Excelcare At Lewes Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewes, Delaware.
- Location
- 301 Ocean View Blvd, Lewes, Delaware 19958
- CMS Provider Number
- 085034
- Inspections on file
- 24
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Excelcare At Lewes Llc during CMS and state inspections, most recent first.
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.
A resident with a neurogenic bladder and chronic Foley catheter experienced repeated catheter-related problems, including difficult reinsertion, multiple dislodgements, frequent leakage, and episodes of bleeding with clots that led to hospital evaluation. Imaging showed the catheter balloon positioned in the penile urethra. LPNs reported ongoing difficulty changing the catheter and indicated that the resident had been recommended for urology follow-up and catheter changes by urology due to the complexity. Despite an expectation to schedule outside providers promptly, the resident was not seen by urology until many months after these ongoing catheter issues, resulting in a deficiency for failure to obtain a timely urology referral.
The facility failed to maintain a homelike environment by routinely using an overhead paging system for non-emergent staff communication during daytime hours. Surveyors repeatedly heard overhead pages during observations, and a resident reported during a council meeting that the paging was unpleasant. The NHA confirmed that overhead paging was used to communicate with staff during the day and discontinued only in the evening, contributing to an environment that residents found uncomfortable.
Two residents with severe cognitive impairment experienced escalating verbal and physical conflict over several weeks, with one resident exhibiting increasing aggression and behavioral disturbances. Despite repeated documentation of these behaviors and ongoing roommate conflict, the facility did not revise care plans, increase supervision, or notify the social worker. The situation culminated in a physical altercation where one resident sustained a head injury and required hospital evaluation.
Two incidents of suspected abuse involving residents were not reported to the State Agency within the required two-hour timeframe. In one case, a resident had a psychotic episode and made physical contact with others, but the report was delayed to ensure accuracy. In another case, a resident alleged being choked by her spouse, but the allegation was not promptly communicated to management or reported as required.
A resident's clinical record lacked required documentation following an incident, including progress notes and consults. Although electronic communication suggested a wellness check occurred, an LPN confirmed that the resident was not seen by a psychiatrist and that no relevant notes were present in the medical record. This deficiency was confirmed through staff interviews and record review.
A resident with chronic health conditions and full cognitive function was left in a room with soiled, odorous bed linens while being served breakfast. Despite requests, staff delayed changing the linens, prioritizing meal tray distribution. Nursing leadership later confirmed that linens should have been changed before the meal was provided, resulting in a failure to ensure a dignified dining experience.
A staff member engaged in a verbal altercation with a cognitively intact resident, using an argumentative tone and profanity, in violation of facility policy prohibiting verbal abuse. The incident was witnessed by a social worker and reported by staff, with varying recollections of the details.
An LPN was found to have taken a resident's prescribed Percocet from the medication cart, resulting in the misappropriation of the medication. The incident was discovered after a medication count discrepancy and confirmed through pharmacy records and facility investigation. The resident had an active order for Percocet for pain management, and the LPN did not respond to contact attempts after leaving the facility.
A resident with moderate cognitive impairment expressed fear of a staff member, but the allegation was not reported to the Abuse Coordinator or State Survey Agency as required by facility policy. The ADON and DON did not initiate an investigation, citing the resident's confusion, and the Administrator later confirmed the report should have been made regardless of cognitive status.
A resident with moderate cognitive impairment reported fear of a staff member to the ADON, but no investigation was conducted due to assumptions about the resident's confusion. The DON and ADON did not report or investigate the allegation, and the administrator later confirmed that the incident should have been reported and investigated according to facility policy.
A resident with bilateral above-knee amputations and diabetes did not receive wound care as ordered, with a scheduled dressing change missed and the care plan not updated to reflect new wound care orders. Nursing staff and leadership confirmed the lapse after reviewing the medical record and physician orders.
A resident with dementia and diabetes, who developed a stage 2 pressure sore and a deep tissue injury, did not receive a low air loss mattress as ordered by the wound care physician. Despite multiple observations and confirmation from the UM and ADON, the mattress was not applied, and the resident remained on a regular pressure reducing mattress, resulting in incomplete implementation of pressure ulcer care interventions.
Two residents sustained injuries during incontinence care when staff failed to follow care plans requiring two-person assistance and use of a mechanical lift. One resident, dependent for all ADLs, rolled off the bed and suffered a forehead laceration when left with only one CNA. Another non-ambulatory resident was assisted to stand without a lift, resulting in a skin tear and requiring multiple staff to return her to bed. Staff interviews and records confirmed care protocols were not followed.
Two residents with indwelling urinary catheters did not have appropriate physician orders or documentation for routine catheter care. One resident with quadriplegia and urinary retention had no orders or evidence of catheter care in the EMR, MAR, or TAR, despite a care plan indicating scheduled changes. Another resident with acute kidney failure and bladder dysfunction also lacked catheter care orders and reported the catheter was overdue for a change. The ADON confirmed missing orders and stated that catheter changes were only done when symptomatic, with some orders not transferring from the hospital.
A resident with quadriplegia was found with side rails raised on both sides of the bed without a physician's order, care plan documentation, or evidence that alternatives were considered. The resident was unable to use the side rails, and staff confirmed that proper assessment and authorization were not completed prior to their use.
A nurse administered Ativan and morphine to a resident without a physician's order, failing to verify the resident's identity before giving the medications. The resident, who had heart failure, anemia, and COPD, did not have these medications ordered, and the error was discovered immediately after administration.
The facility did not ensure proper PPE use for a resident on contact isolation with a PEG tube, as an LPN administered medications without donning a gown as required by policy. Additionally, another resident experiencing multiple episodes of vomiting was not promptly identified or placed on contact isolation after developing COVID-19, and staff failed to communicate the resident's symptoms to nursing leadership in a timely manner.
The facility failed to ensure that referrals for PASARR screenings were completed for five residents who had changes in their mental health conditions or new psychiatric diagnoses. These failures were confirmed through interviews with facility staff and email correspondence with the State PASARR Authority, which indicated that the facility should have submitted resident review PASARRs for these cases. The findings were reviewed with the facility's nursing home administrator, director of nursing, assistant director of nursing, and corporate representatives during the exit conference.
A resident with specific dietary needs was served whole cauliflower florets instead of the prescribed ground cauliflower. The resident, who does not use dentures and has no natural teeth, found the food too hard to consume. Staff confirmed the discrepancy between the meal ticket and the food served.
The facility failed to provide a clean and homelike environment for a resident, with observations revealing dirt, food crumbs, black debris, and a peeling baseboard in the room. Despite the resident reporting these issues to maintenance a year ago, the room remained unclean, and the baseboard was not fixed until later.
The facility failed to ensure that a physician reviewed the total program of care, including medications and treatments, for a resident admitted with an indwelling urinary catheter. The physician's progress note lacked mention of the catheter, resulting in six days without proper orders. This was confirmed by a nurse practitioner and discussed with facility leadership during the exit conference.
The facility failed to ensure a qualified person was present in the kitchen during all hours of food service operation. Only one staff member had a valid Food Protection Manager certificate. These findings were reviewed with the NHA, DON, ADON, and a corporate representative during the exit conference.
The facility failed to ensure proper food storage, preparation, and sanitization. Observations included uncovered food, unlabeled and undated items, and insufficient sanitizer levels, which were confirmed by the NHA and reviewed with the DON, ADON, and a corporate representative.
The facility failed to ensure that the call bell system in a resident's room was functioning properly. The call bell box was taken apart with exposed wires, and no alternate equipment was available for the residents to call for help. An RN confirmed the issue, and the Maintenance Director stated that a work order had been submitted four days prior but could not be addressed sooner. The call bell system was eventually repaired and tested.
A resident with severe cognitive impairment was found with a bruise of unknown origin on the left upper arm. The facility did not document measurements or descriptions, failed to report the incident to the state agency within the required timeframe, and did not notify the resident's family. This was confirmed by the DON and other staff members.
The facility failed to ensure that a resident had physician orders for immediate care upon admission. The resident was admitted with an indwelling urinary catheter and diabetes, but the necessary physician orders for both conditions were not obtained until several days later. Staff interviews confirmed that the admitting nurse forgot to obtain the batch orders from the provider.
The facility failed to ensure that a resident with chronic idiopathic constipation received treatment and care according to physician orders. From 7/1/23 through 9/30/23, the facility did not implement the bowel protocol when the resident failed to have bowel movements for nine shifts on multiple occasions. The necessary medications were not administered, and there was a lack of monitoring and bowel assessments. These findings were confirmed by an RN and reviewed with facility leadership during the exit conference.
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.
Failure to Obtain Timely Urology Referral for Resident With Ongoing Foley Catheter Issues
Penalty
Summary
The deficiency involves the facility’s failure to obtain a timely urology referral for a resident with a neurogenic bladder and chronic Foley catheter, despite ongoing catheter-related problems. The resident was admitted with an indwelling Foley catheter and had a care plan addressing catheter management, including monitoring for discomfort, UTI signs, and pain. On one occasion, the resident returned from an appointment with the Foley catheter out and reinsertion attempts by staff were unsuccessful due to resistance; the provider was notified and ordered the catheter left out with bladder scans every eight hours. The catheter was successfully reinserted the following day. Subsequently, the resident experienced a large amount of bleeding and blood clots from the penis, and the on-call provider ordered labs and a urine culture. The resident later presented with excessive bleeding and clots around the urinary catheter and was sent to the hospital, where a CT scan showed the catheter tip in the penile urethra with the balloon distended just proximal to the tip. Interviews with nursing staff revealed that the resident’s catheter had been difficult to replace and that staff had ongoing difficulty changing it, with multiple catheter dislodgements and frequent leakage reported over the course of the year. LPNs reported that the expectation was for staff nurses to attempt catheter changes and refer out if unsuccessful, and one LPN stated that the resident was recommended to follow up with urology and have catheter changes done there due to the increased difficulty. Another LPN confirmed that the expectation was to schedule residents with outside providers as soon as possible and acknowledged that this resident did not see urology until many months after the documented catheter complications and difficulties. The surveyors concluded that the facility failed to refer the resident to an outside provider in a timely manner while there was an ongoing urinary catheter issue.
Non-Emergent Overhead Paging Disrupts Homelike Environment
Penalty
Summary
The facility failed to honor residents’ right to a safe, clean, comfortable, and homelike environment by repeatedly using an overhead paging system for non-emergent staff communication. During random observations on multiple dates and times, surveyors heard overhead paging announcements used to communicate between staff members during the day. During a resident council meeting, an anonymous resident reported that the overhead paging by facility staff was unpleasant. In a subsequent interview, the Nursing Home Administrator (E1) confirmed that the facility routinely used overhead paging to communicate with staff during the day, stopping only after 7:00 PM. These observations and interviews were reviewed with the NHA (E1), Regional Operations Director (E2), and DON (E3) during the exit conference. No specific resident medical histories or clinical conditions were described in relation to this deficiency, and the report focuses on the environmental impact of overhead paging on residents’ comfort and homelike surroundings.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident (R2) from abuse by another resident (R1), resulting in physical and psychosocial harm. R1 and R2, both with severe cognitive impairment, were roommates and had escalating verbal altercations over a period of several weeks. Documentation showed that R1 exhibited increasing agitation, aggression, and behavioral disturbances, including verbal and physical aggression toward staff and other residents. Despite repeated documentation of these behaviors and ongoing conflict between the two residents, the facility did not revise R1's care plan, reassess the risk of the roommate pairing, or implement additional interventions to prevent harm. Staff interviews and progress notes indicated that R1's behaviors became more difficult to redirect, and that both residents were involved in frequent verbal altercations. Staff reported that the behaviors had been ongoing and that interventions such as redirection were unsuccessful. The social worker was not notified of the escalating conflict, and no changes were made to the residents' room assignments or supervision levels prior to the incident. The facility also failed to obtain behavioral health services for R1, despite documentation of severe behavioral symptoms and cognitive impairment. The situation culminated in an unwitnessed physical altercation in which R2 was found on the floor with a head injury, and R1 was observed standing over him. R2 required transport to the hospital for evaluation and was diagnosed with a head injury, neck muscle strain, and a suspected wrist ligament injury. Interviews with staff and R2 confirmed that R1 had threatened and physically harmed R2, resulting in fear and ongoing psychosocial distress for R2. The facility's lack of timely intervention and failure to address the escalating conflict directly led to the incident of abuse.
Failure to Timely Report Suspected Abuse Allegations
Penalty
Summary
The facility failed to report incidents of suspected abuse involving two residents within the required two-hour timeframe to the State Agency. In the first case, a resident experienced a psychotic episode and made physical contact with three other residents. The incident occurred at approximately 9:00 PM, but the report was not submitted to the State Agency until the following afternoon, well beyond the mandated reporting window. Staff interviews confirmed the timing of the incident and the delayed reporting, with the Assistant Director of Nursing acknowledging the late submission was due to the facility's desire to provide accurate data. In the second case, a resident alleged that her husband, who was also a resident, choked her. This allegation was reported by a CNA to a nurse, who then reported it to the nursing supervisor as per facility protocol. However, the Assistant Director of Nursing was not made aware of the allegation, and there was uncertainty among staff regarding the exact date of the incident and whether it was properly reported. The social worker confirmed that the resident's history of making similar allegations was discussed in an interdisciplinary team meeting, but there was no clear documentation or timely reporting of the specific abuse allegation to the State Agency.
Failure to Maintain Accurate Clinical Documentation
Penalty
Summary
The facility failed to ensure that the clinical record for one resident contained accurate and complete documentation. Specifically, after an incident, there was no evidence in the resident's clinical record of a progress note, consult, medication review, or visit summary. Although the facility provided electronic communication from a nurse practitioner indicating the resident was seen for a wellness check, an LPN confirmed that the resident had not been seen by a psychiatrist on the date in question and that no corresponding progress notes were present in the electronic medical record. This lack of accurate documentation was confirmed during interviews with facility staff and reviewed during the exit conference.
Failure to Maintain Dignified Dining Experience Due to Soiled Bed Linens
Penalty
Summary
A resident with diagnoses including generalized osteoarthritis and chronic obstructive pulmonary disease, and who was cognitively intact, was observed seated in a wheelchair at the foot of his bed. The resident's bed linens were visibly soiled with a large brown stain and the room was described as very odorous. The resident's breakfast tray was present, and the resident expressed distress about being expected to eat while his bed remained soiled, stating that staff had promised to change the linens but had not returned. A registered nurse acknowledged the need to change the bed linens and a second request was made before the bed was eventually changed, resulting in a delay of at least 14 minutes. The nurse explained the delay was due to staff passing meal trays and not wanting them to sit out. The Director of Nursing and Assistant Director of Nursing later confirmed that the bed linens should have been changed before the resident was provided breakfast. This sequence of events resulted in the resident not receiving care in a manner that maintained a dignified dining experience.
Verbal Abuse of Resident by Staff Member
Penalty
Summary
A deficiency occurred when a staff member, specifically a medical records clerk, engaged in a verbal altercation with a resident. The incident was witnessed by a social worker, who observed the staff member using an argumentative tone and, after being advised to disengage, turning back to confront the resident and using profanity. The resident involved was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The facility's policy prohibits verbal abuse, including the use of disparaging or derogatory language toward residents. Interviews with facility staff provided varying accounts of the incident. The Social Service Director reported hearing raised voices and stated that the resident used profanity toward staff, but could not recall if the staff member used profanity toward the resident. The Assistant Director of Nurses remembered the incident but did not provide further details. The administrator confirmed that the staff member was immediately removed from the situation. The incident was reported and reviewed as part of the facility's procedures for preventing and identifying abuse.
Misappropriation of Resident Medication by LPN
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) took a resident's prescribed Percocet pain medication from the medication cart without authorization. The incident began when two blister packs of Percocet were delivered by the pharmacy and were initially placed incorrectly on the medication carts, leading to a discrepancy in the count. After the error was corrected, the narcotics were counted and recorded as correct at the start of the LPN's shift. However, following the LPN's shift, it was discovered that one blister pack containing 30 tablets was missing, and only two tablets remained in the other pack. The facility's investigation determined that the LPN was responsible for the missing medication, and the nurse did not respond to attempts to contact her after leaving the building. The resident involved had a physician's order for Percocet two tablets every six hours for pain management. The facility's policy defined misappropriation as the wrongful use of a patient's belongings or medication without consent. The incident was identified through medication count discrepancies and confirmed by pharmacy records. The LPN's actions resulted in the misappropriation of the resident's medication, as confirmed by interviews and documentation reviewed during the investigation.
Failure to Report Alleged Abuse as Required by Policy
Penalty
Summary
The facility failed to follow its own policies and procedures for reporting suspected abuse to the State Survey Agency (SSA) for one resident. According to the facility's policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but not later than two hours after the allegation is made if it involves abuse or results in serious bodily injury, or within 24 hours if it does not. In this case, a resident with moderate cognitive impairment reported to the Assistant Director of Nurses (ADON) that she was afraid of a female staff member. The ADON did not report this allegation to the Abuse Coordinator or the SSA, citing the resident's confusion as the reason for not reporting. The Director of Nurses (DON) also confirmed that the allegation was not reported or investigated, and the Administrator acknowledged that the report should have been made regardless of the resident's cognitive status. The investigation revealed that the resident's statement about being afraid was not documented or reported in a timely manner, and the initial documentation by the ADON was unsigned and undated. The ADON later provided a revised statement indicating the resident was confused and did not recall the earlier conversation. Despite this, the facility's policy requires all allegations to be reported and investigated, regardless of the resident's mental status. The failure to report and investigate the allegation as required by policy had the potential to contribute to continued abuse for this resident and others.
Failure to Investigate Resident's Allegation of Staff Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of staff-to-resident abuse involving one resident out of a sample of 46. According to the facility's policy, all alleged violations must be thoroughly investigated, and the results reported to the administrator and appropriate officials. On the date in question, a resident with moderate cognitive impairment (BIMS score of 11/15) reported to the ADON that she was afraid of a female staff member with a hairband and long, black hair. Despite this report, no investigation was initiated at that time. Interviews revealed that the DON considered the resident to be confused and did not report or investigate the allegation, stating that it would be addressed during the ongoing five-day investigation for another resident. The ADON also confirmed that no investigation was conducted due to the resident's confusion. The administrator later acknowledged that the allegation had not been reported to her and confirmed that any report of fear from a resident, regardless of cognitive status, should have been reported and investigated. This lack of action resulted in the facility not meeting its policy requirements for responding to and investigating allegations of abuse.
Missed Wound Care Treatment and Care Plan Update
Penalty
Summary
A deficiency occurred when a resident with a history of bilateral above-knee amputations, peripheral vascular disease, and type 2 diabetes mellitus with neuropathy did not receive wound care treatment as ordered by the physician. The resident, who was cognitively intact, reported that the dressing on his left stump had not been changed as scheduled. Observation confirmed that the bandage was dated two days prior, and review of the Treatment Administration Record showed the wound care was not performed on the required date. The physician's order specified that the wound should be cleaned with normal saline and Silvasorb Alginate applied every other day, but this was not followed. Further review revealed that the resident's care plan was not updated to reflect the new wound care treatment ordered by the wound care physician. Interviews with nursing staff and review of the electronic medical record confirmed the omission of the scheduled treatment and the lack of care plan revision. The Director of Nursing and Assistant Director of Nursing acknowledged that the treatment was missed and the care plan did not include the current intervention.
Failure to Provide Ordered Low Air Loss Mattress for Pressure Ulcer Care
Penalty
Summary
A resident with dementia and type 2 diabetes was admitted to the facility and later developed a stage 2 pressure sore on the left buttock and a deep tissue injury on the right heel. The resident was assessed as being at risk for further skin breakdown, and the care plan included the use of a pressure reducing mattress. Physician orders were in place for wound care, including cleansing and dressing changes, but did not specify the use of a low air loss mattress. During wound rounds, the wound care physician ordered a low air loss mattress to prevent worsening of the resident's wounds, and the unit manager reported placing the order in the facility's maintenance request system on the same day. Despite these orders, multiple observations over several days showed that the low air loss mattress was not applied to the resident's bed, and the resident continued to lie on a regular pressure reducing mattress. The unit manager and assistant director of nursing confirmed that the low air loss mattress had not been provided as expected, and that it should have been placed on the resident's bed the same day the order was made. This failure to implement all planned interventions for pressure ulcer care created the potential for further unnecessary skin breakdown for the resident.
Failure to Follow Care Plans During Incontinence Care Results in Resident Injuries
Penalty
Summary
The facility failed to prevent injuries during incontinence care for two residents by not following established care plans and protocols. One resident, who had a diagnosis of cerebral infarction and was dependent on staff for all activities of daily living due to contractures and impaired extremities, required two-person assistance for bed mobility and incontinence care. During an episode of incontinence care, only one CNA was present, and the second CNA left the room to retrieve a sheet. While unattended, the resident rolled off the bed and sustained a laceration to the forehead, requiring emergency department evaluation. Another resident, with diagnoses including schizophrenia, morbid obesity, and congestive heart failure, was non-ambulatory and required two-person assistance with a Hoyer lift for all transfers according to the care plan. Despite this, two CNAs attempted to assist the resident to stand next to the bed for ADL/peri-care without using the mechanical lift. The resident became weak, was lowered to the floor, and sustained a skin tear to the abdomen. Four staff members and a Hoyer lift were then required to return the resident to bed. In both cases, staff did not adhere to the residents' care plans, which specified the need for two-person assistance and the use of a mechanical lift for transfers. These failures resulted in preventable injuries during routine care activities. Interviews with staff and review of documentation confirmed that the required protocols were not followed at the time of the incidents.
Lack of Physician Orders and Documentation for Catheter Care
Penalty
Summary
The facility failed to ensure that two residents with indwelling urinary catheters had appropriate physician orders and documentation for the use and routine care of their catheters. For one resident with quadriplegia and urinary retention, there were no orders in the electronic medical record (EMR) for the use or care of the urinary catheter, and no evidence in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) that routine catheter care was provided. The resident's care plan indicated a suprapubic catheter was in place and scheduled to be changed every four weeks at a urology office, but this was not reflected in the physician orders or care documentation. Interviews with the Director of Nursing (DON) and Assistant DON (ADON) confirmed that their expectation was for physician orders to be present for catheter use and care. Another resident, admitted with acute kidney failure and neuromuscular dysfunction of the bladder, also lacked orders for catheter care in the EMR, MAR, and TAR, despite having an order for a urinary catheter. The resident reported that the catheter was overdue for a change by at least a month, and the ADON confirmed that the last change occurred during a hospital visit for a urinary tract infection. The ADON also noted that the facility's policy was to change catheters only when symptomatic, and that previous orders did not transfer over from the hospital. These omissions resulted in a lack of documented routine catheter care for both residents.
Failure to Assess and Authorize Bed Rail Use for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident with quadriplegia was appropriately assessed and authorized for the use of side rails on his bed. The facility's policy required that alternatives be attempted before installing side rails, that a physician's order be obtained, and that the use of side rails be included in the resident's care plan. However, review of the resident's records showed no physician's order for side rails, no documentation in the care plan regarding their use, and no evidence that alternatives were considered. The Device/Restraint Assessment and Consent Form noted the presence of 1/4 side rails but did not provide a rationale, document attempted alternatives, or indicate that risks had been discussed with the resident. Observations confirmed that the resident, who was completely dependent on staff for all mobility and unable to use the side rails due to quadriplegia, consistently had side rails raised on both sides of his bed. Interviews with the resident and facility staff, including the ADON and DON, confirmed that the resident could not use the side rails and that their presence was not appropriate. The lack of assessment, documentation, and proper authorization for the use of side rails constituted the deficiency.
Medication Error: Administration Without Physician Order
Penalty
Summary
A registered nurse (RN) administered Ativan, an anxiolytic, and morphine, a narcotic pain medication, to a resident without a physician's order for these medications. The RN did not verify the resident's identity by checking the armband or asking the resident's name before administering the medications. The error was discovered immediately after administration when the RN realized the medications were given to the wrong resident. The resident who received the medications had a medical history including heart failure, anemia, and chronic obstructive pulmonary disease (COPD), and did not have orders for Ativan or morphine on their Medication Administration Record. The facility's policy required staff to prepare medications for one resident at a time, confirm the correct medication and dose, and verify the resident's identity, all of which were not followed in this incident.
Failure to Implement Effective Infection Control and PPE Use
Penalty
Summary
The facility failed to implement its infection prevention and control program by not ensuring proper use of personal protective equipment (PPE) for a resident on contact isolation and by not timely identifying and isolating a resident with COVID-19 symptoms. For one resident with a PEG tube and a diagnosis of dysphagia following cerebral infarction, the care plan and physician orders required Enhanced Barrier Precautions, including the use of gown and gloves during high-contact care such as medication administration via the feeding tube. However, during observation, an LPN administered medications through the PEG tube wearing only gloves and a mask, omitting the required gown. The LPN stated she believed a gown was not necessary for this task, despite signage and orders indicating otherwise. The Director of Nursing later confirmed that the expectation was for nurses to wear a gown, mask, gloves, and eye protection during such procedures. In a separate incident, another resident with a history of rheumatoid arthritis and chronic pain syndrome reported feeling unwell and experiencing multiple episodes of vomiting, requiring several bed changes. Despite these symptoms, there was no documentation of vomiting in the resident's record for the day in question, and no isolation signage or appropriate trash receptacles were present in the room. The DON and ADON were unaware of the resident's condition until the following day, and a CNA confirmed that the resident had been sick multiple times without any isolation measures being implemented. The resident was later placed on contact isolation after testing positive for COVID-19, but this was not done in a timely manner. These findings indicate that the facility did not follow its own infection control policies regarding the use of PPE and timely identification and isolation of residents with infectious symptoms. The lack of adherence to established protocols and communication breakdowns among staff contributed to the deficiencies observed during the survey.
Failure to Complete PASARR Screenings for Residents with New or Worsening Psychiatric Conditions
Penalty
Summary
The facility failed to ensure that referrals for PASARR screenings were completed for five residents who had changes in their mental health conditions or new psychiatric diagnoses. For instance, one resident was admitted with a diagnosis of persistent mood affective disorder and later diagnosed with psychosis, but the facility did not submit a PASARR level II review. Another resident was admitted with anxiety disorder, adjustment disorder with depressed mood, and insomnia, but the facility did not verify the accuracy of the PASARR I completed by the hospital and failed to submit a resident review PASARR for the new diagnoses. Similarly, other residents with new or worsening psychiatric conditions did not have the required PASARR screenings submitted by the facility, despite significant changes in their mental health status and medication adjustments. These failures were confirmed through interviews with facility staff and email correspondence with the State PASARR Authority, which indicated that the facility should have submitted resident review PASARRs for these cases. The lack of appropriate PASARR screenings for residents with new or worsening psychiatric conditions represents a significant deficiency in the facility's compliance with regulatory requirements. The findings were reviewed with the facility's nursing home administrator, director of nursing, assistant director of nursing, and corporate representatives during the exit conference.
Failure to Provide Food in Appropriate Form for Resident
Penalty
Summary
The facility failed to prepare food in a form designed to meet the individual needs of a resident (R14). R14 was admitted to the facility on 6/19/18 and had a physician's order dated 2/28/24 for a regular diet with ground meats/mechanical soft texture and regular/thin consistency liquids. A swallow study completed on 3/8/24 confirmed that R14 required ground solids and regular liquids. However, on 3/11/24, during lunch, R14 was served whole cauliflower florets instead of the prescribed ground cauliflower. R14, who does not use dentures and has no natural teeth, attempted to eat the cauliflower but found it too hard and spit it out, stating it was too difficult to consume. The meal ticket also indicated that R14 should have received ground cauliflower, not whole florets. Interviews with staff confirmed the deficiency. E16 (RN) acknowledged that R14 had whole cauliflower florets despite the meal ticket specifying ground cauliflower. E22 (Food Service Director) confirmed that the cauliflower was not ground and mentioned that it was challenging to determine the appropriate consistency. E23 (Dietician) also confirmed that R14 was on a ground diet and had failed his swallow study, and that the cauliflower served on 3/11/24 was not ground. These findings were reviewed with the Nursing Home Administrator (E1), Director of Nursing (E2), Assistant Director of Nursing (E3), and a corporate representative (E4) during the exit conference on 3/20/24.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for a resident in room [ROOM NUMBER]. Observations revealed a substantial amount of dirt and food crumbs scattered throughout the bedroom, and the bathroom had small, circular black debris and a brown circular area next to the toilet. Additionally, approximately 3 feet of baseboard was peeling off the wall and onto the floor. The resident reported that the baseboard had been in this condition for a year and that maintenance had been informed. Despite these issues being observed on 3/11/24, the room remained unclean the following day, and the resident confirmed that no cleaning had been done on 3/11/24. Interviews with staff confirmed the unclean conditions and the long-standing issue with the baseboard. E24, a floor tech, acknowledged the unclean state of the room and proceeded to clean it, removing the black debris and the brown area by the toilet. E24 also confirmed that the baseboard issue had been reported to E26, the Director of Maintenance, about a year ago. E26 admitted that the issue might have been verbally communicated but was not entered into the maintenance system for follow-up. The baseboard was eventually fixed by 3/18/24. E25, the Director of Environmental Services, confirmed that resident rooms are supposed to be cleaned daily, including sweeping, wet mopping, and bathroom cleaning. The resident expressed a preference for E24 to clean the room but was also acceptable to having two of the four housekeepers clean the room.
Failure to Review Total Program of Care for Resident with Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that the physician reviewed the total program of care, including medications and treatments, for a resident (R309) who was admitted with an indwelling urinary catheter. Upon admission, an assessment indicated the presence of the catheter, but the physician's progress note on the same day lacked any mention of it. The resident confirmed the use of the catheter due to neurogenic bladder. It was later confirmed by a nurse practitioner that the physician did not mention or assess the catheter, resulting in six days without proper physician orders for the catheter. These findings were reviewed with the nursing home administrator, director of nursing, assistant director of nursing, and a corporate representative during the exit conference.
Lack of Qualified Food Service Personnel
Penalty
Summary
The facility failed to ensure that a qualified person in charge was present in the kitchen during all hours of food service operation. During an interview, a dietary aide disclosed that only one staff member in the food service department possessed a valid Food Protection Manager certificate from an Accredited Food Safety Program. These findings were reviewed with the nursing home administrator, director of nursing, assistant director of nursing, and a corporate representative during the exit conference.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in a manner that prevents foodborne illness to the residents. During an initial tour of the kitchen, a partially uncovered container of stuffed peppers was found in the walk-in refrigerator, exposing the food to potential contaminants. Additionally, the reach-in refrigerator contained an unlabeled and undated plate of liverwurst. In the nourishment refrigerators located in the Henlopen and Sussex hallways, cartons of Nutritional Shake were found undated or past the discard date as per the instructions on the carton. Furthermore, a dietary aide tested the sanitizer level of the solution in two red sanitizing buckets, and the test strips indicated that the chemical concentration was insufficient for proper sanitization. These findings were confirmed with the Nursing Home Administrator (NHA) and reviewed with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and a corporate representative during the exit conference.
Non-Functional Call Bell System in Resident Room
Penalty
Summary
The facility failed to ensure that the call bell system in room [ROOM NUMBER] was functioning properly. During a random observation, it was found that the call bell box on the wall was taken apart with exposed wires, rendering both A and B bed call bells non-functional. There was no alternate equipment available for the residents to call for help. An RN confirmed the issue and was unsure how long the call bells had been non-functional, estimating it might have been since the previous week. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were made aware of the issue and initially provided cow bells as a temporary solution. Further investigation revealed that a work order for the broken call bells had been submitted electronically four days prior to the observation, marked as critical. However, the Maintenance Director stated that he could not address the issue sooner. The call bell system was eventually repaired and tested, confirming it was functioning properly. The findings were reviewed with the NHA, DON, Assistant Director of Nursing (ADON), and a corporate representative during the exit conference.
Failure to Report Bruise of Unknown Origin
Penalty
Summary
The facility failed to report a bruise of unknown origin for a resident with severe cognitive impairment. The resident was noted with a left upper arm bruise during care, but no measurements or descriptions were documented in the clinical record. The resident was unable to explain the cause of the bruise. The facility did not report the incident to the state agency within the required eight-hour timeframe, nor did they notify the resident's family. This was confirmed during an interview with the Director of Nursing and other staff members.
Failure to Obtain Immediate Physician Orders for Resident Care
Penalty
Summary
The facility failed to ensure that a resident (R309) had physician orders for immediate care upon admission. R309 was admitted with an indwelling urinary catheter, but the admitting nurse did not obtain the necessary physician orders for the catheter until several days later. The resident's clinical record showed that an admission assessment was completed on the day of admission, and a care plan for the indwelling urinary catheter was initiated. However, the physician's order for the catheter was not documented until six days after admission. Interviews with staff confirmed that the admitting nurse forgot to obtain the batch orders related to the catheter from the provider. Additionally, the facility failed to ensure immediate physician orders for diabetes management for R309. Although a care plan for diabetes management was initiated on the day of admission, the admission assessment did not indicate that R309 was diabetic. A physician's order for diabetic medications was written on the day of admission, but the order for blood glucose monitoring and sliding scale insulin coverage was not documented until six days later. Interviews with staff confirmed that the admitting nurse forgot to obtain the batch orders related to diabetic management from the provider. The findings were reviewed with the nursing home administrator, director of nursing, assistant director of nursing, and corporate representative during the exit conference.
Failure to Implement Bowel Protocol for Resident with Chronic Constipation
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and physician orders for bowel and bladder incontinence care. The resident was admitted with a diagnosis of chronic idiopathic constipation and had specific physician orders for various medications to manage constipation. However, from 7/1/23 through 9/30/23, the facility did not implement the physician's orders when the resident failed to have bowel movements for nine shifts on multiple occasions. Specifically, the facility did not administer the prescribed medications such as Milk of Magnesia, Bisacodyl suppository, Bisacodyl oral tablets, Senna s tablets, and Miralax powder as required by the bowel protocol. The CNA documentation and MARs for the resident revealed a lack of evidence of monitoring and initiating the bowel protocol during the specified dates. Additionally, the progress notes lacked evidence of bowel assessments related to the dates when the resident did not have bowel movements. An interview with an RN confirmed that the bowel protocol was not followed, and the necessary medications were not administered. These findings were reviewed with the Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, and Corporate representative during the exit conference.
Latest citations in Delaware
Multiple cognitively impaired residents with known behavioral issues, including wandering, agitation, and physical aggression, were not adequately protected from resident‑to‑resident abuse. In one case, a resident with dementia and PTSD was pushed to the floor by another resident who had a history of combative behavior, resulting in multiple fractures and facial lacerations after staff initially documented the event as an unwitnessed fall. In another case, two residents with dementia and psychotic features engaged in a physical altercation in a dayroom after one placed his hand on the other’s chest, leading to mutual punching. A separate incident occurred when a resident with dementia and behavioral disturbances entered another resident’s room, pulled at the bedcovers, yelled that the room was his house, and allegedly struck the other resident, who was later noted with puffiness around one eye. In all incidents, the involved residents had documented behavioral care plans and significant cognitive impairment, yet physical confrontations still occurred.
A resident with dementia, spinal stenosis, and total dependence for transfers, care-planned for Hoyer lift use with two-person assist, was being transferred from a shower bed to a Geri-chair when the Hoyer lift tipped sideways. Staff reported the lift’s legs had been widened and that one CNA manually pushed the feet apart instead of using the control, and straps may have been unevenly positioned. The resident was lowered to the floor while still in the sling and sustained a small skin tear to the elbow; imaging later showed no fractures. The DON stated that three CNAs were involved, including one on light duty who was not supposed to be using the lift, and that no mechanical defect was found with the lift.
The facility failed to thoroughly investigate several allegations of verbal and potential physical abuse involving four cognitively intact residents with conditions including hemiplegia, rheumatoid arthritis, type 2 DM, epilepsy, and heart disease. In each case, the facility’s investigations were limited, often including only the directly involved resident and omitting interviews with other potentially knowledgeable residents or staff. One resident reported a verbal altercation with a CNA after a fall to the floor, another reported being verbally abused by a roommate’s family member, a third reported a male CNA was too rough and upset while changing linens, and a fourth reported a staff member insulted her and refused brief care. Investigation files lacked broader resident and staff interviews, timely physical and psychosocial assessments, and review of the accused staff member’s employee record, contrary to the facility’s abuse policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
A resident with rectal cancer and intact cognition reported that an RN on night shift confronted him when he returned from smoking off campus, spoke to him loudly about his smoking, used profanity, and threatened to have staff refuse to buzz him back into the building. A CNA corroborated that the RN was upset about being called in to work and used curse words toward the resident, but did not report the incident at the time because the RN was the night supervisor. The resident reported the event to the Social Services Director the next day, yet the facility initially treated it as a grievance rather than abuse and delayed submitting a report to the State Survey Agency until weeks later, after determining it was a reportable abuse incident.
Two residents did not receive required ADL and hygiene care as care planned. One resident with dementia and osteoarthritis, dependent for toileting and personal hygiene, was not toileted during an evening shift, with CNA documentation showing no toileting and the oncoming CNA finding the resident’s clothing, linens, and mattress saturated with urine; the assigned CNA reported care resistance but did not notify an RN or LPN. Another resident with dementia and stroke, requiring assistance with dressing and personal hygiene, remained in bed in pajamas into the afternoon without having received morning care, despite CNA documentation indicating dressing was completed; the CNA later confirmed that care was only provided after being questioned by an RN supervisor following a family complaint.
A resident with left-sided weakness after a stroke, high fall risk, and total dependence for ADLs and bed mobility was being turned onto their side for peri care by an aide when they fell from the bed to the floor, sustaining head trauma and a scalp laceration while on blood thinners. The care plan required extensive to total assistance with two-person support for bed mobility, but the fall occurred during care without documentation of the required level of assistance, indicating the facility did not provide adequate supervision and assistance to prevent accidents as outlined in its own fall prevention practices.
A resident with significant upper extremity weakness and recent surgery was discharged home to a multi-story residence without confirmed DME delivery, home health services, or caregiver support. Although referrals for home health, skilled nursing, and DME were made and family attended a discharge care plan meeting, staff did not verify that services were active, did not set or confirm a start-of-care date with the agency, and did not confirm delivery of a hospital bed. The resident, who lived alone and could not manage fine motor tasks, arrived home without in-home assistance, reported difficulty with eating and self-care, and was later found by an HHA RN in unsafe conditions, unable to access food or medications, leading to emergency transport back to the hospital.
A resident with dementia, Parkinson’s disease, CHF, and a history of AKI had documented fluid goals and was identified as at risk for dehydration and malnutrition, yet daily intake records repeatedly showed fluid consumption well below the recommended amounts. Despite severely impaired cognition, poor oral intake, and documented changes in mentation, lethargy, falls, and restlessness, the facility did not consistently implement or document enhanced monitoring, assistive feeding measures, or timely provider consultation focused on hydration. The resident was hospitalized twice with AKI, dehydration, hypotension, and anemia, and staff interviews confirmed that while expectations existed to encourage fluids and notify providers when goals were not met, there was no clear evidence that these expectations were carried out for this resident.
A resident with cardiac conditions was discharged home with a documented post-discharge plan for home health aide, home health RN/LPN, and PT/OT, but the facility did not complete the home health referral before discharge. The resident went home with a family member and, according to a complaint, did not receive PT, OT, or a nursing wellness check for about a week. The SW later confirmed the referral for home health and therapy services was not requested until several days after discharge, and services did not begin until even later, despite therapy recommendations that are typically communicated to social services to arrange home care.
The facility failed to consistently revise care plans to reflect residents’ current needs and behaviors and did not ensure a cognitively intact resident was involved in ongoing care planning. One resident participated in an initial care conference but was not included in later care plan updates. Another resident with an order for a palm protector was frequently observed without it and often refused it, yet the care plan did not address refusals. Two cognitively impaired residents whose MDS assessments showed dependence for bathing had care plans that still listed only setup or one‑person assist. A cognitively impaired resident with combative behaviors and an incident of striking another resident had a behavior care plan that was not updated to include attempts to hit other residents or the risk of resident‑to‑resident altercations.
Failure to Prevent Resident‑to‑Resident Physical Abuse Among Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from resident‑to‑resident physical abuse. One resident with dementia, agitation, depression, anxiety, and PTSD, and a BIMS score indicating moderate cognitive impairment, was pushed to the floor by another resident after that resident entered his room and followed him into the hallway. Staff initially documented the event as an unwitnessed fall after hearing loud screaming and finding the resident on the floor with complaints of right shoulder and left wrist pain, active bleeding from facial lacerations, and clamminess. Subsequent review of surveillance footage showed that another resident walked into the victim’s room, then followed him out and pushed him, causing the fall that resulted in multiple fractures, including a closed left distal radius fracture, a closed, displaced comminuted right proximal humerus fracture, and a closed, displaced distal clavicle fracture. The resident who pushed him had dementia with mood disturbances, bipolar disorder with psychotic features, PTSD, insomnia, and depression, and a BIMS score indicating severe cognitive impairment. His care plan identified a behavior problem related to bipolar disorder and dementia, including wandering, refusal of care, and physical aggression toward staff and others, such as biting a CNA and swinging a walker at a CNA. The care plan directed staff to anticipate and meet his needs, divert him with alternative objects or activities, intervene to protect the rights and safety of others, and conduct safety checks. Despite these identified risks and interventions, he was able to enter another resident’s room and subsequently push that resident in the hallway, resulting in serious injury. Another incident involved two residents with significant cognitive impairment and behavioral symptoms, including delusions, physical behaviors toward others, agitation, and a tendency to invade others’ personal space. One resident, who was described as aggressive toward others, easily agitated, and prone to getting into others’ personal space, walked next to another resident sitting in a dayroom chair and placed his hand on that resident’s chest. The seated resident responded by punching him in the face with the back of his fist, and the first resident then punched back. Staff and psychiatric documentation noted this altercation and ongoing behavioral concerns such as combativeness with care, agitation, and wandering, but the record contained no additional progress notes describing the incident itself beyond the brief psychiatric follow‑up entry. A further incident occurred when a resident with anxiety, major depressive disorder, dementia with behavioral disturbances, agitation, and severe cognitive impairment entered another resident’s room on the memory care unit. The resident in the room, who had depression, anxiety, dementia without behavioral disturbances, PTSD, insomnia, hallucinations, verbal behaviors toward others, other behavioral symptoms, and wandering, reported that he was hit in the face. Staff heard yelling and found the intruding resident pulling covers at the foot of the bed and yelling that the room was his house, while the other resident sat on the side of the bed and stated that he had been hit and told staff to get a gun and shoot the other resident. Slight puffiness was noted around the reporting resident’s left eye. The intruding resident’s care plan documented compulsiveness, invading others’ personal space, yelling, restlessness, physical aggression, and attempts to assist other residents he believed needed help, with interventions to divert him, familiarize him with his surroundings, and intervene to protect the rights and safety of others. Despite these identified behaviors and interventions, he was able to enter another resident’s room, engage in a confrontation, and allegedly strike the resident.
Resident Injury from Improper Hoyer Lift Operation During Transfer
Penalty
Summary
The deficiency involves the facility’s failure to prevent an accident during a Hoyer lift transfer, resulting in a fall and skin tear injury to a resident. The resident had diagnoses including spinal stenosis, Alzheimer’s disease, vascular dementia with behavioral disturbance, bipolar disorder, and pain, and was documented on the MDS as dependent on staff for transfers from bed to chair. The care plan and physician orders specified that the resident required a Hoyer lift with assistance of two staff for transfers. On the day of the incident, the resident was being transferred via Hoyer lift after a shower, from a shower bed back to a Geri-chair. Progress notes and the post-fall evaluation documented that the fall occurred in the bathroom during a Hoyer transfer with staff assistance of two, and that the Hoyer lift tipped sideways. The resident was found on the floor in the sling, with staff reporting that the Hoyer lift’s legs were widened and that as the resident was being positioned over the chair, the lift tipped to the side. Staff held the sling on each side of the resident’s head and lowered the resident to the floor, after which a skin tear measuring 1.0 cm x 0.1 cm was noted on the elbow. The facility’s investigation determined that the Hoyer tipped because one CNA pushed the lift’s feet apart manually instead of using the designated button to open the legs. Interviews indicated that the manual mechanical lift used at the time was considered less steady and required manual operation of a foot pedal to open the legs, and that the straps may have been more to one side than the other. The DON reported that three CNAs were involved with operating the lift at the time of the incident, including one CNA on light duty who was not supposed to be using the Hoyer lift, and that the lift itself was later found to have no mechanical problems. As a result of the tipping incident, the resident sustained a skin tear to the elbow and required diagnostic imaging to rule out fractures.
Incomplete Investigations of Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of verbal or potential physical abuse as required by its abuse, neglect, and exploitation policy. One cognitively intact resident with hemiplegia following a stroke reported a verbal altercation with a CNA after sliding to the floor while being assisted back to bed. The resident requested use of a Hoyer lift, the CNA told him he could get himself up, and an argument ensued in which the CNA told the resident it was not his room and did not leave until directed by an LPN. The facility’s investigation file for this incident contained only the resident’s interview and no interviews with other residents on the unit who might have had knowledge of similar verbal abuse by the CNA. Another cognitively intact resident with rheumatoid arthritis, hypertension, and peripheral vascular disease reported that her roommate’s daughter came into her room and verbally abused her after the roommate had been relocated due to aggression. The daughter allegedly cursed at the resident, calling her an offensive name and telling her she was going to hell. The investigation file for this incident contained no interviews with other residents on the unit to determine whether they had experienced verbal abuse by this family member or had knowledge of the event. The DON acknowledged that no such interviews were conducted. A third cognitively intact resident with type 2 diabetes and epilepsy reported, through her daughter, that a male CNA wearing a red shirt was too rough with her and appeared upset about having to change her linens. The facility’s investigation into this potential staff-to-resident abuse included an interview with the resident but did not include interviews with other interviewable residents in the same area who might have had knowledge of the incident. A fourth cognitively intact resident with type 2 diabetes and heart disease, later discharged, reported that a staff member entered her room, called her a poor excuse for a human being, and refused to assist with changing her brief. The investigation documentation for this allegation lacked interviews with additional residents or staff, did not show that the resident was promptly assessed physically and psychosocially in relation to the allegation, and did not include a review of the accused staff member’s employee record, resulting in an incomplete investigation contrary to facility policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
Failure to Protect Resident From Verbal Abuse and Delay in Reporting Incident
Penalty
Summary
The facility failed to protect a cognitively intact resident from verbal abuse by a staff member. The resident, admitted with rectal cancer and independently ambulatory with a rolling walker, reported that during an overnight shift he left the campus to smoke and, upon returning and walking toward the nursing station, was confronted by an RN. According to the resident’s report, the RN told him that when she was on the night shift he was not allowed to go outside, using profanity toward him, and further stated that if he went out the door she would instruct staff not to buzz him back into the building. A CNA later confirmed that the RN had been upset about being called in to work, spoke loudly to the resident about his smoking, and used curse words when he responded to her. The incident was not promptly reported to facility administration despite occurring during the night shift, with the CNA stating that the RN involved was the supervisor at the time. The resident reported the incident the following day to the Social Services Director, but the facility did not immediately recognize or treat the allegation as reportable abuse. Instead, the administration initially considered it a grievance and investigated it in that manner. The incident report was not submitted to the State Survey Agency until several weeks after the resident’s report, and only after the facility later determined that the event constituted a reportable abuse incident.
Failure to Provide Required ADL and Hygiene Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL assistance to maintain grooming and personal hygiene for two dependent residents. One resident with dementia, osteoarthritis, and moderately impaired cognition was care planned to receive partial to substantial assistance with personal and oral care, scheduled toileting every two hours, and assistance with toilet transfers. CNA documentation for an evening shift showed “N/A” for all scheduled toileting times, and a facility incident report stated that the CNA assigned to this resident failed to provide incontinence care during that shift. The oncoming night-shift CNA later found the resident’s clothing, linens, and mattress saturated and soaked with urine and provided the needed care, with the prior-shift LPN confirming the condition when notified. The assigned CNA reported the resident was resistant to care but did not notify the LPN or RN for assistance or document the issue. The second resident, with dementia, stroke, weakness, and moderately impaired cognition, was care planned for an ADL self-care deficit requiring setup or cleanup assistance with eating, partial to substantial assistance with personal hygiene and oral care, and substantial assistance with toileting, showering/bathing, and lower body dressing. On a morning shift, the resident’s daughter-in-law reported to the LSW that she did not believe the resident had received morning care because he was still in bed wearing pajamas and had not yet received his lunch tray. A CNA statement indicated the resident had eaten breakfast and was later found asleep in bed, and CNA documentation for that shift showed the dressing task as completed. However, the facility’s follow-up summary documented that the CNA confirmed care had not been provided to the resident prior to being questioned by the RN supervisor, and the LSW confirmed that the CNA changed the resident only after the family reported the concern and nursing was notified.
Failure to Provide Adequate Supervision and Assistance During Bed Mobility for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for a resident with significant functional and cognitive impairments. The resident was admitted with left-sided weakness after a stroke and was care planned as extensively to totally dependent for bed mobility, requiring the support of two persons. A fall risk evaluation documented a score of 10, indicating high fall risk, and a quarterly MDS assessment showed the resident was unable to participate in a cognitive assessment and was completely dependent on staff for all ADLs. Despite these identified needs and risks, the resident was being turned onto their side for peri care by an aide when they fell from the bed to the floor. During this incident, the resident sustained head trauma and a small scalp laceration, and was on blood thinners at the time of the fall. The fall occurred while the aide was providing peri care and turning the resident, but the report does not document the presence of a second staff member, despite the care plan indicating the need for two-person assistance for bed mobility. The facility’s own policy on falls emphasized instituting individualized practices to minimize fall risk and maximize safety for residents identified as high risk, but the resident’s documented high fall risk and total dependence were not adequately addressed in the supervision and assistance provided at the time of the fall.
Failure to Ensure Safe Discharge with Confirmed Home Services and Support
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s discharge home included confirmed durable medical equipment (DME), home health services, and adequate caregiver support. The resident was admitted with spinal stenosis, cervical disc disorder, muscle weakness, carpal tunnel syndrome, and a recent post-fasciotomy to the right arm, and was documented as cognitively intact with a BIMS score of 14/15. Despite these physical limitations, the facility discharged the resident home in the evening via medical transport to a three-story residence, where no caregiver support was present. The facility’s own policy required a post-discharge plan of care developed with the resident and representative, and orientation to ensure a safe and orderly transfer or discharge, but the record lacked evidence that services were confirmed as in place prior to discharge. Prior to discharge, the social worker documented that the resident would have a safe discharge home with services and supports in place, and that referrals for home health care, skilled nursing services, and DME had been made, with family members in attendance at the discharge care plan. However, the clinical record did not contain confirmation that these services were actually arranged and active before the resident left the facility. The resident was discharged with medications called to the pharmacy for home delivery, but there was no documentation that the hospital bed had been delivered or that home health nursing, therapy, or home health aide services were scheduled to start at the time of discharge. The social worker later acknowledged not informing the agency of a specific start-of-care date, assuming the agency and VA would contact the resident, and confirmed not calling to verify delivery of the hospital bed. After discharge, it was discovered that the hospital bed ordered days earlier was not delivered until the morning after the resident arrived home, and that therapy, RN, and HHA services had not yet begun or contacted the resident by the time the facility followed up. The resident reported living alone, being unable to use their hands, needing a caretaker, and having to rely on a sister-in-law for limited assistance with hygiene, meals, and rearranging furniture for the bed that arrived later. The significant other confirmed that no one lived with the resident, that they had their own health issues, and that neither they nor their son stayed with the resident after discharge. When a home health RN eventually visited, the resident was found sitting on a couch in minimal clothing, reporting not having eaten adequately for two days, having little or no accessible food, and being unable to open medications or bottles due to impaired fine motor skills. The RN observed the resident’s inability to grip or perform fine motor tasks, assisted with toileting, and then contacted the agency director and emergency services due to the unsafe conditions in which the resident had been left. These events led surveyors to determine that the facility failed to ensure services and caregiver support were in place prior to discharge, resulting in an immediate jeopardy situation.
Removal Plan
- Audited discharge documentation related to home health services, appropriate caregiver/family support, and any necessary services to meet residents' care needs to determine if any residents were affected.
- Reviewed planned discharges by the Administrator, DON, Director of Social Services, and Director of Rehabilitation to ensure home health services, appropriate caregiver/family support, and necessary services to meet the resident's care needs are in place before discharge.
- Completed a root cause analysis identifying failure to have a robust discharge care plan meeting with the interdisciplinary team (IDT), resident, and resident representative.
- Reviewed the procedure for safe and effective discharge planning with the IDT.
- Re-educated the discharge planning IDT on the discharge policy and procedure to ensure sufficient preparation and orientation for a safe discharge.
- Implemented review of residents scheduled to be discharged to ensure appropriate discharge planning is in place.
- Implemented review of residents scheduled for discharge to ensure ADL support is in place, durable medical equipment is available prior to or on the discharge date, medications are available upon discharge, and identified needs/support are available.
- Implemented review of residents scheduled for discharge to ensure safe discharge planning is in place and to address any issues identified.
- Implemented oversight during utilization review by the NHA/designee to ensure discharge planning preparation and services are in place prior to discharge.
- Initiated audits and educational in-services to the IDT team and conducted staff interviews to confirm education received regarding discharge to the community and/or transfers to other facilities.
Failure to Maintain Adequate Hydration Resulting in Recurrent AKI and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate hydration for a resident with significant medical conditions, including acute kidney injury (AKI), congestive heart failure (CHF), dementia, and Parkinson’s disease. Upon admission, the resident’s care plan identified potential for altered nutrition and included interventions such as assisting at meals, encouraging oral fluids, and monitoring for additional nutrition interventions. A nutrition assessment established an initial fluid goal of 1943–2098 mL/day and documented that the resident was at risk for dehydration and malnutrition, with early labs showing a BUN of 29, creatinine of 1.4, and eGFR of 53. The admission MDS documented that the resident was severely cognitively impaired and required setup assistance for feeding and hydration. Daily fluid intake records from CNA task flow sheets and the MAR showed that the resident’s intake frequently fell below the recommended fluid goals, with multiple days of intake under 1200 mL and some days as low as 360–720 mL. A malnutrition risk assessment identified the resident as at risk for malnutrition due to severe dementia and tremors. A subsequent nutrition note on 5/12/25 documented that the resident’s average fluid intake was 330 mL/day, recommended discontinuing a prescribed hydration pass due to CHF, and set a new fluid goal of 1635–1766 mL/day, while continuing to recommend encouraging oral fluids. Despite these documented risks and low intakes, there is no evidence in the record of intensified monitoring or additional interventions to ensure the resident met the revised fluid goals. The resident experienced multiple clinical deteriorations associated with poor intake and changes in condition. On 6/1/25, after a day with only 360 mL of recorded intake, the resident was transferred to the hospital following falls, hypotension, and confusion, and was admitted with AKI and dehydration. After readmission to the facility, nursing documentation noted low oral intake and a plan to discuss adding the resident to an assist-to-feeding list, but the record lacked evidence that this occurred. Subsequent notes documented lethargy, increased confusion, agitation, restlessness, and continued poor intake, yet a physician progress note following two unwitnessed falls did not include an assessment of hydration status or interventions to improve hydration. On 6/19/25, labs showed a BUN of 62 mg/dL and creatinine of 1.7 mg/dL, and the resident was again sent to the hospital and admitted with AKI, hypotension, and anemia, requiring IV fluid resuscitation. Staff interviews confirmed expectations to monitor intake, encourage fluids, and notify providers when fluid goals were not met, but there was no documentation that the provider was consistently notified or that appropriate interventions were implemented in response to the resident’s ongoing inadequate fluid intake and changes in condition.
Failure to Arrange Timely Home Health Services Prior to Discharge
Penalty
Summary
The facility failed to ensure a timely referral for home health care services prior to discharge for one resident. Facility policy dated 5/1/25 required sufficient preparation and orientation to residents to ensure an orderly transfer or discharge. The resident was admitted on 7/28/25 with diagnoses including aortic valve replacement, aortic regurgitation, and congestive heart failure. A discharge summary dated 8/11/25 documented a post-discharge plan for home health aide, home health RN/LPN, and occupational and physical therapy. The resident was discharged home with a family member on 8/12/25. A complaint received by the Division on 9/30/25 stated that the resident was discharged to a family member's home without a home health care agency referral and that, after one week at home, the resident had not received any physical or occupational therapy or a wellness check from a nurse. During an interview on 2/16/26, the social worker reported needing to check if a referral was made and later confirmed that the referral for home health and therapy services was not requested until 8/15/25, with services opened on 8/20/25. The director of therapy confirmed that physical and occupational therapy were recommended for the resident and stated that such recommendations are typically communicated to social services to set up home care. Findings were reviewed with facility leadership during the exit conference.
Failure to Revise Care Plans and Involve Resident in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise person‑centered care plans and to involve a cognitively intact resident and/or representative in the care planning process. One resident with an intact BIMS score of 15 was admitted and had a documented care conference shortly after admission, but there was no evidence of any subsequent care conferences during the following year despite multiple care plan updates. The resident reported not recalling quarterly care plan meetings, and staff confirmed that no care conferences occurred after the initial one, with no documentation that the resident or representative participated in the later care plan revisions. Additional residents’ care plans were not revised to reflect current, individualized needs and behaviors. One resident had a physician’s order for a right palm protector or substitute, was repeatedly observed without it in place, and routinely refused it according to nursing and CNA interviews, yet the care plan did not address potential refusals. Two cognitively impaired residents whose MDS assessments documented dependence for bathing had care plans that continued to list only setup assistance or one‑person assist, without updating to reflect full dependence. Another cognitively impaired resident with documented combative behaviors toward staff and a reported incident of striking another resident with a remote had a behavior care plan that was not revised to include the new behavior of attempting to hit other residents or the potential for resident‑to‑resident altercations.
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