Kentmere Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, Delaware.
- Location
- 1900 Lovering Avenue, Wilmington, Delaware 19806
- CMS Provider Number
- 085001
- Inspections on file
- 23
- Latest survey
- December 13, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Kentmere Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls was left unsupervised during care, resulting in a fall, head laceration, and a fractured femur, after which comfort care was initiated and the resident expired. Additionally, broken glass was left unaddressed in another resident's restroom on a dementia unit, despite staff awareness, creating a hazard for residents, including those who wander. Facility policy requiring hazard identification and adequate supervision was not followed in both cases.
Surveyors found multiple dietary deficiencies, including improperly stored and labeled food items in the walk-in refrigerator and freezer, such as opened products without dates, spoiled produce with mold, cracked eggs stored with intact eggs, and dry goods and frozen items left open to air. Staff failed to follow policy requiring all refrigerated and frozen foods to be covered, labeled, and dated. The dishwashing machine was operated at inadequate temperatures, with a low wash temperature and a “Probe Error” on the final rinse, and the dietary aide did not monitor or report these issues as required by policy. Hot foods on the tray line, including pureed vegetables and mechanically altered meat, were held below the required 135°F, and the hot holding unit lacked a thermometer for temperature monitoring at the time of observation.
The facility did not report allegations of abuse, including physical aggression and sexual abuse between residents, to the state survey agency within the required two-hour timeframe. In several cases, staff also failed to immediately notify the DON or Executive Director of abuse incidents, resulting in delayed reporting and investigation. Facility leadership acknowledged that these incidents were not reported in accordance with policy.
The facility did not interview all staff members with knowledge of or involvement in two separate incidents of resident injury and alleged abuse. In one case, a cognitively intact resident reported an LPN caused a finger injury, but the investigation omitted a statement from a therapist who was told about the event. In another case, a resident with severe cognitive impairment sustained a finger fracture of unknown origin, and the investigation did not include statements from the RN or LPN who cared for the resident at the time. Facility leadership acknowledged that not all relevant staff were interviewed as required by policy.
The facility did not maintain an effective pest control program, leading to ongoing rodent infestation on one floor. Multiple observations found rodent droppings in resident rooms and common areas, and a live mouse was seen in the dining room. Staff and leadership acknowledged the persistent rodent issue and described the use of sticky traps and reporting to pest control, but these measures did not resolve the problem.
The facility failed to ensure proper documentation of narcotic count sheets on medication carts, with missing initials from oncoming and off-going nurses across five carts. Staff interviews revealed awareness of the requirement, but no explanations for the omissions. An RN admitted to pre-signing a sheet, and the DON acknowledged the issue, noting previous reminders from the pharmacy.
The facility failed to ensure kitchen staff with beards wore beard guards during food preparation, as required by their policy. Observations over two days showed two male staff members without beard nets, despite the Dietary Manager and aides acknowledging the requirement. This oversight risked physical contamination of food for all 89 residents.
The facility failed to adhere to menu portion sizes for residents on mechanical soft and regular texture diets, affecting their nutritional intake. Observations revealed incorrect scoop sizes and serving methods were used, leading to smaller portions than specified. Interviews with staff highlighted a lack of standardization and understanding of portion sizes, with the RD stressing the importance of correct servings to maintain residents' weights.
A resident, severely cognitively impaired and dependent on staff for transfers, was involved in a fall when a CNA attempted to transfer them alone, contrary to the care plan requiring two staff members and a Hoyer lift. The resident's knees buckled, resulting in a fall onto a mat, but no injuries were sustained. The facility's policy mandates two staff members for mechanical lift transfers, which was not followed, increasing accident risk.
A facility failed to inform a resident of the risks and benefits of prescribed antidepressant medications, as required by their policy on resident rights. The resident, who was cognitively intact, was prescribed Escitalopram Oxalate and Trazadone for depression and insomnia. The DON could not provide documentation confirming that the resident had been informed about these medications.
A resident with chronic bronchitis and COPD was not allowed to self-administer cough drops as per physician's order, despite being cognitively intact. The cough drops were kept at the nurses' station, and the resident had to request them, with no self-administration assessment documented.
A resident experienced a fall from a wheelchair, resulting in a hospital visit. The facility failed to accurately reflect this incident in the resident's significant change MDS assessment, which was intended to address the fall. The MDS Coordinator confirmed the omission, despite the resident being severely cognitively impaired.
The facility failed to provide consistent ADLs for two residents. One resident with dementia and quadriplegia did not receive scheduled showers, with inadequate documentation of refusals or alternatives. Another resident with a stroke and vascular dementia had poor oral hygiene, despite being dependent on staff for assistance. Staff interviews revealed inconsistencies in monitoring and documentation of care plans.
A facility failed to notify a PCP about a new wound on a resident's ankle, leading to a lack of treatment orders. Additionally, a blood pressure medication was administered without obtaining the required blood pressure reading, as the MAR lacked necessary alerts. These deficiencies in communication and protocol adherence placed residents at risk.
A resident with mobility issues had uncut toenails extending beyond the toes, despite requesting a podiatry appointment. The facility's policy required podiatry care, but staff were unaware of the resident's need, leading to a lack of follow-up and communication. The DON confirmed the requirement for podiatry appointments to prevent infection.
A facility failed to provide necessary adaptive equipment and follow physician orders for two residents. One resident, with a leg fracture, was not consistently placed in a high back wheelchair with padded footrests as recommended, while another resident with right-sided paralysis did not consistently receive a physician-ordered splint for her arm and hand. Observations and interviews revealed inconsistencies in care, with staff confirming the lack of adherence to recommended equipment use and physician orders, leading to deficiencies in resident care.
A resident's high back wheelchair was found to be broken, specifically the removable armrest, and was not reported for repair. The facility's staff, including the DOR and RN, were unaware of the issue due to a breakdown in communication and reporting procedures. The Maintenance Director confirmed no report was received through the TELS system, highlighting a failure in maintaining essential equipment.
Three residents experienced abuse in a facility, including a cognitively impaired resident who was subjected to inappropriate treatment by a nurse, a hospice resident threatened by a CNA, and a resident who felt demoralized by another CNA. Investigations confirmed the abuse, leading to staff terminations.
Two residents experienced misappropriation of their credit cards by a CNA, leading to unauthorized charges. Both residents were moderately cognitively impaired, and the CNA was caught on video using the stolen cards. The facility's policy allowed for securing valuables, but this was not effectively utilized.
A facility failed to report a potential abuse allegation to the SSA within the required two-hour timeframe. A resident with dementia sustained a skin tear during care, which was identified as a potential mistreatment incident. The MDSC escalated the incident to the DON but did not report it to the SSA until four hours later, violating the facility's policy.
A resident with dementia sustained bruising and skin tears after a CNA failed to follow dementia care protocols during care provision. Despite being trained, the CNA held the resident's wrists, causing harm. The facility's investigation confirmed the injuries and led to the CNA's termination.
Failure to Prevent Resident Fall and Remove Environmental Hazard
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident with severe cognitive impairment and a history of repeated falls. During morning care, a CNA turned her back to the resident to obtain a washcloth, at which point the resident, known to have jerking movements, fell from the bed. The resident sustained a laceration to the forehead requiring sutures and, two days later, was found to have swelling and limited range of motion in the left leg. An x-ray revealed a displaced fracture of the left femur. The resident's responsible party, after consultation with the physician, opted for comfort care due to the resident's poor surgical candidacy and advanced dementia. The resident subsequently expired in the facility. The facility also failed to identify and remove an accident hazard in a resident's room on the dementia unit. Broken glass was observed in a picture frame in the restroom of a resident with severe cognitive impairment. Although a staff member observed the broken glass, no action was taken to remove it. The glass remained in the room, posing a risk to the resident and others, including wandering residents who could enter the room. Interviews confirmed that staff were aware of the hazard but did not report or address it in a timely manner. Facility policy required all staff to be involved in identifying and addressing environmental hazards and to provide adequate supervision to prevent accidents, taking into account each resident's unique needs. In both incidents, staff failed to follow these protocols: in the first case, by leaving a dependent resident unsupervised during care, and in the second, by not removing a known environmental hazard. These failures resulted in actual harm to one resident and the potential for harm to others.
Improper Food Storage, Dishwashing, and Hot Holding Temperatures in Dietary Services
Penalty
Summary
Surveyors identified deficiencies in the facility’s food storage practices in the walk-in refrigerator and freezer. Policy required all refrigerated and frozen foods to be covered, labeled, and dated with a use-by date, and for food to be received and stored according to safe food handling practices. During observation with the Dietary Director (DD), multiple items in the walk-in refrigerator were found without labels or dates, including opened horseradish sauce, minced garlic, chocolate syrup, leftover cooked carrots, and parsley. Employee water was stored on a shelf with resident food. Several items were spoiled or past the manufacturer’s best-by date, including flour tortillas, bell peppers with mold, celery that was brown and soft in brown liquid, and a box of tomatoes that were soft/mushy with mold. Cracked eggs were stored on a flat with other eggs, exposing contents onto surrounding eggs, and an opened box of yellow cake mix was left exposed to air. In the freezer, a bag of frozen omelets was stored open to air without being sealed or dated. Additional deficiencies were found in dishwashing machine use and monitoring. Facility policy required hot-water dish machines to maintain specific wash and rinse temperatures, and for the operator to check and record temperatures with each cycle, reporting inadequate temperatures immediately. During observation of Dietary Aide (DA) #10 operating the dish machine, the wash temperature registered only 118°F and the final rinse showed a “Probe Error, Final Rinse” message, with no temperature reading. DA #10 stated he did not check dish machine temperatures before or during the wash cycle and did not report the probe error to the DD. The DD later stated he was unaware of the probe error because it had not been reported, and that staff were expected to monitor wash and rinse temperatures and report concerns. Surveyors also found deficiencies in hot food holding on the tray line. Facility policy required hot foods to be held at 135°F or greater. During observation of the lunch tray line, the pureed green beans measured 111°F and the mechanically chopped pork measured between 127°F and 131°F, both below the required holding temperature. Staff member #11 acknowledged that hot foods should be held at 135°F or higher and noted that the hot holding unit typically had a thermometer for monitoring, but at the time of observation there was no thermometer in the unit. The DD confirmed that hot foods should be held at or above 135°F and that the thermometer used to monitor the hot holding unit temperature was not inside the unit, stating he had last seen it there a few days earlier.
Failure to Timely Report Allegations of Abuse and Notify Supervisory Staff
Penalty
Summary
The facility failed to timely report allegations of abuse to the state survey agency and did not ensure immediate notification of supervisory staff regarding abuse incidents involving multiple residents. According to facility policy, allegations of resident abuse must be reported to the appropriate state regulatory authority within two hours. However, documentation revealed that an incident involving physical aggression between two residents was reported to the state agency four and a half hours after it occurred, exceeding the required timeframe. The Director of Nursing (DON) confirmed that the report was not submitted within the mandated two-hour window. Additionally, the facility did not ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to the DON or Executive Director. In one case, a resident with severe cognitive impairment touched another resident inappropriately, but the incident was not reported to the DON or state agency until the following day. The DON and Executive Director both acknowledged that the incident should have been reported within two hours, and that the responsible LPN failed to follow the notification process. Another incident involved a resident who sustained bruising and swelling to the hand after allegedly having an inhaler forcibly removed by an LPN. The resident reported the injury to nursing leadership several days after the incident, and the state agency was not notified until hours after the injury was identified. The DON and Executive Director both acknowledged that the incident was not reported in a timely manner, as required by facility policy.
Failure to Interview All Relevant Staff in Abuse Investigations
Penalty
Summary
The facility failed to interview all individuals identified as involved or with knowledge of alleged abuse incidents for two of seven sampled residents. In the first case, a resident with intact cognition and a history of COPD, anxiety, traumatic brain injury, and asthma reported to the DON that an LPN caused a bruise and swelling to their finger by pulling an inhaler from their hand. The facility's investigation included interviews with the resident, the LPN, and statements from staff who worked with the resident, but did not include a statement from a therapist who was reported to have been told by the resident about the incident. The Speech Language Pathologist later confirmed having a vague recollection of the resident mentioning an incident with a staff member. In the second case, a resident with severe cognitive impairment and a history of dementia, osteoporosis, glaucoma, muscle weakness, and falls was found to have a bruised, swollen, and warm finger, later determined to be fractured with an unknown origin. The facility's investigation did not include statements from the RN or LPN who documented or provided care at the time of the injury. Interviews with facility leadership confirmed that not all staff who worked with the resident within the relevant look-back period were interviewed, contrary to facility policy and expectations.
Failure to Maintain Effective Pest Control Program Resulting in Rodent Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, resulting in an ongoing rodent infestation on the 3rd floor. Observations revealed multiple instances of rodent droppings in various locations, including the dining room, common room, and several resident rooms. A live mouse was also observed in the dining room. The facility's policy required a written agreement with an outside pest control service, regular and scheduled pest control services, safe use of chemicals, and a reporting system for pest issues between scheduled visits. Despite these requirements, evidence of rodent activity persisted in resident and common areas. Interviews with staff, including a CNA, the Director of Maintenance, the Executive Director, and the Director of Nursing, confirmed awareness of the rodent problem, with reports indicating that mice were frequently seen, especially at night. Staff described the use of sticky traps and acknowledged ongoing complaints about rodents. The Executive Director confirmed that the rodent issue had been a problem for the past year, and the Director of Maintenance described the process of reporting pest sightings and notifying the pest control company. However, these actions were insufficient to prevent or eradicate the infestation, as evidenced by continued rodent activity and staff reports.
Failure to Document Narcotic Counts on Medication Carts
Penalty
Summary
The facility failed to ensure proper documentation of narcotic count sheets on medication carts, which is a critical aspect of pharmaceutical services. The report highlights that the narcotic count sheets on each medication cart were not consistently initialed by the oncoming and off-going nurses, as required by the facility's policy and standard nursing practice. This issue was observed across five medication carts reviewed, affecting 40 sample residents. The absence of initials was noted on multiple occasions, indicating a pattern of non-compliance with the established procedures for controlled medication storage and accountability. Interviews with nursing staff, including LPNs and RNs, revealed an awareness of the requirement to initial the narcotic sheets when coming on and going off shift. However, the staff could not provide explanations for the missing initials. Additionally, one RN admitted to pre-signing the narcotic sheet, which is against standard practice, citing that she was the only one with the keys. The Unit Manager and Director of Nursing acknowledged the issue, with the latter stating that the pharmacy had previously reminded staff to sign in and out, but the problem persisted. The facility's pharmacist confirmed that reviewing narcotic sheets is part of their responsibility, although they had not yet reviewed the sheets for November. The pharmacist also stated that pre-signing narcotic sheets is not an acceptable practice. The report indicates a lack of oversight and monitoring of narcotic sheet documentation, which could potentially lead to drug diversion, although this risk is not explicitly stated in the report.
Failure to Enforce Beard Guard Policy in Kitchen
Penalty
Summary
The facility failed to ensure that beard guards were worn by kitchen staff during food production, which is a requirement according to their own policy titled 'Food Safety and Preparation.' This policy mandates that staff with facial hair must wear a beard net to prevent physical contamination of food. Observations were made during multiple meal preparations over two days, where two male kitchen staff members with beards were seen not wearing beard nets at the food preparation station. The Dietary Manager (DM) confirmed during an interview that staff with beards are required to wear beard nets, but admitted to not noticing the non-compliance until it was pointed out. Additionally, two Dietary Aides (DA3 and DA4) acknowledged their awareness of the requirement to wear beard guards but stated they had forgotten to do so. This oversight had the potential to affect all 89 residents who consumed food from the kitchen, as it could lead to physical contamination of the food served in the facility.
Failure to Follow Menu Portion Sizes
Penalty
Summary
The facility failed to ensure that menus were followed in terms of portion sizes for residents on mechanical soft diets and regular texture diets. This deficiency was observed in four residents who were on a mechanical soft diet and other residents receiving regular texture diets. The facility's Portion Control Chart specified scoop sizes for serving portions, but these were not adhered to during meal service, leading to incorrect portion sizes being served. During observations, it was noted that a dietary aide used incorrect scoop sizes and serving methods for meals, resulting in residents receiving less than the designated portion sizes. For instance, residents on mechanical soft diets were served with a light gray handled scoop instead of the required dark gray handled scoop, and tongs were used to serve sauteed onions and mushrooms instead of measuring the correct portion size. Additionally, residents on regular texture diets were served fewer raviolis than specified in the menu. Interviews with the Dietary Manager and Registered Dietician revealed a lack of standardization in serving tools and a misunderstanding of the correct portion sizes. The Registered Dietician emphasized the importance of serving the correct portion sizes to monitor residents' intake and maintain stable weights. The Director of Nursing expressed an expectation for kitchen staff to ensure correct portion sizes to prevent weight loss among residents.
Inadequate Assistance During Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate assistance to prevent accidents for a resident who was dependent on staff for transfers. The resident, who was severely cognitively impaired and had multiple diagnoses including dementia and muscle weakness, was care planned to be transferred with the assistance of two staff members using a Hoyer lift. However, a Certified Nurse Aide (CNA) attempted to transfer the resident alone, resulting in the resident's knees buckling and a fall onto a fall mat. Fortunately, the resident did not sustain any injuries from the fall. The facility's policy required two staff members to be present when using a mechanical lift, but this was not adhered to in the incident involving the resident. The Director of Nursing confirmed that the resident should have been transferred using a Hoyer lift with two staff members present. The incident was reported, and the CNA involved was suspended pending investigation and subsequently terminated for neglect. The failure to follow the care plan and facility policy increased the risk of accidents for the resident and potentially for other residents in the facility.
Failure to Inform Resident of Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure that a resident was fully informed of the risks versus benefits of using psychotropic medications, specifically antidepressants. This deficiency was identified during a review of the facility's adherence to its policy on resident rights, which mandates that residents be informed and participate in their treatment decisions. The resident in question, who was admitted with a diagnosis of major depressive disorder, was prescribed Escitalopram Oxalate and Trazadone for depression and insomnia, respectively. Despite having a cognitive status that indicated the resident was capable of making informed decisions, there was no documentation to confirm that the resident had been informed of the risks and benefits of these medications. During an interview, the Director of Nursing (DON) was unable to provide documentation that the resident had been informed about the risks and benefits of the prescribed antidepressant medications. The DON acknowledged the absence of such documentation and indicated that efforts were being made to locate it. This lack of documentation suggests a failure in the facility's process to ensure residents are informed about their treatment options, as required by their own policy on resident rights.
Failure to Allow Resident to Self-Administer Cough Drops
Penalty
Summary
The facility failed to allow a resident to self-administer cough drops as per the physician's order, which violated the resident's right to self-administer medication when clinically appropriate. The resident, who was admitted with chronic bronchitis and chronic obstructive pulmonary disease, had a physician's order permitting them to keep cough drops at their bedside and self-administer one every four hours. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS), and the care plan included the order for unsupervised self-administration of cough drops. Despite these provisions, the resident reported that the cough drops were kept in a cabinet at the nurses' station, and they had to request them from the nursing staff. The Unit Manager confirmed that the cough drops were stored in the cabinet and that the resident occasionally asked for them. However, there was no documentation of a self-administration assessment being conducted to allow the resident to keep the cough drops in their room, as required by the facility's policy on resident rights.
Inaccurate MDS Assessment Following Resident Fall
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, which could potentially lead to inaccurate federal reimbursements and care planning. The deficiency was identified through a review of the Resident Assessment Instrument (RAI) Manual and the resident's electronic medical records (EMR). The resident, who was admitted to the facility on an unspecified date, experienced a fall from her wheelchair on 07/18/24, resulting in swelling to her forehead. The incident was reported by a Certified Nurse Aide (CNA) and documented in the nursing Incident Report progress notes. The resident was subsequently transported to a local hospital for evaluation and treatment as per the physician's orders. Despite the fall being a significant event, the resident's significant change MDS with an Assessment Reference Date (ARD) of 08/08/24 did not reflect this incident. The MDS assessment indicated that the resident was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of zero out of 15. During an interview, the MDS Coordinator confirmed that the significant change MDS did not include the fall, even though the purpose of the assessment was related to the fall. This oversight highlights a failure in accurately coding the MDS, which is crucial for proper assessment and care planning.
Inconsistent ADL Provision and Documentation for Two Residents
Penalty
Summary
The facility failed to consistently provide activities of daily living (ADLs) according to the care plan for two residents. Resident 93, who was admitted with dementia and functional quadriplegia, did not receive showers as scheduled on multiple occasions. The Point of Care (POC) documentation did not indicate whether the showers were given or refused, and there was no record of bed baths being provided. Interviews with staff, including a Licensed Practical Nurse (LPN), a Certified Nurse Aide (CNA), and the Unit Manager (UM), revealed a lack of consistent monitoring and documentation of the resident's shower schedule, which was supposed to occur twice weekly. Resident 23, admitted with a stroke and vascular dementia, was found to have inadequate oral hygiene. Despite being cognitively intact, the resident was dependent on staff for oral care due to limited mobility. Observations showed a significant coating on the resident's teeth, and documentation indicated that the resident was often dependent on staff for oral hygiene. The Director of Nursing (DON) acknowledged the discrepancy in the documentation, which incorrectly stated the resident was dependent rather than requiring extensive assistance. This lack of proper oral care documentation and assistance was confirmed through interviews and observations.
Communication and Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper communication and treatment for a resident with a newly identified skin alteration. A Licensed Practical Nurse (LPN) identified a new wound on a resident's right ankle but did not notify the Primary Care Physician (PCP) or the wound care team, nor were any treatment orders obtained. The resident, who had an unstageable pressure ulcer on the right heel, was dependent on staff for activities of daily living and had memory problems. The wound was discovered during a visit by the wound doctor, who was unaware of the abrasion and decided to treat it as a wound. The Director of Nursing (DON) acknowledged that the LPN missed steps in notifying the physician and family and completing a wound alert form. The facility also failed to adhere to physician orders regarding medication administration for another resident. A blood pressure medication was administered without obtaining the required blood pressure reading, as per the physician's order to hold the medication if the systolic blood pressure (SBP) was below 120. The LPN administering the medication was unaware of the requirement due to the absence of an alert on the Medication Administration Record (MAR). The DON confirmed that the necessary documentation for blood pressure monitoring was missing from the MAR, and the pharmacist noted that the medication review for the new admission had not been completed. These deficiencies highlight lapses in communication and adherence to established protocols for resident care. The failure to notify the PCP and obtain treatment orders for the new wound, as well as the oversight in medication administration without proper monitoring, placed residents at risk for health complications. The facility's policies on provider notification and medication administration were not followed, leading to these deficiencies.
Failure to Provide Nail Care for Resident
Penalty
Summary
The facility failed to provide appropriate nail care for a resident, identified as R1, who was admitted with diagnoses of abnormalities in gait, muscle weakness, and lack of mobility. Despite being cognitively intact and requiring limited assistance for personal hygiene, R1's toenails were observed to be uncut and extended beyond the tips of the toes. R1 had requested a podiatry appointment from several staff members since admission but had not received one. The facility's policy required podiatry care for residents, as staff were not permitted to trim toenails themselves. Interviews with staff revealed a breakdown in communication and follow-up regarding R1's need for podiatry care. RN5, responsible for making podiatry appointments, was unaware of R1's need for nail care and had not received any complaints or referrals from staff. CNA17, who was informed by R1 that an appointment had been made, did not verify or communicate this information further. Other CNAs involved in R1's care were also unaware of the need for toenail trimming. The Director of Nursing confirmed that the facility required podiatry appointments for all residents and conducted frequent skin audits to prevent infection.
Failure to Provide Adaptive Equipment and Follow Physician Orders
Penalty
Summary
The facility failed to provide appropriate adaptive equipment and follow physician orders for two residents, leading to deficiencies in their care. One resident, who had a fracture of the right tibia/fibula, was recommended by the therapy department to use a high back wheelchair with padded footrests for proper positioning and to prevent further trauma. However, observations revealed that the resident was often placed in a standard wheelchair without the necessary padded footrests, which were found in the bathroom instead of being used. Interviews with staff confirmed the lack of adherence to the recommended equipment use, and the resident's care plan did not address the need for these specific positioning aids. Another resident, who had a history of a cerebral vascular accident resulting in right-sided paralysis, was not consistently provided with a physician-ordered splint for her right arm and hand. The splint was supposed to be applied during the day and at night, but observations and interviews indicated that it was not consistently used as ordered. The resident herself reported that the splint was only sometimes applied, and documentation in the Treatment Administration Record showed inconsistencies in the application of the splint. The facility's policies on repositioning and the use of splints and positioning devices were not followed, leading to these deficiencies. The lack of proper equipment and adherence to physician orders placed the residents at risk of improper support and positioning, potentially worsening their conditions. Interviews with the Director of Rehabilitation, Certified Nurse Aides, and the Director of Nursing highlighted the discrepancies between the expected care and the care provided, confirming the deficiencies identified by the surveyors.
Failure to Maintain Resident's Wheelchair
Penalty
Summary
The facility failed to ensure that a resident's wheelchair was functioning properly, which had the potential to affect the resident's comfort and safety. The resident, identified as R36, was observed using a high back wheelchair and later a standard wheelchair. It was discovered that the high back wheelchair, which was the resident's original equipment, was broken and had been placed in the resident's bathroom. A Certified Nurse Aide (CNA) confirmed that the wheelchair was broken, specifically noting that the removable armrest on the right side was damaged. The deficiency was further compounded by a breakdown in communication and reporting procedures. The Director of Rehabilitation (DOR) and a Registered Nurse (RN) were unaware of the issue, indicating a failure in the reporting process. The Maintenance Director also confirmed that no report of the broken wheelchair had been received through the TELS system, which is the facility's electronic program for reporting repairs. The CNA admitted to missing the report, although she typically reported such issues. This lack of communication and failure to follow established procedures led to the deficiency in maintaining essential equipment for the resident.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect three residents from abuse, as evidenced by incidents involving inappropriate actions by staff members. Resident 103, who had severely impaired cognition, reported that a male nurse, RN6, held a nebulizer mask too tightly on her face, causing pain and leaving red marks. Despite the resident's complaints, RN6 continued the treatment, leading to fear and distress for the resident and her daughter. The facility's investigation confirmed the abuse, and RN6 was suspended and later terminated. Resident 39, who was cognitively intact and receiving hospice care, experienced verbal threats from CNA12. The resident reported multiple altercations with CNA12, who was overheard threatening to punch the resident. The facility's investigation substantiated the allegations, and CNA12 resigned before disciplinary action could be taken. The resident expressed fear of the CNA and was informed of the investigation's outcome. Resident 105, also cognitively intact, reported feeling demoralized by CNA13, who allegedly threw clothing at her and used non-verbal gestures to communicate. The resident expressed concerns about her mental health and fear of retaliation. The facility's investigation confirmed verbal intimidation by CNA13, who was suspended and later terminated. The resident was informed of the investigation's findings.
Misappropriation of Resident Property by CNA
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their property, specifically their credit cards, by a Certified Nurse Aide (CNA). Resident 17, who was moderately cognitively impaired, discovered unauthorized charges on her credit card statement, which she reported to the state and police. The Director of Nursing (DON) confirmed that CNA16, who had received training on abuse and misappropriation, was responsible for stealing the credit card information. The resident had left her credit card bill on her dresser, which was likely where the CNA obtained the information. Similarly, Resident 95, also moderately cognitively impaired, reported a stolen credit card with unauthorized charges. The facility's investigation revealed that CNA16 used the resident's debit card to make purchases, which were captured on video. The DON confirmed the unauthorized use of the card on two occasions, and the incident was reported to the police. The facility's policy allowed residents to secure their valuables in their nightstands, but it appears this measure was not effectively utilized or enforced in these cases.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of potential abuse to the State Survey Agency (SSA) in a timely manner, as required by their policy. The policy mandates that any witnessed or suspected incidents of abuse must be reported immediately, and allegations of resident abuse should be reported to the appropriate state regulatory authority within two hours. In this case, a Certified Nurse Aide (CNA) informed the MDS Coordinator (MDSC) that a resident sustained a skin tear during care, which was identified as a potential allegation of mistreatment. The incident was reported to the SSA approximately four hours after it was determined to be a potential allegation of mistreatment, exceeding the two-hour reporting requirement. The resident involved, who was admitted with a diagnosis of dementia, had short-and-long-term memory problems and required assistance for toileting and hygiene. The MDSC, who conducted the initial skin assessment, escalated the incident to the Director of Nursing (DON) but failed to ensure the allegation was reported to the SSA within the required timeframe. The delay in reporting this potential abuse incident highlights a lapse in adhering to the facility's policy, which could potentially affect the timely reporting of other abuse or neglect allegations.
Inadequate Dementia Care Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that residents with dementia received appropriate care interventions, resulting in harm to a resident identified as R108. The resident, who had a history of becoming physically aggressive during care, sustained visible bruising and skin tears after an encounter with a Certified Nurse Aide (CNA1). The facility's policy required staff to be trained in dementia care and to provide person-centered care, but CNA1 did not adhere to these guidelines during the incident. R108 was admitted with diagnoses including dementia, mood disturbance, and anxiety, and had documented short-and-long-term memory problems. The resident's care plan included interventions for managing physical aggression, such as providing care at alternate times and using diversion techniques. However, during the provision of care, CNA1 held the resident's wrists, leading to skin tears and bruising. The resident reported being grabbed and hurt, and the injuries were confirmed by the MDS Coordinator and an LPN. The facility's investigation revealed that CNA1, who was hired in August 2023, admitted to causing the skin tear while attempting to clean the resident. Despite being trained in dementia care, CNA1 did not follow the facility's protocol to step away and reapproach the resident later if aggression occurred. The facility terminated CNA1's employment due to the failure to provide proper dementia care as directed by the training received.
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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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