Gilpin Hall
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, Delaware.
- Location
- 1101 Gilpin Avenue, Wilmington, Delaware 19806
- CMS Provider Number
- 085047
- Inspections on file
- 20
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Gilpin Hall during CMS and state inspections, most recent first.
A resident with severe cognitive impairment had a motion-activated camera in their room, permitted and monitored by their representative. Despite staff being aware of the camera and instructed not to touch it, a CNA was observed on multiple occasions turning the camera to face the wall, interfering with its intended use by the resident's representative.
A resident with severe dementia and a history of care resistance was subjected to physical and mental abuse by a CNA and an RN, as captured on video. The CNA forcefully handled the resident during toileting and dressing, causing distress, while the RN attempted to forcibly retrieve medication from the resident's hand and verbally reprimanded her after being struck. Staff failed to follow the care plan and did not properly document or report incidents, resulting in psychosocial harm to the resident.
The facility did not maintain a surety bond in an amount sufficient to cover all residents’ personal funds held in trust. Documentation showed that the surety bond in place was for $20,000, while a current account summary listed forty-five residents with a combined trust account balance of $28,733.79. During an interview, the Executive Director confirmed the bond amount, demonstrating that the bond did not fully cover the total resident trust funds managed by the facility.
The facility did not report allegations of abuse and an injury of unknown origin within the required two-hour timeframe for two residents. In one case, a hand fracture was reported to authorities about three days after discovery, and in another, a resident-to-resident abuse incident was reported approximately four hours after it occurred.
Surveyors found that controlled substances storage boxes in two medication rooms were either placed on top of the refrigerator or inside the refrigerator without being permanently affixed, as required. Staff confirmed that these medications were kept in the refrigerators and counted every shift, but the required permanent affixation was not in place. Facility leadership was informed of these findings.
A resident with DM2 and normal cognition had a weekly Ozempic order. An LPN signed for delivery of multiple Ozempic pens and stored them in a locked medication room refrigerator accessible only to nursing staff. Days later, another LPN could not locate the medication when it was needed for administration. The resident reported not giving anyone permission to take any medications. The facility’s failure to safeguard the medication and ensure it was available for use resulted in misappropriation of the resident’s property.
A resident was discharged home to live with family, as documented in a nurse progress note, but the facility failed to notify the Ombudsman of this discharge as required. Review of the transfer log showed no evidence of Ombudsman notification for the community discharge, and the NHA later confirmed in an interview that the Ombudsman had not been informed when the monthly list of discharges was submitted. The omission was identified during surveyor record review and discussed with facility leadership, including the NHA, DON, and ADON.
Two residents experienced significant changes in mental health status, including new diagnoses of MDD, delusional disorder, unspecified psychosis, and psychotic disorder, along with initiation or continuation of antipsychotic medications such as Risperdal and Seroquel. One resident’s record evolved from a primary dementia diagnosis with anxiety treated by Lexapro and Zyprexa to multiple additional psychiatric diagnoses and documented psychosis, while another progressed from dementia with anxiety and depression and no problematic behaviors to documented aggressiveness, physical altercations with staff, and poor impulse control. Despite these changes and confirmation from the State PASRR Authority that a new assessment was needed for at least one resident, the facility did not complete updated PASRR screenings or coordinate reassessments after the status changes, as confirmed by the DON.
A resident with heart failure had a physician order for daily weights at a specific time, with instructions to notify the MD for certain weight gains. Review of the eMAR showed that staff did not obtain or document the ordered daily weights on multiple days and did not record any reasons for the missed weights. An RN reported that nurses were responsible for weighing the resident and stated the resident sometimes refused, but the clinical record contained no documentation of such refusals, resulting in a failure to follow and document the ordered daily weight regimen.
Surveyors found that the facility’s written abuse policy did not meet CMS requirements, as it lacked coordination with the QAPI program, did not specify required training on recognizing signs and types of abuse, and omitted language prohibiting and preventing retaliation for reporting abuse. During interview, the NHA reported that extensive abuse training is conducted but acknowledged unawareness that the policy itself was missing these elements, which was later reviewed with the NHA, DON, and ADON at exit.
Surveyors found that the facility’s medication regimen review policy did not include defined time frames for the steps in the monthly drug regimen review process or specify what actions a pharmacist must take when an urgent medication irregularity is identified. Review of the written policy and interview with the DON confirmed that, although the consultant pharmacist conducts MRRs, the policy lacks these required procedural details, and this was acknowledged by facility leadership during the survey exit conference.
The facility failed to protect residents from abuse, including physical and verbal aggression. Incidents involved a resident being physically assaulted, inappropriate sexual behavior by a male resident, and verbal abuse by a staff member. The facility's interventions were insufficient to prevent these occurrences.
The facility failed to ensure proper infection control during resident care. CNAs did not change gloves or perform hand hygiene during incontinence care for a resident, and an LPN did not disinfect an overbed table or perform hand hygiene during wound care for another resident. Additionally, an LPN did not follow the recommended drying times for a glucometer, using a tissue to dry it instead. These actions were against the facility's policies and increased the risk of cross-contamination.
A resident with severe cognitive impairment fell and sustained injuries, but the facility failed to notify the Resident Representative (RR) as required by policy. The resident was sent to the hospital, and the RR was informed by a third party, not the facility. Attempts to contact the RR were reportedly unsuccessful, and documentation of the notification was missing.
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two residents, preventing them from making informed decisions about the costs of continued therapy services. The Admission Coordinator and Administrator confirmed the oversight, citing concerns about potential confusion for residents and families when Medicaid was the payment source.
A facility failed to follow its grievance procedures for a resident who did not receive a dinner tray. A family member filed a grievance, but the Administrator did not provide a written response or resolution, as required by the facility's policy. This oversight increased the potential for unresolved grievances.
The facility failed to thoroughly investigate abuse allegations involving three residents. One resident felt humiliated by a CNA, leading to the CNA's termination, but the investigation lacked interviews with other potential witnesses. Another resident reported being punched by a fellow resident, yet the investigation did not include witness interviews. The ADON and Administrator acknowledged the lack of comprehensive investigative documentation.
A resident with cognitive impairment and arthritis experienced a delay in receiving an x-ray for a swollen knee, resulting in a three-day wait before discovering an acute fracture. The facility failed to notify the physician of the delay or seek alternative x-ray services, leading to inadequate pain management and delayed treatment.
A facility failed to follow transfer protocols for a resident requiring a Hoyer lift with two staff, as a CNA used a stand-up lift alone, contrary to the care plan. The resident, with cognitive impairments, was dependent on staff for transfers. Additionally, another resident had a Keurig coffee maker in their room without a documented safety assessment, despite being cognitively intact and independent in some activities.
A resident with cognitive impairment and arthritis experienced inadequate pain management due to delayed x-ray and lack of pain assessments. The resident received Tylenol for knee swelling and pain over three days without proper documentation or assessment, leading to the discovery of a femur fracture. The facility adjusted pain management only after the x-ray confirmed the fracture.
Failure to Honor Resident Representative's Rights Regarding Room Camera
Penalty
Summary
Staff failed to honor the rights of a resident's representative, who was designated as power of attorney for care, by not following the established permission for a motion-activated camera in the resident's room. The resident, who was severely cognitively impaired due to dementia, had a camera installed and monitored by the representative, with the facility and nursing staff aware of its presence and purpose. On multiple occasions, a CNA was observed on video turning the camera to face the wall and away from the resident, despite being educated not to touch the resident's personal property, including the camera. The CNA later confirmed in a written statement and interview that she had turned the camera because she did not consent to being recorded.
Failure to Protect Resident from Physical and Mental Abuse by Staff
Penalty
Summary
A resident with severe dementia, depression, and anxiety disorder was admitted to the facility and care planned for significant assistance with activities of daily living (ADLs), including toileting and dressing. The resident was known to be frequently resistive to care and required staff to use specific approaches such as encouragement, clear explanations, and providing choices. Despite these care plan directives, video evidence captured multiple incidents where a CNA physically forced the resident into the bathroom and handled her roughly during care, resulting in the resident screaming and expressing distress. In one incident, the CNA forcefully grabbed and pushed the resident into the bathroom while she was screaming, and in another, the CNA pulled the resident up from the bed and pushed her from behind without verbal communication, despite the resident's vocal protests. Additionally, a separate incident involving an RN was captured on video, where the nurse attempted to administer medication to the same resident. The resident resisted by holding the medication in her hand and verbally expressing her refusal. The RN attempted to retrieve the medication from the resident's closed fist, during which the resident screamed and accused the nurse of breaking her fingers. The resident then struck the nurse, who responded by pointing a finger at the resident's face and verbally reprimanding her. There was no documentation in the clinical record of the medication refusal or the altercation, and the nurse did not report the incident to a supervisor as required. These incidents demonstrate that the facility failed to protect the resident from physical and mental abuse by staff. The staff did not follow the resident's care plan for managing resistive behaviors and did not adhere to protocols for reporting and documenting refusals of care or incidents of abuse. The actions of the staff resulted in dehumanization and psychosocial harm to the resident, as evidenced by the resident's distress and the nature of the interactions captured on video.
Insufficient Surety Bond Coverage for Residents’ Trust Funds
Penalty
Summary
The facility failed to assure the security of all personal funds of residents deposited with the facility by not maintaining a surety bond in an amount sufficient to cover the total balance of residents’ trust accounts. On review of documents, the surveyor was provided a surety bond from the facility’s insurance company in the amount of $20,000, effective from 12/08/24 to 12/08/25. The facility also provided a list labeled “Trust- Current Account Balance as of 8/27/25,” which identified forty-five residents with personal funds accounts managed by the facility and showed a current total balance of $28,733.79. In an interview, the Executive Director confirmed that the surety bond amount was $20,000, which was less than the total amount of residents’ funds held in trust, resulting in the deficiency. No additional resident-specific medical history or clinical conditions were described in the report, and the deficiency pertained solely to the financial protection of residents’ personal funds.
Failure to Timely Report Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report allegations of abuse and injury of unknown origin within the required two-hour timeframe for two out of six residents reviewed. For one resident, an x-ray report indicating an acute hand fracture was received, but the injury of unknown origin was not reported to the State Agency until approximately three days later. In another case, an incident report documented an allegation of resident-to-resident abuse, but the facility reported the incident to the State Agency about four hours after the altercation. These delays in reporting were confirmed through record review and staff interview.
Controlled Substances Storage Boxes Not Permanently Affixed in Medication Rooms
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage of controlled substances in two medication rooms. On multiple occasions, the storage box for controlled substances on the second floor was found placed on top of the refrigerator rather than being secured inside and permanently affixed. In the third-floor medication room, the controlled substances box was inside the refrigerator but was not permanently affixed as required. These findings were consistent over several days of observation. During an interview, a registered nurse confirmed that controlled substances requiring refrigeration were kept in the refrigerators and counted every shift, but did not address the lack of permanent affixation. The findings were reviewed with facility leadership during the exit conference. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Protect Resident Medication from Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident’s personal property, specifically a prescribed medication, and ensure it was available for use. The resident was admitted with diabetes and had an active order for weekly Ozempic injections for DM2. According to the facility’s abuse policy, misappropriation of resident property includes intentional theft or mishandling of a resident’s money or property by personnel authorized to handle it. The resident’s quarterly MDS showed normal cognition, and there is no indication that the resident gave anyone permission to take any of their medications. On the morning of 6/8/25, an LPN signed for delivery of three Ozempic pens for the resident and placed them in the refrigerator in the locked medication room on the third floor. On the morning of 6/13/25, another LPN was unable to locate the Ozempic in that refrigerator. The medication, which had been properly delivered and stored in a secure area accessible only to nurses, was missing when needed for administration. As a result, the facility did not have the resident’s ordered Ozempic dose available at the scheduled time, constituting a failure to protect the resident’s property and ensure its availability for the resident’s use.
Failure to Notify Ombudsman of Resident Discharge to the Community
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to notify the Ombudsman of a resident’s discharge to the community. Record review showed that on 7/3/25 at 2:30 PM, a nurse progress note documented that the resident’s daughter arrived at the facility to pick up the resident, who was discharging home to live with her daughter. Review of the facility’s April 2025 Transfer Log on 8/28/25 at 1:15 PM lacked any evidence that the Ombudsman was notified of this discharge to the community on 7/3/25. In an email dated 8/28/25 at 4:09 AM, the Nursing Home Administrator (E1) documented that the Ombudsman was notified that day of the resident’s discharge home, and in a follow-up interview on 8/29/25 at 8:39 AM, E1 confirmed that the Ombudsman had not been notified of the resident’s discharge when the July 2025 list was submitted to the Ombudsman on 8/15/25. Findings were subsequently reviewed with the Nursing Home Administrator (E1) and Director of Nursing (E2) on 8/29/25 at 1:33 PM, and again during the exit conference on 8/29/25 at 2:30 PM with E1, E2, and the Assistant Director of Nursing (E5).
Failure to Coordinate PASRR Reassessments After Significant Mental Health Changes
Penalty
Summary
The deficiency involves the facility’s failure to coordinate with the PASRR program and submit updated assessments when residents experienced significant mental health status changes. For one resident, a Level I PASRR completed at admission documented a primary neurocognitive disorder/dementia and use of Lexapro and Zyprexa for anxiety. Subsequently, the resident was care planned for antipsychotic use (Risperdal) related to frontotemporal dementia, delusions, and a history of psychosis. Over time, multiple new psychiatric diagnoses were added to the record, including major depressive disorder (MDD), delusional disorder with psychosis, unspecified dementia with psychosis, other specified behavioral and emotional disorders with onset in childhood/adolescence, and pseudobulbar affect. A quarterly MDS later documented active anxiety disorder, depression, psychotic disorder, and pseudobulbar affect. The State PASRR Authority later confirmed by email that the facility should submit a new PASRR assessment for a status change to include MDD as a new major diagnosis and to update the resident’s current mental status and diagnoses, but this had not been done. For a second resident, the clinical record showed admission with dementia, peripheral vascular disease, and diabetes mellitus, and a Level I PASRR that listed dementia, anxiety, and major depressive disorder, with trazodone and lorazepam prescribed and no known problematic behaviors. Later nursing documentation described increased issues evidenced by aggressiveness and physical altercations with staff. The resident was then diagnosed with delusional disorder and unspecified psychosis, and an antipsychotic (Seroquel) was ordered. A subsequent psychiatric note described the resident as difficult to manage, with no impulse control, poor response to redirection, and requiring medications, and a quarterly MDS documented anxiety, depression, and psychotic disorder. During interview, the DON stated that the last PASRR screening in the chart was the earlier Level I and confirmed there was no PASRR screening after that date, indicating the facility did not coordinate with PASRR for reassessment after the significant change in mental health status and diagnoses.
Failure to Complete and Document Ordered Daily Weights for Heart Failure Management
Penalty
Summary
A resident with a diagnosis of heart failure was admitted to the facility and later had a physician’s order dated 10/24/24 for a daily weight at 8:00 AM, with instructions to notify the MD for specified weight gains related to heart failure management. Review of the resident’s electronic MAR for June 1–24, 2025, showed that daily weights were not obtained or documented on 7 of 24 ordered days, and there was no documented reason for the missed weights. During interview, an RN stated it was the nurse’s responsibility to weigh the resident and acknowledged that the resident sometimes refused, but the clinical record contained no evidence that the resident had refused the ordered weights. The deficiency centers on the facility’s failure to provide and document ordered daily weights and any refusals, as required by the physician’s order for heart failure monitoring.
Failure to Include Required Elements in Abuse Prevention Policy
Penalty
Summary
Surveyors determined that the facility failed to develop and implement an abuse policy that met CMS requirements. The Resident Abuse Policy/Procedure provided for review did not show evidence of coordination with the facility’s QAPI program, did not include required training content regarding recognizing signs of abuse and identifying different types of abuse, and did not contain language prohibiting and preventing retaliation against individuals who report abuse. During interview, the NHA stated that the facility conducts extensive abuse training throughout the year but was not aware that the written abuse policy lacked these specific CMS-required elements, including training on signs and types of abuse, anti-retaliation provisions, and QAPI involvement. These findings were discussed with the NHA, DON, and ADON during the exit conference. No residents or specific patient conditions were mentioned in the report.
Incomplete Medication Regimen Review Policy Lacking Time Frames and Urgent Action Steps
Penalty
Summary
The facility failed to ensure that its monthly drug regimen review (MRR) policy contained required elements, specifically time frames for the different steps in the MRR process and directions for actions the pharmacist must take when an irregularity requiring urgent action is identified. Review of the facility document titled “Medication Regimen Review,” revised on multiple dates, showed that while it stated medications are reviewed in multiple ways, including the MRR conducted by the consultant pharmacist, it lacked evidence of defined time frames for each step of the process and did not specify the steps the pharmacist must take when an irregularity is identified. During an interview, the DON confirmed that the policy does not include time frames for the different steps in the medication review process. These findings were discussed with the NHA, DON, and ADON during the exit conference. No specific residents, medical histories, or clinical conditions were identified in the report in relation to this deficiency.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect several residents from abuse, including resident-to-resident abuse, as evidenced by multiple incidents involving physical and verbal aggression. One incident involved a resident with cognitive impairment who wandered into another resident's room and was physically assaulted, resulting in a subconjunctival hemorrhage and corneal abrasion. The assaulted resident was on anticoagulant medication, which increased the risk of excessive bleeding. Despite the altercation, the facility did not implement adequate measures to prevent further incidents between these residents. Another incident involved a cognitively impaired resident who was observed engaging in inappropriate sexual behavior with a female resident who was non-ambulatory and dependent on staff for activities of daily living. The male resident had a history of sexually inappropriate behavior, yet the facility's interventions were insufficient to prevent the incident. The dietary aide who witnessed the event intervened, but the lack of staff presence in the area allowed the incident to occur. Additional incidents included verbal abuse by a staff member towards a resident, resulting in the resident feeling humiliated and manipulated. The staff member was terminated following the investigation. Other incidents involved physical aggression between residents, with one resident attempting to hit another with a walker. These events highlight the facility's failure to adequately supervise and protect residents from abuse, as well as to implement effective interventions to prevent such occurrences.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during incontinence care for a resident with cognitive impairment and incontinence issues. Certified Nursing Assistants (CNAs) did not change gloves or perform hand hygiene after cleaning the resident's soiled areas and before adjusting the resident's clothing and bed. The CNAs also did not follow the correct cleaning technique, as they cleaned the resident's perineal area in a back-to-front motion, which is against the facility's policy. During wound care for a resident with a stage III pressure sore, the Licensed Practical Nurse (LPN) did not disinfect the overbed table after a wash basin left a wet spot. The LPN also failed to perform hand hygiene between changing gloves while conducting the dressing change. These actions were contrary to the facility's policy, which requires creating a clean field and washing hands between glove changes to prevent contamination. The facility also failed to follow the recommended disinfectant drying times for a multi-use glucometer. An LPN used a tissue to dry the glucometer immediately after wiping it with a disinfectant, instead of allowing it to air dry for the required time. This practice was not in line with the facility's policy and the manufacturer's guidelines, which specify a drying time to ensure effective disinfection.
Failure to Notify Resident Representative After Fall
Penalty
Summary
The facility failed to notify the Resident Representative (RR) following a fall with injuries for one of the residents, identified as R94. This failure resulted in a delay for the RR to reach the hospital before the resident's condition worsened. The facility's policy required that the responsible party, physician, and Director of Nursing be contacted and documented in the progress notes and incident report. However, the documentation and communication were inadequate in this case. R94 was admitted with diagnoses including dementia, gait abnormalities, and seizures, and had a history of wandering and falls. The resident was part of a safety program and had interventions such as safety checks and non-slip footwear. On the day of the incident, R94 was witnessed by dietary staff getting up from a wheelchair and falling, resulting in facial lacerations and bleeding. The primary care physician was notified, and the resident was sent to the hospital, but attempts to notify the RR were unsuccessful. Interviews revealed that the RR was informed of the incident by a third party and not by the facility. The RR stated that the facility never called, and by the time they reached the hospital, R94 was intubated and later placed on hospice care. The LPN involved claimed to have attempted to contact the RR but was unsuccessful. The hospital transfer form, which should have documented the notification, was not found in the electronic medical record, and the facility's administration was unable to provide it upon request.
Failure to Provide SNFABN to Residents
Penalty
Summary
The facility failed to provide the required Form CMS-10055, also known as the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), to two residents, identified as R10 and R77, who were reviewed for liability notices. This form is essential for informing residents or their representatives about potential financial liabilities for services not covered by Medicare or Medicaid. The absence of this notice prevented these residents or their responsible parties from making informed decisions regarding the costs associated with continued therapy services after the end of their skilled services. The deficiency was identified through interviews and record reviews. R10 and R77 continued to reside in the facility after their skilled services ended, but they were not provided with the SNFABN. The Admission Coordinator confirmed during an interview that the ABN letter was not given alongside the Notice of Medicare Non-Coverage (NOMNC). The facility's Administrator acknowledged that the ABN notice was never provided, citing concerns that it might confuse residents and their families, especially when Medicaid was the payment source. This oversight highlights a failure in the facility's process to ensure residents are adequately informed about their financial responsibilities.
Failure to Follow Grievance Procedures for Resident
Penalty
Summary
The facility failed to adhere to its grievance procedures for a resident, identified as R79, who was part of a sample of 34 residents reviewed for grievances. The facility's policy, dated 03/11/22, mandates that residents have the right to voice grievances without fear of discrimination or reprisal, and the facility must make prompt efforts to resolve these grievances. However, a review of the grievance log dated 01/16/24 revealed that a family member of R79 filed a grievance regarding the resident not receiving a dinner tray the previous night. The log indicated a delay in staff delivery, but there was no further information provided by the Administrator, who handles all grievances. During interviews conducted on 10/16/24, the Administrator confirmed that she did not provide residents or family members with a written response to grievances, including the resolution. This lack of documentation and communication regarding the resolution of grievances indicates a failure to follow the established grievance procedures, potentially leaving resident grievances unresolved.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse involving three residents. In the first case, a resident with a history of depression and anxiety reported feeling humiliated and manipulated by a CNA during care. The CNA was suspended and later terminated based on the resident's statement and the CNA's own account. However, the investigation lacked documentation of interviews with other residents or staff who may have interacted with the CNA, which could have provided additional context or corroboration. In another incident, a resident reported being punched by another resident. The facility's investigation did not include interviews with potential witnesses, such as other staff or residents who might have observed the altercation. The ADON confirmed the absence of such interviews in the investigative file, and the Administrator noted that witness interviews are collected based on the situation, indicating inconsistency in the investigative process.
Delay in X-ray Leads to Untreated Fracture
Penalty
Summary
The facility failed to ensure timely treatment for a resident who experienced swelling in the right knee, leading to a delay in obtaining a necessary x-ray. The resident, who was cognitively impaired and dependent on staff for mobility and activities of daily living, was admitted with diagnoses including arthritis, dementia, and Alzheimer's disease. On the day the swelling was noted, the physician ordered a 2-view x-ray of the right knee. However, the x-ray was not obtained until three days later, during which time the resident was administered non-narcotic pain medication and experienced continued swelling and pain. Throughout the three-day period, there was no documentation indicating that the physician was notified of the delay in obtaining the x-ray, nor were there attempts to contact another mobile x-ray company or seek further physician guidance regarding the resident's pain management. The x-ray, when finally completed, revealed an acute fracture of the distal femur. The delay in obtaining the x-ray and notifying the physician resulted in a delay in appropriate treatment for the resident's condition.
Failure to Follow Transfer Protocols and Assess Environmental Hazards
Penalty
Summary
The facility failed to ensure that a resident, identified as R30, was transferred using the appropriate mechanical lift and the required number of staff as per the resident's care plan. R30, who was admitted with diagnoses including arthritis, dementia, and Alzheimer's disease, was assessed as cognitively impaired and dependent on staff for transfers and activities of daily living. The care plan specified that R30 required a Hoyer lift with two staff members for transfers. However, video evidence and interviews revealed that CNA9 used a stand-up lift instead of the Hoyer lift and performed the transfer alone, contrary to the care plan and facility policy. The facility's EZ Lift Policy and Procedures, revised on 08/01/24, mandated that two staff members be present when using the EZ Way Lift or EZ Way stand-up lift to prevent injury. Despite this, CNA9 was observed on video using the stand-up lift alone to transfer R30, and later, after lunch, taking the resident into the spa room without assistance. The Director of Nursing confirmed that CNA9 was aware of the requirement for two staff members during transfers and had access to the resident's care information through the facility's electronic medical record system. Additionally, the report mentions another resident, R38, who had a Keurig coffee maker in their room. Although R38 was cognitively intact and independent in certain activities, there was no documented assessment for the safe use of the coffee maker. The Assistant Director of Nursing was unaware if the resident had been assessed for its use and stated that staff typically made coffee for the resident. This lack of assessment for potential hazards in the resident's environment was noted during the survey.
Inadequate Pain Management and Delayed X-ray for Resident with Fracture
Penalty
Summary
The facility failed to provide adequate pain management for a resident who experienced swelling in the right knee and was later found to have a fracture in the right distal femur. The resident, who was cognitively impaired and dependent on staff for mobility and activities of daily living, was administered Tylenol for pain relief over a period of three days while awaiting an x-ray. During this time, the facility did not assess the resident's pain before or after administering the medication, nor did they document the reason for administering Tylenol. The x-ray, which was delayed, eventually revealed a fracture, and the resident was sent to the Emergency Department for further evaluation. The resident's medical records indicated that Tylenol was administered multiple times without proper pain assessments, and the x-ray was not completed until three days after it was ordered. Upon receiving the x-ray results, the facility adjusted the resident's pain management to include stronger medications such as Oxycodone and Morphine. The Director of Nursing confirmed the delay in obtaining the x-ray, which contributed to the inadequate pain management for the resident.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
