agitation, and severe cognitive impairment entered another resident’s room on the memory care unit. The resident in the room, who had depression, anxiety, dementia without behavioral disturbances, PTSD, insomnia, hallucinations, verbal behaviors toward others, other behavioral symptoms, and wandering, reported that he was hit in the face. Staff heard yelling and found the intruding resident pulling covers at the foot of the bed and yelling that the room was his house, while the other resident sat on the side of the bed and stated that he had been hit and told staff to get a gun and shoot the other resident. Slight puffiness was noted around the reporting resident’s left eye. The intruding resident’s care plan documented compulsiveness, invading others’ personal space, yelling, restlessness, physical aggression, and attempts to assist other residents he believed needed help, with interventions to divert him, familiarize him with his surroundings, and intervene to protect the rights and safety of others. Despite these identified behaviors and interventions, he was able to enter another resident’s room, engage in a confrontation, and allegedly strike the resident.
Resident Injury from Improper Hoyer Lift Operation During Transfer
Penalty
Summary
The deficiency involves the facility’s failure to prevent an accident during a Hoyer lift transfer, resulting in a fall and skin tear injury to a resident. The resident had diagnoses including spinal stenosis, Alzheimer’s disease, vascular dementia with behavioral disturbance, bipolar disorder, and pain, and was documented on the MDS as dependent on staff for transfers from bed to chair. The care plan and physician orders specified that the resident required a Hoyer lift with assistance of two staff for transfers. On the day of the incident, the resident was being transferred via Hoyer lift after a shower, from a shower bed back to a Geri-chair. Progress notes and the post-fall evaluation documented that the fall occurred in the bathroom during a Hoyer transfer with staff assistance of two, and that the Hoyer lift tipped sideways. The resident was found on the floor in the sling, with staff reporting that the Hoyer lift’s legs were widened and that as the resident was being positioned over the chair, the lift tipped to the side. Staff held the sling on each side of the resident’s head and lowered the resident to the floor, after which a skin tear measuring 1.0 cm x 0.1 cm was noted on the elbow. The facility’s investigation determined that the Hoyer tipped because one CNA pushed the lift’s feet apart manually instead of using the designated button to open the legs. Interviews indicated that the manual mechanical lift used at the time was considered less steady and required manual operation of a foot pedal to open the legs, and that the straps may have been more to one side than the other. The DON reported that three CNAs were involved with operating the lift at the time of the incident, including one CNA on light duty who was not supposed to be using the Hoyer lift, and that the lift itself was later found to have no mechanical problems. As a result of the tipping incident, the resident sustained a skin tear to the elbow and required diagnostic imaging to rule out fractures.
Incomplete Investigations of Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of verbal or potential physical abuse as required by its abuse, neglect, and exploitation policy. One cognitively intact resident with hemiplegia following a stroke reported a verbal altercation with a CNA after sliding to the floor while being assisted back to bed. The resident requested use of a Hoyer lift, the CNA told him he could get himself up, and an argument ensued in which the CNA told the resident it was not his room and did not leave until directed by an LPN. The facility’s investigation file for this incident contained only the resident’s interview and no interviews with other residents on the unit who might have had knowledge of similar verbal abuse by the CNA. Another cognitively intact resident with rheumatoid arthritis, hypertension, and peripheral vascular disease reported that her roommate’s daughter came into her room and verbally abused her after the roommate had been relocated due to aggression. The daughter allegedly cursed at the resident, calling her an offensive name and telling her she was going to hell. The investigation file for this incident contained no interviews with other residents on the unit to determine whether they had experienced verbal abuse by this family member or had knowledge of the event. The DON acknowledged that no such interviews were conducted. A third cognitively intact resident with type 2 diabetes and epilepsy reported, through her daughter, that a male CNA wearing a red shirt was too rough with her and appeared upset about having to change her linens. The facility’s investigation into this potential staff-to-resident abuse included an interview with the resident but did not include interviews with other interviewable residents in the same area who might have had knowledge of the incident. A fourth cognitively intact resident with type 2 diabetes and heart disease, later discharged, reported that a staff member entered her room, called her a poor excuse for a human being, and refused to assist with changing her brief. The investigation documentation for this allegation lacked interviews with additional residents or staff, did not show that the resident was promptly assessed physically and psychosocially in relation to the allegation, and did not include a review of the accused staff member’s employee record, resulting in an incomplete investigation contrary to facility policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
Failure to Protect Resident From Verbal Abuse and Delay in Reporting Incident
Penalty
Summary
The facility failed to protect a cognitively intact resident from verbal abuse by a staff member. The resident, admitted with rectal cancer and independently ambulatory with a rolling walker, reported that during an overnight shift he left the campus to smoke and, upon returning and walking toward the nursing station, was confronted by an RN. According to the resident’s report, the RN told him that when she was on the night shift he was not allowed to go outside, using profanity toward him, and further stated that if he went out the door she would instruct staff not to buzz him back into the building. A CNA later confirmed that the RN had been upset about being called in to work, spoke loudly to the resident about his smoking, and used curse words when he responded to her. The incident was not promptly reported to facility administration despite occurring during the night shift, with the CNA stating that the RN involved was the supervisor at the time. The resident reported the incident the following day to the Social Services Director, but the facility did not immediately recognize or treat the allegation as reportable abuse. Instead, the administration initially considered it a grievance and investigated it in that manner. The incident report was not submitted to the State Survey Agency until several weeks after the resident’s report, and only after the facility later determined that the event constituted a reportable abuse incident.
Failure to Provide Required ADL and Hygiene Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL assistance to maintain grooming and personal hygiene for two dependent residents. One resident with dementia, osteoarthritis, and moderately impaired cognition was care planned to receive partial to substantial assistance with personal and oral care, scheduled toileting every two hours, and assistance with toilet transfers. CNA documentation for an evening shift showed “N/A” for all scheduled toileting times, and a facility incident report stated that the CNA assigned to this resident failed to provide incontinence care during that shift. The oncoming night-shift CNA later found the resident’s clothing, linens, and mattress saturated and soaked with urine and provided the needed care, with the prior-shift LPN confirming the condition when notified. The assigned CNA reported the resident was resistant to care but did not notify the LPN or RN for assistance or document the issue. The second resident, with dementia, stroke, weakness, and moderately impaired cognition, was care planned for an ADL self-care deficit requiring setup or cleanup assistance with eating, partial to substantial assistance with personal hygiene and oral care, and substantial assistance with toileting, showering/bathing, and lower body dressing. On a morning shift, the resident’s daughter-in-law reported to the LSW that she did not believe the resident had received morning care because he was still in bed wearing pajamas and had not yet received his lunch tray. A CNA statement indicated the resident had eaten breakfast and was later found asleep in bed, and CNA documentation for that shift showed the dressing task as completed. However, the facility’s follow-up summary documented that the CNA confirmed care had not been provided to the resident prior to being questioned by the RN supervisor, and the LSW confirmed that the CNA changed the resident only after the family reported the concern and nursing was notified.
Failure to Provide Adequate Supervision and Assistance During Bed Mobility for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for a resident with significant functional and cognitive impairments. The resident was admitted with left-sided weakness after a stroke and was care planned as extensively to totally dependent for bed mobility, requiring the support of two persons. A fall risk evaluation documented a score of 10, indicating high fall risk, and a quarterly MDS assessment showed the resident was unable to participate in a cognitive assessment and was completely dependent on staff for all ADLs. Despite these identified needs and risks, the resident was being turned onto their side for peri care by an aide when they fell from the bed to the floor. During this incident, the resident sustained head trauma and a small scalp laceration, and was on blood thinners at the time of the fall. The fall occurred while the aide was providing peri care and turning the resident, but the report does not document the presence of a second staff member, despite the care plan indicating the need for two-person assistance for bed mobility. The facility’s own policy on falls emphasized instituting individualized practices to minimize fall risk and maximize safety for residents identified as high risk, but the resident’s documented high fall risk and total dependence were not adequately addressed in the supervision and assistance provided at the time of the fall.
Failure to Ensure Safe Discharge with Confirmed Home Services and Support
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s discharge home included confirmed durable medical equipment (DME), home health services, and adequate caregiver support. The resident was admitted with spinal stenosis, cervical disc disorder, muscle weakness, carpal tunnel syndrome, and a recent post-fasciotomy to the right arm, and was documented as cognitively intact with a BIMS score of 14/15. Despite these physical limitations, the facility discharged the resident home in the evening via medical transport to a three-story residence, where no caregiver support was present. The facility’s own policy required a post-discharge plan of care developed with the resident and representative, and orientation to ensure a safe and orderly transfer or discharge, but the record lacked evidence that services were confirmed as in place prior to discharge. Prior to discharge, the social worker documented that the resident would have a safe discharge home with services and supports in place, and that referrals for home health care, skilled nursing services, and DME had been made, with family members in attendance at the discharge care plan. However, the clinical record did not contain confirmation that these services were actually arranged and active before the resident left the facility. The resident was discharged with medications called to the pharmacy for home delivery, but there was no documentation that the hospital bed had been delivered or that home health nursing, therapy, or home health aide services were scheduled to start at the time of discharge. The social worker later acknowledged not informing the agency of a specific start-of-care date, assuming the agency and VA would contact the resident, and confirmed not calling to verify delivery of the hospital bed. After discharge, it was discovered that the hospital bed ordered days earlier was not delivered until the morning after the resident arrived home, and that therapy, RN, and HHA services had not yet begun or contacted the resident by the time the facility followed up. The resident reported living alone, being unable to use their hands, needing a caretaker, and having to rely on a sister-in-law for limited assistance with hygiene, meals, and rearranging furniture for the bed that arrived later. The significant other confirmed that no one lived with the resident, that they had their own health issues, and that neither they nor their son stayed with the resident after discharge. When a home health RN eventually visited, the resident was found sitting on a couch in minimal clothing, reporting not having eaten adequately for two days, having little or no accessible food, and being unable to open medications or bottles due to impaired fine motor skills. The RN observed the resident’s inability to grip or perform fine motor tasks, assisted with toileting, and then contacted the agency director and emergency services due to the unsafe conditions in which the resident had been left. These events led surveyors to determine that the facility failed to ensure services and caregiver support were in place prior to discharge, resulting in an immediate jeopardy situation.
Removal Plan
- Audited discharge documentation related to home health services, appropriate caregiver/family support, and any necessary services to meet residents' care needs to determine if any residents were affected.
- Reviewed planned discharges by the Administrator, DON, Director of Social Services, and Director of Rehabilitation to ensure home health services, appropriate caregiver/family support, and necessary services to meet the resident's care needs are in place before discharge.
- Completed a root cause analysis identifying failure to have a robust discharge care plan meeting with the interdisciplinary team (IDT), resident, and resident representative.
- Reviewed the procedure for safe and effective discharge planning with the IDT.
- Re-educated the discharge planning IDT on the discharge policy and procedure to ensure sufficient preparation and orientation for a safe discharge.
- Implemented review of residents scheduled to be discharged to ensure appropriate discharge planning is in place.
- Implemented review of residents scheduled for discharge to ensure ADL support is in place, durable medical equipment is available prior to or on the discharge date, medications are available upon discharge, and identified needs/support are available.
- Implemented review of residents scheduled for discharge to ensure safe discharge planning is in place and to address any issues identified.
- Implemented oversight during utilization review by the NHA/designee to ensure discharge planning preparation and services are in place prior to discharge.
- Initiated audits and educational in-services to the IDT team and conducted staff interviews to confirm education received regarding discharge to the community and/or transfers to other facilities.
Failure to Maintain Adequate Hydration Resulting in Recurrent AKI and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate hydration for a resident with significant medical conditions, including acute kidney injury (AKI), congestive heart failure (CHF), dementia, and Parkinson’s disease. Upon admission, the resident’s care plan identified potential for altered nutrition and included interventions such as assisting at meals, encouraging oral fluids, and monitoring for additional nutrition interventions. A nutrition assessment established an initial fluid goal of 1943–2098 mL/day and documented that the resident was at risk for dehydration and malnutrition, with early labs showing a BUN of 29, creatinine of 1.4, and eGFR of 53. The admission MDS documented that the resident was severely cognitively impaired and required setup assistance for feeding and hydration. Daily fluid intake records from CNA task flow sheets and the MAR showed that the resident’s intake frequently fell below the recommended fluid goals, with multiple days of intake under 1200 mL and some days as low as 360–720 mL. A malnutrition risk assessment identified the resident as at risk for malnutrition due to severe dementia and tremors. A subsequent nutrition note on 5/12/25 documented that the resident’s average fluid intake was 330 mL/day, recommended discontinuing a prescribed hydration pass due to CHF, and set a new fluid goal of 1635–1766 mL/day, while continuing to recommend encouraging oral fluids. Despite these documented risks and low intakes, there is no evidence in the record of intensified monitoring or additional interventions to ensure the resident met the revised fluid goals. The resident experienced multiple clinical deteriorations associated with poor intake and changes in condition. On 6/1/25, after a day with only 360 mL of recorded intake, the resident was transferred to the hospital following falls, hypotension, and confusion, and was admitted with AKI and dehydration. After readmission to the facility, nursing documentation noted low oral intake and a plan to discuss adding the resident to an assist-to-feeding list, but the record lacked evidence that this occurred. Subsequent notes documented lethargy, increased confusion, agitation, restlessness, and continued poor intake, yet a physician progress note following two unwitnessed falls did not include an assessment of hydration status or interventions to improve hydration. On 6/19/25, labs showed a BUN of 62 mg/dL and creatinine of 1.7 mg/dL, and the resident was again sent to the hospital and admitted with AKI, hypotension, and anemia, requiring IV fluid resuscitation. Staff interviews confirmed expectations to monitor intake, encourage fluids, and notify providers when fluid goals were not met, but there was no documentation that the provider was consistently notified or that appropriate interventions were implemented in response to the resident’s ongoing inadequate fluid intake and changes in condition.
Failure to Arrange Timely Home Health Services Prior to Discharge
Penalty
Summary
The facility failed to ensure a timely referral for home health care services prior to discharge for one resident. Facility policy dated 5/1/25 required sufficient preparation and orientation to residents to ensure an orderly transfer or discharge. The resident was admitted on 7/28/25 with diagnoses including aortic valve replacement, aortic regurgitation, and congestive heart failure. A discharge summary dated 8/11/25 documented a post-discharge plan for home health aide, home health RN/LPN, and occupational and physical therapy. The resident was discharged home with a family member on 8/12/25. A complaint received by the Division on 9/30/25 stated that the resident was discharged to a family member's home without a home health care agency referral and that, after one week at home, the resident had not received any physical or occupational therapy or a wellness check from a nurse. During an interview on 2/16/26, the social worker reported needing to check if a referral was made and later confirmed that the referral for home health and therapy services was not requested until 8/15/25, with services opened on 8/20/25. The director of therapy confirmed that physical and occupational therapy were recommended for the resident and stated that such recommendations are typically communicated to social services to set up home care. Findings were reviewed with facility leadership during the exit conference.
Failure to Revise Care Plans and Involve Resident in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise person‑centered care plans and to involve a cognitively intact resident and/or representative in the care planning process. One resident with an intact BIMS score of 15 was admitted and had a documented care conference shortly after admission, but there was no evidence of any subsequent care conferences during the following year despite multiple care plan updates. The resident reported not recalling quarterly care plan meetings, and staff confirmed that no care conferences occurred after the initial one, with no documentation that the resident or representative participated in the later care plan revisions. Additional residents’ care plans were not revised to reflect current, individualized needs and behaviors. One resident had a physician’s order for a right palm protector or substitute, was repeatedly observed without it in place, and routinely refused it according to nursing and CNA interviews, yet the care plan did not address potential refusals. Two cognitively impaired residents whose MDS assessments documented dependence for bathing had care plans that continued to list only setup assistance or one‑person assist, without updating to reflect full dependence. Another cognitively impaired resident with documented combative behaviors toward staff and a reported incident of striking another resident with a remote had a behavior care plan that was not revised to include the new behavior of attempting to hit other residents or the potential for resident‑to‑resident altercations.
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