Excelcare At Newark Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Newark, Delaware.
- Location
- 4949 Ogletown-stanton Road, Newark, Delaware 19713
- CMS Provider Number
- 085025
- Inspections on file
- 19
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at Excelcare At Newark Llc during CMS and state inspections, most recent first.
A resident with a history of femur fracture developed acute shortness of breath and low oxygen saturation, but nursing staff failed to consistently assess, monitor, or document vital signs and did not promptly notify the provider or initiate emergency care. Despite observable respiratory distress and declining oxygen levels, interventions were delayed and inconsistently applied, resulting in the resident being transferred to the hospital unresponsive, where she later expired.
A resident admitted with metastatic prostate cancer did not have a completed and signed admission agreement due to being asleep or too tired during multiple attempts, and the agreement remained incomplete until the resident's death. The medical record was missing this legal document, which should have outlined rights, facility policies, and services.
A resident admitted with metastatic cancer was not allowed to sign multiple consent forms, despite an initial assessment indicating normal cognitive function. Instead, a friend and staff signed the consents, based on a later BIMS score showing moderate impairment. Staff relied on incomplete information and did not verify the resident's cognitive status or responsible party, resulting in the resident's exclusion from important care decisions.
A resident with a history of femur fracture experienced new shortness of breath and low oxygen saturation, leading staff to initiate oxygen therapy and call EMS. Despite these significant changes, there was no evidence that the physician was consulted or notified, as confirmed by record review and staff interviews.
A resident's care plan conference was conducted without participation or input from a Physician, Nurse Practitioner, or Physician Assistant. Only social services, an LPN, and a therapy staff member attended, with the dietician providing input in advance. The provider did not participate or contribute, and any concerns raised would be relayed after the conference.
The facility failed to ensure adequate supervision and a safe environment for two residents, leading to accidents and injuries. One resident fell and sustained facial bone fractures due to inadequate support during bed mobility. Another resident was exposed to tripping hazards from fall mats left on the floor while in a wheelchair, contrary to their care plan.
The facility failed to ensure proper sanitation practices and food storage. Observations included a dietary aide without proper coverings, a lack of paper towels at the hand washing sink, and unlabeled containers in the freezer. Additionally, the dishwashing machine did not reach the required temperature for sanitization, and no chemical sanitization was attached.
The facility failed to meet professional standards by allowing LPNs to complete admission assessments and progress notes for five residents, tasks that should have been performed by RNs according to Delaware State regulations. Interviews revealed confusion among staff regarding proper procedures for completing admission paperwork.
The facility failed to properly plan and execute the discharge process for a resident with ataxia and weakness, leading to inadequate care and multiple falls post-discharge. The resident's functional abilities were not accurately assessed, and the caregiver was not adequately informed about the resident's care needs, resulting in a readmission to the hospital.
A resident who experienced a fall resulting in multiple wounds was discharged without proper documentation of wound care treatment orders in the discharge summary. This omission was confirmed by a registered nurse and reviewed with facility administrators.
A resident's care plan required daily ambulation with a walker, but documentation and interviews revealed inconsistent assistance with walking. The resident reported irregular walking therapy, and an RN unit manager confirmed aides sometimes marked tasks as 'not applicable' without proper verification. These findings were reviewed with facility leadership and Ombudsman representatives.
The facility failed to honor the care preferences of three residents, leading to deficiencies in resident self-determination and choice. One resident was forced to receive care despite refusal, another did not receive scheduled showers due to conflicting dialysis appointments, and a third had inconsistent shower provision with inadequate documentation.
The facility failed to provide evidence that a resident or her responsible party was notified of Medicare non-coverage prior to discharge. The resident had moderate cognitive impairment and was admitted with ataxia and weakness. The absence of a Notice of Medicare Non-Coverage (NOMNC) form was confirmed during an interview with the NHA and reviewed with other staff and Ombudsman representatives.
A resident reported an allegation of physical abuse by someone posing as an aide while in the hospital. The facility's investigation lacked documented evidence of attempts to interview the resident in the hospital, the hospital staff, and specific residents. Additionally, the facility's Verification of Investigation form was incomplete, missing critical elements and signatures from key personnel.
The facility failed to accurately complete resident assessments for three residents. One resident's need for continuous oxygen was not documented in the MDS assessment, another resident's Parkinson's Disease was omitted from the admission MDS, and a third resident's pressure ulcer was not recorded in the discharge MDS. These errors were confirmed by staff and reviewed with facility leadership and Ombudsman representatives.
The facility failed to revise care plans for two residents to reflect their current care needs, including restorative walking services and monitoring for nephrostomy tube dislodgement, despite multiple hospitalizations.
The facility failed to complete AIMS assessments for a resident on anti-psychoactive medications and did not effectively monitor another resident for side effects related to antipsychotic medication use. Additionally, a resident missed seven doses of Olanzapine due to a lapse in pharmacy delivery, and the facility did not follow its pharmacy policy.
The facility failed to ensure that residents received the selected food and drinks from the menu as indicated on their meal tickets. During random dining observations, it was noted that one resident did not receive cranberry juice or sautéed spinach for lunch, and another resident did not receive oatmeal for breakfast. These discrepancies were confirmed by the staff members present at the time.
A facility failed to create an accurate care plan for a resident on IV antibiotics for endocarditis, incorrectly identifying the diagnosis as sepsis and omitting specific details about the IV access and antibiotic therapy. This was identified during a record review and discussed with facility administrators and Ombudsman representatives.
A resident with normal cognition experienced distress when the nebulizer facemask was left on for over an hour after a treatment. Despite multiple calls for help, staff did not respond promptly, and the facemask was eventually removed by a nurse after a family member intervened. The facility's policy on nebulizer therapy was not followed, leading to the resident's unnecessary anxiety.
The facility failed to ensure timely transportation for a resident requiring dialysis. The resident, with end-stage renal disease, missed the scheduled pick-up for dialysis and had to wait in the lobby until an alternative ride was arranged. Staff interviews revealed confusion about transportation responsibilities, despite the facility's agreement stating it is their duty.
The facility failed to maintain an infection control program as an LPN did not disinfect a glucometer between uses on two residents, contrary to policy and manufacturer guidelines.
The facility failed to provide training for nephrostomy care, as evidenced by a resident requiring daily saline flushes performed by an LPN without specific facility training. The Staff Developer confirmed the lack of nephrostomy tube flush education for nursing staff.
The facility failed to provide a comprehensive Medication Regimen Review (MRR) policy with specific time frames for provider response to identified irregularities and a complete process for urgent action follow-up. The policy lacked critical components, leading to deficiencies in ensuring timely and appropriate responses to medication regimen review irregularities.
The facility failed to maintain and safeguard medical records for six residents, resulting in incomplete and inaccurately documented records. Urine culture results, including organism identification and sensitivities, were not uploaded into the EMRs, making them inaccessible. This issue was confirmed through staff interviews and review of the facility's practices.
The facility failed to maintain a clean and sanitary environment in two shower rooms and multiple resident rooms. Observations revealed blackened substances and chipped tiles in the shower rooms, and a thick, blackened, greasy substance on the floors of several resident rooms. These findings were confirmed with facility management and reviewed with relevant staff and representatives.
Failure to Assess and Respond to Acute Respiratory Distress
Penalty
Summary
A deficiency occurred when a resident with a history of a right femur fracture experienced a significant change in condition, specifically acute shortness of breath, during the early morning hours. Despite the resident's complaints and observable respiratory distress, there was a lack of timely and thorough assessment by nursing staff. Vital signs and oxygen saturation were either not monitored or not documented, and there was no evidence that the medical provider was promptly consulted during the initial onset of symptoms. The resident's oxygen saturation dropped to critically low levels, and interventions such as oxygen therapy were inconsistently applied and not properly documented. Multiple staff interviews revealed that although the resident was placed on oxygen and her condition was recognized as serious, there was confusion and delay in escalating care. Staff could not recall exact times of interventions, and several admitted to not documenting vital signs or assessments. The resident's respiratory status continued to deteriorate, and only after a significant delay was emergency medical assistance requested. When EMS arrived, the resident's oxygen saturation remained low, and she was ultimately transferred to the hospital unresponsive, where she later expired. The facility's own documentation and staff statements indicated a failure to follow established protocols for monitoring, assessment, and timely notification of changes in resident condition. There was also a lack of adherence to training regarding oxygen therapy and emergency response. These failures led to an Immediate Jeopardy finding due to the inadequate response to the resident's acute respiratory distress and the absence of appropriate clinical interventions and documentation.
Removal Plan
- Licensed nursing staff were re-educated on recognition of respiratory distress, respiratory assessments, including vital signs and oxygen saturation, initiation and monitoring of oxygen therapy, and provider notification
- Residents were screened by licensed nursing staff for respiratory distress
- Residents identified with respiratory distress were assessed and interventions were implemented
Incomplete Admission Agreement for Deceased Resident
Penalty
Summary
A deficiency was identified when a resident admitted with advanced prostate cancer and metastases to the bone and brain did not have a completed and signed admission agreement upon entry to the facility. The resident was admitted on a Friday evening shift and was listed as his own responsible party. Attempts to complete the admission agreement were unsuccessful: the resident was asleep during the initial attempt, remained asleep during a follow-up, and later refused due to fatigue. The admission packet remained incomplete and unsigned up to the time of the resident's death. Additionally, the hospital facesheet listed two individuals as siblings, but it was later discovered they were not family members, and the resident's actual brother was only identified on the day of death. As a result, the resident's medical record lacked a completed and signed admission packet, which is a legal document outlining resident rights, facility policies, and healthcare services to be provided.
Failure to Support Resident Self-Determination in Consent Process
Penalty
Summary
A deficiency occurred when the facility failed to promote and facilitate a resident's right to self-determination regarding the signing of multiple consents upon admission. The resident was admitted with diagnoses including prostate cancer with metastasis to the bone and brain and was listed as his own responsible party. Documentation showed conflicting cognitive assessments: a speech therapy evaluation recorded a BIMS score of 14/15 (normal cognition), while a subsequent BIMS by a social worker and the admission MDS both recorded a score of 10/15 (moderate impairment). Despite the initial indication of cognitive intactness, the facility allowed a friend (not a legal representative) and staff to sign various consent forms, including those for CPR/DNR, treatment, care management, and vaccinations, rather than obtaining the resident's own signature. Staff interviews revealed that the admitting nurse did not obtain the required consents, and another nurse completed them later, relying on the lower BIMS score to justify not seeking the resident's signature. The nurse was unaware of the higher BIMS score documented by speech therapy and stated that she was told the friend was the resident's brother, which was later found to be untrue. The facility's failure to verify the resident's cognitive status and responsible party status led to the omission of the resident's participation in consent decisions, thereby not supporting the resident's right to self-determination.
Failure to Notify Physician of Resident's Respiratory Distress and Oxygen Initiation
Penalty
Summary
A deficiency was identified when the facility failed to consult with a resident's physician after the resident experienced a new onset of shortness of breath and required initiation of oxygen therapy. The resident, who had been admitted with a right femur fracture, was noted by a certified occupational therapy assistant to have labored breathing and an oxygen saturation of 89%, resulting in a shortened therapy session. There was no documentation in the clinical record that the medical provider was notified of this change in condition. Subsequently, nursing staff responded to the resident's complaint of difficulty breathing, observed an oxygen saturation of 88%, and initiated oxygen therapy at 2 liters per minute. Later, emergency medical services were called, and the resident was placed on 5 liters per minute of oxygen via a non-rebreather mask. Interviews with staff confirmed that the resident's complaints and low oxygen saturation were observed and reported among staff, but there was no evidence that the physician was consulted at any point during these events. The deficiency was confirmed through record review and staff interviews, and findings were reviewed with facility leadership during the exit conference.
Failure to Ensure Full IDT Participation in Care Plan Conference
Penalty
Summary
The facility failed to ensure that all required interdisciplinary team (IDT) members contributed to the care plan conference for one resident reviewed for death. Review of the resident's clinical record showed that the Care Conference Summary was unsigned and incomplete, lacking documentation of input from a Physician, Nurse Practitioner, or Physician Assistant. Only social services, an LPN/Charge Nurse, and a therapy staff member attended the care plan conference, with the dietician providing input ahead of time due to absence. Interviews confirmed that the provider did not participate in the conference or provide input, and any concerns raised by the resident during the conference would only be shared with the provider afterward. The deficiency was confirmed during interviews and record review, with no evidence that all required IDT members contributed to the resident's care plan conference.
Failure to Ensure Resident Safety and Adequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and a safe environment for two residents, leading to accidents and injuries. One resident, admitted with a history of falls and a broken pelvis, was care planned for extensive assistance with bed mobility and other activities of daily living. Despite this, a CNA unfamiliar with the resident's needs did not provide the necessary support during a bed mobility task, resulting in the resident rolling off the bed and sustaining facial bone fractures. The CNA admitted to not holding or supporting the resident during the turn, which directly led to the fall and subsequent injury. Another resident, with diagnoses including dementia, schizoaffective disorder, and impaired mobility, was observed multiple times with fall mats placed on the floor while the resident was in a wheelchair. The resident's care plan specified that fall mats should only be on the floor when the resident was in bed. Despite this, staff consistently left the fall mats on the floor, creating a tripping hazard. Interviews with staff revealed a misunderstanding of the care plan, as they believed the mats were a precautionary measure regardless of the resident's position. The facility's failure to adhere to care plans and provide appropriate supervision and environmental safety measures resulted in significant risks and actual harm to the residents. The incidents were reviewed with facility leadership and representatives from the Ombudsman Office, highlighting the need for better adherence to care plans and staff training on resident-specific needs and safety protocols.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper sanitation practices and food storage in accordance with professional standards. During an initial kitchen tour, it was observed that a dietary aide did not have a hair net or beard covering, the hand washing sink lacked paper towels, and the walk-in freezer contained unlabeled and undated containers of soup and gravy. These findings were immediately confirmed with the Dietary Services Director (E42). Additionally, the facility did not ensure that dishes were chemically sanitized when the dishwashing machine temperatures failed to reach the required level for heat sanitization. During a follow-up kitchen tour, it was observed that the dishwashing machine's wash cycle was at 130°F, below the required 140°F, and no chemical sanitization was attached. The Dietary Services Director confirmed the absence of the sanitizing agent and subsequently attached a replacement sanitizer/bleach to the machine. These findings were reviewed with the Nursing Home Administrator, Director of Nursing, Corporate Clinical Operations, Regional Clinical Specialist, and representatives from the Ombudsman Office.
Failure to Adhere to Delaware Board of Nursing Scope of Practice
Penalty
Summary
The facility failed to meet professional standards of the Delaware Board of Nursing Scope of Practice by allowing Licensed Practical Nurses (LPNs) to complete the admission assessments and admission progress notes for five residents. According to Delaware State regulations, Registered Nurses (RNs) are required to perform these tasks. The deficiency was identified through a review of clinical records and interviews with staff members. Specifically, LPNs completed the clinical admission forms, elopement risk evaluations, fall risk evaluations, dehydration risk evaluations, and Braden scale assessments for residents R37, R63, R96, R446, and R447. Additionally, LPNs wrote the clinical admission notes for these residents, which is also a task that should have been performed by an RN as per state regulations. Interviews with staff members revealed a lack of clarity and adherence to the proper procedures for completing admission paperwork. One LPN confirmed completing the admission process for two residents, while another LPN stated that the nurse assigned to the room of the new admit patient completes the admission process paperwork. The RN Unit Manager explained that the unit manager or nursing supervisor is supposed to complete the admission process, depending on the shift. However, the Assistant Director of Nursing (ADON) was unaware of the state-required RN admission assessment and deferred to the Director of Nursing (DON) for clarification. These findings were reviewed with the Nursing Home Administrator (NHA), DON, Corporate Clinical Operations, Regional Clinical Specialist, and representatives from the Ombudsman office.
Inadequate Discharge Planning and Communication
Penalty
Summary
The facility failed to adequately plan and execute the discharge process for a resident (R96) with ataxia and weakness, who had moderate cognitive impairment. The resident's functional abilities were not properly assessed, and the caregiver's availability and capability to perform required care were not considered. The facility did not re-evaluate and update the resident's changing needs, nor did it show evidence of the Interdisciplinary Team (IDT) involvement in the discharge process. Additionally, the facility failed to document community referrals and contact information for the resident's post-discharge care. The resident's clinical records indicated that the resident required substantial assistance with toileting and mobility at the time of admission, but the discharge goals were set unrealistically high, aiming for independence. In the week prior to discharge, the resident's functional abilities fluctuated significantly, requiring varying levels of assistance. Despite these fluctuations, the facility did not adequately educate the resident's caregiver about the resident's current mobility levels and care needs. The caregiver was not informed about the need for new equipment or the resident's medication requirements, leading to multiple falls and a subsequent readmission to the hospital. Interviews with facility staff revealed that the social worker responsible for the discharge process left the facility abruptly on the day of discharge, and there was no documentation of the home care agency's contact information in the discharge plan. The granddaughter of the resident reported that she was not contacted to discuss the discharge plans and was not provided with necessary information about the resident's care needs. The facility's failure to properly plan and communicate the discharge process resulted in inadequate care and safety for the resident post-discharge.
Failure to Document Post-Discharge Wound Care Instructions
Penalty
Summary
The facility's discharge summary failed to accurately capture and document a resident's post-discharge plan of care. The resident was admitted to the facility from the hospital and later experienced an unwitnessed fall resulting in a skin tear to the left arm and lacerations to the left eye and cheek. Physician's orders were given for wound care, including monitoring steri strips, cleansing the skin tear with soap and water, applying bacitracin, and covering with a dry dressing. However, upon discharge, the discharge instructions and post-discharge plan of care form lacked documentation of these wound care treatment orders. This omission was confirmed during an interview with a registered nurse and reviewed with facility administrators and representatives from the Ombudsman Office.
Inconsistent Restorative Services for Resident
Penalty
Summary
The facility failed to ensure that a resident received consistent restorative services as prescribed. The resident's care plan was updated to include participation in a restorative walking program, requiring ambulation with a walker for 30 feet daily or as tolerated. However, documentation and interviews revealed that the resident was not consistently assisted with walking on multiple dates in February. The resident expressed that receiving walking therapy had been inconsistent. An RN unit manager confirmed that aides sometimes marked tasks as 'not applicable' when they believed it was not their responsibility, and there was a lack of verification that the walking was completed. These findings were reviewed with the nursing home administrator, director of nursing, corporate clinical operations, regional clinical specialist, and representatives from the Ombudsman Office.
Failure to Honor Resident Care Preferences
Penalty
Summary
The facility failed to honor the care preferences of three residents, leading to deficiencies in resident self-determination and choice. One resident, admitted with a stroke and aphasia, was forced to receive care from a CNA despite indicating refusal through gestures. The CNA insisted on providing care, causing the resident distress, and other staff members confirmed the resident's refusal and the CNA's aggressive behavior. This incident highlighted the facility's failure to respect the resident's right to refuse care and choose their caregiver. Another resident, admitted with end-stage renal disease and on hemodialysis, reported only being bathed once since admission, despite having scheduled showers. The resident's dialysis schedule conflicted with the assigned shower times, and the facility's documentation confirmed that the resident was often unavailable for showers due to dialysis appointments. The facility did not adjust the shower schedule to accommodate the resident's needs, resulting in inadequate personal hygiene care. A third resident, admitted with a left kneecap fracture, had scheduled showers that were not consistently provided. The resident's medical records showed instances where showers were either refused or not given, and there was a lack of documentation indicating that the nurse was informed of these occurrences. The facility failed to ensure that the resident received the scheduled showers and did not properly document the refusals or missed showers, leading to a deficiency in care provision.
Failure to Provide Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide evidence that a resident or her responsible party was notified of Medicare non-coverage prior to her discharge. The resident was admitted with diagnoses including ataxia and weakness and had a BIMS score indicating moderate cognitive impairment. Despite these conditions, the facility did not have a Notice of Medicare Non-Coverage (NOMNC) form for the resident at the time of her discharge. This deficiency was confirmed during an interview with the Nursing Home Administrator and reviewed with other facility staff and representatives from the Ombudsman office.
Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse made by a resident (R100) who was cognitively intact, as indicated by a BIMS score of 13. The resident was sent to the hospital for an unrelated medical reason, where she reported an allegation of physical abuse by someone posing as an aide. The facility's documentation included a typed statement of a conversation between the resident's family member and the DON, transcribed statements from 14 nursing staff, progress notes, and abuse in-service sign-in sheets. However, the investigation lacked documented evidence of attempts to interview the resident in the hospital, the hospital nursing staff to whom the allegation was made, and specific residents interviewed as part of the investigation. Additionally, the facility's Verification of Investigation form was incomplete, missing critical elements such as a summary of factual investigative findings and signatures from the DON and Executive Director. Despite the facility's efforts to gather information from staff and other residents, there was no documented evidence of a thorough investigation into the specific details of the abuse allegation. The facility did not attempt to interview the resident in the hospital or the hospital staff who received the initial report. Furthermore, the facility's documentation did not include a completed Verification of Investigation form, which should have contained a summary of the investigation, contributing factors, interventions, and signatures from key personnel. This lack of thorough documentation and follow-up indicates a failure to properly address and investigate the abuse allegation made by the resident.
Failure to Accurately Complete Resident Assessments
Penalty
Summary
The facility failed to accurately complete resident assessments for three residents. For one resident, a physician's order indicated the need for continuous oxygen, but the quarterly MDS assessment incorrectly documented that oxygen was not in use, despite daily administration as recorded in the MAR. This error was confirmed by the RNAC during an interview. Another resident, admitted with Parkinson's Disease, had physician's orders for specific medications and a care plan addressing the condition. However, the admission MDS assessment did not include Parkinson's Disease under the Neurological Diagnoses section, an omission confirmed by the RNAC in an interview. A third resident, admitted with multiple diagnoses including diabetes and dementia, had a documented pressure ulcer that was not accurately reflected in the discharge MDS assessment. The resident's medical records detailed the presence and progression of a sacral wound, which was noted by the Wound MD as an unavoidable stage 3 pressure injury. Despite this, the discharge MDS assessment failed to document the pressure ulcer, an error confirmed by the MDS Coordinator. These findings were reviewed with the facility's NHA, DON, Corporate Clinical Operations, Regional Clinical Specialist, and representatives from the Ombudsman Office.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plan to reflect the current care needs for two residents. For one resident, the clinical record indicated that the resident received restorative services for walking training and range of motion (ROM). However, the care plan did not include interventions related to walking, despite the CNA Task list indicating the resident should participate in a restorative walking program. This discrepancy was confirmed by the unit manager during an interview. For another resident, who was admitted with multiple diagnoses including kidney cancer and chronic kidney disease, the care plan was not updated to reflect the monitoring for nephrostomy tube dislodgement. This resident had multiple hospitalizations due to the nephrostomy tube becoming dislodged, yet the care plan did not include these incidents. This was confirmed by an LPN during an interview. The findings were reviewed with the nursing home administrator, director of nursing, corporate clinical operations, regional clinical specialist, and representatives from the Ombudsman Office.
Failure to Complete AIMS Assessments and Medication Administration Lapses
Penalty
Summary
The facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident (R2) taking anti-psychoactive medications. Despite a documented requirement for quarterly AIMS evaluations, the clinical record lacked evidence of such an evaluation for October 2023. Interviews with the RN and DON confirmed the absence of the required AIMS assessment for R2, who was on Seroquel for major depressive disorder and delusions. This oversight indicates a failure to monitor for adverse side effects as per the facility's policy and recognized standards of practice. Additionally, the facility did not effectively monitor another resident (R198) for side effects related to antipsychotic medication use, as AIMS testing was not completed from November 2022 to May 2023. Furthermore, R198 missed seven doses of Olanzapine due to a lapse in pharmacy delivery. The facility's pharmacy policy was not followed, and the facility only utilized one pharmacy, which led to the medication unavailability. Interviews with the DON and an LPN confirmed the medication was not administered due to the delay in delivery, and the facility was in the process of setting up a backup pharmacy system.
Failure to Provide Menu-Selected Food and Drinks
Penalty
Summary
The facility failed to ensure that residents received the selected food and drinks from the menu as indicated on their meal tickets. During a random dining observation, it was noted that one resident did not receive cranberry juice or sautéed spinach for lunch, and another resident did not receive oatmeal for breakfast. These discrepancies were confirmed by the staff members present at the time. The findings were reviewed with the Nursing Home Administrator, Director of Nursing, Corporate Clinical Operations, Regional Clinical Specialist, and representatives from the Ombudsman Office.
Inaccurate Care Plan for Resident on IV Antibiotics
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that accurately reflected a resident's medical needs. The resident was admitted with diagnoses including heart disease and anxiety and was on IV antibiotics for endocarditis. However, the care plan incorrectly identified the diagnosis as sepsis, despite a negative blood culture indicating no active sepsis. The care plan also lacked specific details about the IV access location and type, as well as the specific antibiotic and its duration. These deficiencies were identified during a review of the resident's records and discussed with facility administrators and representatives from the Ombudsman office.
Failure to Provide Proper Nebulizer Treatment
Penalty
Summary
The facility failed to provide care consistent with professional standards regarding a resident's albuterol nebulizer treatment. The resident, who had normal cognition, was prescribed albuterol sulfate inhalation nebulization solution to be administered four times a day. On one occasion, the resident's family member reported that the nebulizer facemask was left on the resident's face for over an hour, causing the resident to become anxious. The resident's roommate confirmed the incident, stating that after the resident's evening nebulizer treatment, the facemask was left on for an extended period, and despite calling for help multiple times, no staff responded promptly. Eventually, the roommate had to call a family member to contact the front desk, after which a nurse came in and removed the facemask without explanation. The incident was corroborated by the resident during an interview, who confirmed that the facemask was left on for over 45 minutes. The facility's policy on nebulizer therapy states that treatments should be administered by nursing staff using proper technique and standard precautions, and the treatment should be considered complete with the onset of nebulizer sputtering. The failure to adhere to this policy resulted in the resident experiencing unnecessary distress. The findings were reviewed with the nursing home administrator, director of nursing, corporate clinical operations, regional clinical specialist, and representatives from the Ombudsman office.
Failure to Ensure Timely Transportation for Dialysis
Penalty
Summary
The facility failed to ensure that a resident's transportation needs related to dialysis were met. The resident, who was admitted with end-stage renal disease requiring hemodialysis, had a care plan indicating dialysis appointments on Mondays, Wednesdays, and Fridays with a scheduled pick-up time between 6:00 and 6:30 AM. On the day of the incident, the resident was observed sitting in the facility lobby at 7:15 AM because the arranged transportation did not arrive. The facility had to arrange an alternative ride, and the resident was eventually driven to the dialysis treatment in the facility bus at 9:35 AM. Interviews with staff revealed confusion regarding the responsibility for arranging dialysis transportation. The Assistant Director of Nursing stated that the hospital arranges transport for the first two weeks post-discharge, after which it becomes the dialysis center social worker's responsibility. However, the facility's Long Term Facility Outpatient Dialysis Services Coordination Agreement clearly states that the long-term care facility is responsible for arranging suitable and timely transportation for dialysis. This discrepancy led to the failure to ensure timely transportation for the resident's dialysis treatment.
Failure to Disinfect Glucometer
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program as evidenced by the improper disinfection of a glucometer. During a medication observation, an LPN obtained a blood glucose level on one resident using a glucometer and did not clean or disinfect the device after use. Shortly after, the same LPN used the uncleaned glucometer on another resident. The LPN confirmed the failure to disinfect the glucometer after use. The facility's policy and the manufacturer's guidelines both require the glucometer to be cleaned and disinfected after each use to prevent cross-contamination.
Failure to Provide Nephrostomy Care Training
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for staff, as evidenced by the absence of nephrostomy care on the Nursing Orientation Check List. A resident with kidney cancer and chronic kidney disease, who had a nephrostomy tube placed, required daily saline flushes. Despite a physician's order for this procedure, an LPN admitted to performing the flush without receiving specific training from the facility, relying instead on prior experience from another facility. The Staff Developer confirmed that nephrostomy tube flush education had not been provided to the nursing staff. These findings were reviewed with the Nursing Home Administrator, Director of Nursing, Corporate Clinical Operations, Regional Clinical Specialist, and representatives from the Ombudsman office.
Failure to Provide Comprehensive Medication Regimen Review Policy
Penalty
Summary
The facility failed to provide a Medication Regimen Review (MRR) policy with specific time frames for response from the provider for identified irregularities and a complete process for following up on urgent action irregularities. The policy, dated 4/1/20, lacked stated time frames for provider response to pharmacist-identified irregularities and did not include a complete process for urgent action irregularities, such as time frames for informing the provider of the urgent finding and steps to take if the provider fails to respond within a designated time frame. This deficiency was identified through record review and interviews with facility staff, including the Nursing Home Administrator (NHA), Director of Nursing (DON), Corporate Clinical Operations, Regional Clinical Specialist, and representatives from the Ombudsman office. The surveyor reviewed the MRR policy and found that while the policy required the pharmacist to communicate recommendations and identified irregularities within 10 working days and to inform the DON or designee verbally for urgent action irregularities, it did not specify the time frames for provider response or the complete process for urgent action follow-up. The facility was unable to provide evidence of these critical components in their MRR policy, leading to the determination that the facility failed to ensure a comprehensive and timely response to medication regimen review irregularities, particularly those requiring urgent action to protect residents.
Failure to Maintain and Safeguard Medical Records
Penalty
Summary
The facility failed to maintain and safeguard medical records information on six residents, resulting in incomplete, inaccurately documented, and not readily accessible records. For Resident 98, the facility lacked evidence of the admission agreement upon admission. For Residents 42, 63, 76, 107, and 108, the electronic medical records (EMRs) did not have readily accessible documentation of urine culture results, including the organism and sensitivities, which are crucial for identifying the appropriate antibiotic treatment. The facility was able to produce printouts from the laboratory's website upon the surveyor's request, but these results were not uploaded into the EMRs, and only a limited number of people had access to the laboratory's website. This lack of documentation in the EMRs was confirmed through interviews with facility staff, including the Nursing Home Administrator (NHA) and other clinical operations personnel. The surveyor's review revealed that the facility's failure to upload urine culture results into the EMRs led to incomplete medical records for the affected residents. This deficiency was observed in multiple cases where urine cultures indicated the presence of Klebsiella species, including Klebsiella oxytoca ESBL and Klebsiella pneumoniae ESBL. The surveyor noted that the facility's practice of not uploading these results into the EMRs hindered the accessibility and completeness of the residents' medical records. The findings were reviewed with the NHA, Director of Nursing (DON), Corporate Clinical Operations, Regional Clinical Specialist, and representatives from the Ombudsman, who acknowledged the issue.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to provide a clean and sanitary environment in two shower rooms and multiple resident rooms. During an observation of the East and [NAME] wings shower rooms, several large areas of a blackened substance were observed where the walls met the tiles, along with multiple areas of chipped and broken floor and wall tiles. Additionally, an environmental tour revealed that the floors in rooms E101 through E122 and W101 through W122 were coated with a thick, blackened, greasy substance. These findings were confirmed with the Corporate Resource Manager and the Maintenance/Housekeeping Director, and were reviewed with the Nursing Home Administrator, Director of Nursing, Corporate Clinical Operations, Regional Clinical Specialist, and representatives from the Ombudsman Office.
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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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