Kutz Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, Delaware.
- Location
- 704 River Road, Wilmington, Delaware 19809
- CMS Provider Number
- 085043
- Inspections on file
- 20
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Kutz Rehabilitation And Nursing during CMS and state inspections, most recent first.
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.
The facility did not ensure that hospice care plans matched the medications administered to three residents, leading to discrepancies that could delay symptom management. Additionally, a resident experienced a delay in care after a fall due to lack of vital sign monitoring, missed lab work, and failure to notify the provider of a low heart rate, resulting in hospitalization for phenytoin toxicity and hyponatremia. Other issues included inaccurate documentation of vital signs after falls and failure to assess skin discoloration in a resident at risk for bleeding.
Two residents identified as high fall risks were not provided care according to their individualized care plans, resulting in preventable accidents. One resident was transferred by a single CNA instead of two staff with a Hoyer lift, leading to a leg laceration requiring sutures. Another resident, dependent for bed mobility, rolled off the bed during incontinence care when only one staff was present, resulting in a fall and hospital evaluation. In both cases, care plans and fall risk protocols were not followed, leading to resident harm.
Two residents with significant physical impairments were subjected to verbal abuse and neglect by CNAs, including refusal to provide necessary assistance with toileting and transfers, rude and punitive language, and falsified care documentation. These actions caused distress to the residents and were confirmed by interviews and video surveillance.
The facility did not report several allegations of abuse, neglect, and injuries of unknown source to the State Agency within the required timeframes. In multiple cases, incidents involving residents with cognitive and physical impairments were reported days after the facility became aware, rather than immediately or within the specified reporting periods as required by policy and state law.
Multiple residents with significant mobility and medical issues were found to have bedrails or enablers installed without documented assessments or informed consent. Staff interviews confirmed that no evaluations or consents had been completed prior to installation, and there was a lack of awareness among staff regarding the need for these procedures.
The facility did not ensure that nurses and nurse aides had the required competencies for medication administration and clinical assessment. An LPN repeatedly documented medications as given when they were not, without evidence of completed competency checks. Two nurses failed to recognize and respond to a resident's prolonged bradycardia, with incomplete or missing documentation of their competency in vital sign assessment. Another LPN administered IV antibiotics without proper training or skills verification, resulting in a medication error.
Two residents with complex medical needs did not receive multiple doses of their prescribed medications due to pharmacy delivery issues, insurance coverage problems, and lack of stock. Nursing staff documented the unavailability of medications, and both the physician and family were notified. The facility's policy required immediate action for unavailable medications, but the necessary steps were not effectively carried out, resulting in missed doses and affected resident conditions.
Multiple residents did not receive their prescribed medications as ordered, including missed doses of antiviral, COPD, and critical chronic disease medications, as well as an instance of an antibiotic being administered incorrectly. These errors were due to medication unavailability, pharmacy delays, lack of prior authorization, and staff unfamiliarity with medication administration procedures, resulting in significant medication errors.
The QAPI program did not effectively address ongoing issues with staff-to-resident abuse, repeated medication errors by nursing staff, and persistent problems with medication availability from the pharmacy. Although these issues were discussed in meetings and some staff education was provided, there was no evidence of measurable goals, systemic changes, or sustained monitoring. Additionally, there was no current performance improvement plan for abuse incidents.
A new LPN was assigned to administer IV antibiotics to a resident without having received training or a skills checkoff in IV medication administration, as the facility lacked an effective training program for this skill. Despite a prior facility assessment identifying insufficient staff competency in IV medication, no evidence of a training process or action plan was provided.
A resident with a large body habitus and multiple medical conditions fell from a standard-sized bed during incontinence care due to insufficient space for safe movement. Despite expressing ongoing fear and discomfort and requesting a larger bed, the facility did not provide one, citing that the resident did not meet criteria for a larger bed. Staff confirmed the resident's concerns and the facility's decision, resulting in a failure to accommodate the resident's needs and preferences.
The facility's abuse policy did not provide staff with clear procedures for identifying abuse based on resident outcomes, such as suspicious injuries or behavioral changes, and failed to specify required reporting timeframes under federal and state regulations.
A resident with Parkinson's disease and dementia was involved in an alleged neglect incident, and although the initial report was made, the required five-day follow-up investigation report was submitted to the State Agency eighteen days late, contrary to facility policy.
Two residents did not have comprehensive, person-centered care plans that addressed their specific needs. One resident with a dialysis fistula did not have clear care plan instructions to avoid blood pressure measurements on the affected arm, and another resident who received bed enabler bars after a fall did not have this intervention added to the care plan. Staff were aware of some requirements, but documentation and care plan updates were lacking.
A resident with a right hand contracture did not receive a physician-ordered palm guard for over 10 months because the order was incorrectly entered into the EMR, omitting the frequency and causing it to be absent from nursing task lists. Staff were unaware of the active order, and the device was never applied, as confirmed by observations and staff interviews.
A medication cart was found to contain an open insulin aspart pen without an open date label. An LPN confirmed the missing label during an interview, and the issue was discussed with facility leadership and department representatives.
Two residents' medical records contained inaccurate fall risk assessments, with one resident's assessments failing to document all predisposing diseases, recent falls, and incontinence, and another resident's assessment omitting two prior falls. These inaccuracies were confirmed by facility staff during interviews.
A resident with an indwelling Foley catheter and multiple diagnoses, including neurogenic bladder and obstructive uropathy, did not have Enhanced Barrier Precautions (EBP) ordered or implemented during their stay, despite facility policy and ongoing high-contact catheter care. Staff interviews and record review confirmed the absence of EBP, and leadership acknowledged the deficiency during the survey.
A resident who was completely dependent for care and admitted with end stage renal disease was observed multiple times without access to a functioning call bell system. Staff confirmed the previous call bell was removed due to malfunction and had not been replaced, leaving the resident unable to request assistance.
A resident with severe cognitive impairment and unsteadiness fell and suffered a concussion due to a CNA's failure to follow the care plan, which required extensive assistance and the use of a gait belt. The CNA stood the resident up without the gait belt and attempted to pull up her pants from behind, leading to the fall. The facility's policy on fall prevention was not adhered to, and training for nursing assistants on fall prevention had not yet been implemented.
A resident experienced a decline in urinary continence after losing the ability to use a walker, but the facility failed to complete required assessments or implement a toileting program. The resident was placed in incontinence briefs and remained in bed, dependent on staff for changes, without attempts to maintain continence. Staff interviews and record reviews confirmed the lack of appropriate care and adherence to the facility's Bladder Management Program policy.
The facility failed to address and resolve resident grievances discussed in monthly resident council meetings, including issues with CNAs using phones during care, long call light response times, and staff rudeness. Despite recurring complaints, no documented actions or thorough investigations were conducted.
The facility failed to thoroughly investigate and document abuse allegations for three residents. One resident reported a male staff member disconnected her call light, another reported rough treatment and yelling by staff, and a third mentioned rude staff behavior. Investigations were incomplete, lacking interviews with involved staff and verification of claims.
The facility failed to maintain the kitchen in a sanitary condition, affecting 79 out of 82 residents. Issues included food residue on clean items, improper storage of utensils and food, and discolored residue in the dish room. The Dietary Manager and Registered Dietitian confirmed these findings, which were against the facility's policies.
A resident with hemiplegia and hemiparesis refused to wear her left resting hand splint for most of a two-week period, but the physician was not notified. Interviews and records confirmed the lack of communication, leading to a deficiency identified by surveyors.
A resident with anxiety disorder, weakness, and chronic kidney disease reported multiple instances of staff not answering call lights or changing soiled briefs timely. The facility failed to document sufficient findings or provide written responses to these grievances, as confirmed by the Social Service Director and Administrator.
A CNA left the facility without informing staff, resulting in eight residents not receiving care. One severely cognitively impaired resident fell and was found with her head on the floor and pelvis on the bed. The resident was sent to the ED for evaluation and returned after a CT scan showed no injuries. The CNA was suspended and later terminated for job abandonment and misconduct.
The facility failed to report potential abuse and neglect involving nine residents in a timely manner. One incident involved a CNA unplugging a resident's call light, and another involved a CNA abandoning eight residents, leading to a fall. The facility did not follow its own policies or state regulations for reporting these incidents.
The facility failed to provide written transfer notices to two residents who were hospitalized. Although family members were notified, the residents themselves did not receive the required written notices. The Social Service Director and Administrator were unaware of the federal requirement to notify residents in writing.
The facility failed to provide bed hold notices within 24 hours to two residents during their emergent transfers to the hospital. Both the Social Service Director and the Administrator were unaware of the requirement to notify both the resident and the family member in writing.
The facility failed to update the care plan for a resident who experienced a significant decline in her ability to ambulate, transfer, use the toilet, and maintain continence. Despite the resident's increased need for assistance and use of a Hoyer lift, the care plan was not revised to reflect these changes.
A resident developed a coccyx wound upon admission, but the facility failed to notify the wound nurse practitioner, resulting in a six-day delay in treatment. The wound was not assessed or treated by the nurse practitioner until ten days after admission, leading to worsening of the wound.
A resident with hemiplegia and hemiparesis following a stroke did not receive consistent application of a left-hand resting splint as ordered by the physician. Documentation revealed inconsistencies, and staff interviews confirmed the splint was not applied regularly. The care plan did not include the splint, and there was no documentation of the resident's refusals in the nursing notes.
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 Coordinate Hospice Care and Monitor Resident Conditions
Penalty
Summary
The facility failed to ensure that the most recent hospice plan of care included the services furnished by the facility for several residents. For three residents under hospice care, there were discrepancies between the medications listed on the hospice plan of care and those being administered by the facility. For example, certain medications ordered by hospice were not present on the facility's medication list, and vice versa. These discrepancies were confirmed by facility staff and could lead to delays in symptom treatment for the affected residents. Additionally, the facility did not provide care in accordance with professional standards of practice for multiple residents. One resident experienced a significant delay in care after a fall, as the facility failed to monitor and document vital signs appropriately, did not notify the provider of a low heart rate, and did not complete ordered lab work to monitor phenytoin levels. This resident was later hospitalized with phenytoin toxicity and hyponatremia, conditions that were not identified or managed in a timely manner by the facility. Other deficiencies included the failure to monitor and document vital signs after unwitnessed falls, as well as the failure to identify and assess skin discoloration in a resident at risk for bleeding. In one case, vital signs were either not documented or the same values were copied across multiple shifts, and skin assessments did not include observed discoloration. These failures were confirmed by interviews with facility staff and through review of clinical records and facility policies.
Failure to Follow Care Plans Results in Resident Falls and Injuries
Penalty
Summary
The facility failed to ensure that residents' care plans were followed to prevent accidents for two residents identified as high fall risks. One resident, with diagnoses including dementia, aphasia, and a history of falls, had a physician's order for Hoyer lift transfers with two staff. Despite this, the resident was transferred by a single CNA using a stand and pivot method, resulting in a laceration to the lower leg that required sutures in the emergency room. The incident was not reported to the State Agency as required. Another resident, who had a large body habitus, muscle weakness, and was cognitively intact, required substantial assistance for bed mobility and was identified as high risk for falls. During incontinence care, a CNA asked the resident to turn in bed, leading to the resident rolling off the bed onto the floor. The resident was sent to the emergency room for evaluation and returned with no acute findings. At the time of the fall, the care plan only required one staff for turning and repositioning, and it was not updated to require two-person assistance until several months after the incident. In both cases, the facility did not implement or follow individualized interventions as outlined in the residents' care plans and fall risk assessments. The lack of adherence to prescribed transfer and repositioning protocols directly contributed to the residents' injuries and hospitalizations.
Failure to Protect Residents from Abuse and Neglect by Staff
Penalty
Summary
Two residents experienced abuse and neglect by staff members, as documented through interviews, record reviews, and video surveillance. One resident, who had a history of stroke, cerebral palsy, and muscle weakness, and required substantial assistance with toileting, reported being verbally abused by a CNA. The CNA responded rudely and angrily when the resident requested to use the bathroom, telling the resident it was too late and scolding him for attempting to wipe himself. Another CNA corroborated the resident's account, stating that the staff member spoke very rudely and that the resident was visibly upset. The resident later described feeling punished and yelled at by the staff member during the incident. A second resident, admitted with a left knee fracture and requiring partial moderate assistance for transfers, reported that a CNA refused to assist with transferring out of bed, telling the resident to do it herself and speaking in a nasty manner. Video footage confirmed that the CNA spent minimal time in the resident's room and did not provide the care documented in the resident's chart, including assistance with toileting and repositioning. The resident's social worker confirmed that the resident was very upset by the staff member's refusal to help, and the facility's documentation showed discrepancies between the care provided and what was recorded.
Failure to Timely Report Alleged Abuse, Neglect, and Injuries of Unknown Source
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and injuries of unknown source to the State Agency within the required timeframes for four out of fourteen residents reviewed. In one case, a resident with a history of stroke and cognitive impairment was found with a facial skin tear, and the incident was reported to the State Agency thirty-five hours after it was first noted, exceeding the required reporting window. Another resident reported being blocked from leaving the bathroom by a CNA, and this alleged mistreatment was reported eighteen days after the incident and fifteen days after the facility became aware of it. Additionally, a resident reported that staff delayed responding to another resident who was vomiting, and this alleged neglect was reported twenty days after the incident and fifteen days after the facility was informed. In a separate case, a resident's allegation of verbal abuse by a CNA was reported six days after the facility was notified, rather than within the required two-hour timeframe. The facility's own policies, consistent with Delaware State Law, require immediate reporting of suspected abuse, neglect, or misappropriation of funds, with specific timeframes for reporting incidents involving serious bodily injury or other events. The records and interviews reviewed indicate that the facility did not adhere to these requirements, resulting in delayed reporting of multiple incidents involving potential abuse, neglect, or injury of unknown source. These delays were documented through clinical records, grievance reviews, and interviews with residents and staff.
Failure to Assess and Obtain Consent for Bedrail Use
Penalty
Summary
The facility failed to assess residents for the use of bedrails or enablers and did not obtain informed consent prior to their installation for four residents. Observations revealed that bedrails or enablers were present on the beds of these residents, but reviews of their clinical records showed no documentation of bedrail use assessments, consideration of alternatives, risk versus benefit analysis, or informed consent. Interviews with staff, including the contracted Director of Rehabilitation (DOR), confirmed that no assessments or consents had been completed for any residents using bedrails or enablers at the time of the survey. The DOR also stated that efforts to obtain assessments were only just beginning, and the therapy company did not have access to previous therapy provider records. The residents involved had significant medical histories, including stroke with hemiplegia, hemiparesis, large body habitus, muscle weakness, and osteoporosis, which could impact their mobility and safety needs. Despite these conditions, there was no evidence that the facility evaluated the appropriateness of bedrail use or discussed the associated risks and benefits with the residents or their representatives. Staff interviews further confirmed the lack of awareness regarding the need for assessments and consent, and no documentation was provided to the surveyor to demonstrate compliance with these requirements.
Failure to Ensure Nursing Staff Competency in Medication Administration and Clinical Assessment
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the appropriate competencies to care for residents, specifically in the areas of medication administration and clinical assessment. One LPN was found to have repeatedly documented the administration of medications that were not actually given, with multiple prior incidents of medication errors and falsification of medical records. Despite these occurrences, there was no evidence that this LPN had completed a medication administration competency since her hire date. Additionally, the facility's orientation policy required documentation of training and competency evaluations, but this was not maintained in the employee's educational file as required. In another instance, the facility failed to ensure that two nurses had the specific competencies to recognize and respond to a resident's bradycardia. The resident, who had a history of seizure disorder and hypopituitarism, experienced a low heart rate for nearly 24 hours, which was documented in the medical record but not addressed by staff. Review of the nurses' skills checkoff forms revealed incomplete or missing documentation of competency in vital sign assessment, and the facility was unable to provide evidence that these nurses were competent in recognizing abnormal heart rates. Additionally, a newly hired LPN administered intravenous antibiotics to a resident without having received training or a skills checkoff for IV medication administration. The nurse reported that she had not been trained on IV antibiotics during orientation, and the facility could not provide documentation of her competency in this area. This resulted in a medication administration error, as the antibiotic was given at incorrect times and not properly documented.
Failure to Ensure Timely Availability and Administration of Resident Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents by not ensuring the timely availability and administration of prescribed medications. One resident, with complex medical conditions including seizure disorder, diabetes insipidus, central blindness, and hypopituitarism, was readmitted to the facility with an order for hydrocortisone (Cortef). Despite the physician's order, the medication was not available for several days due to issues with pharmacy delivery and insurance coverage, resulting in the resident missing nine doses. Documentation shows repeated notations by nursing staff that the medication was not available, and lab results indicated an elevated serum sodium level during this period. Communication with the physician and family confirmed the ongoing unavailability of the medication, and the resident's condition was affected, as evidenced by lethargy and the need for further medical evaluation. Another resident, admitted with diagnoses including HIV and COPD, experienced multiple missed doses of critical medications, specifically Dovato (an antiviral) and Formoterol (a bronchodilator). The Medication Administration Records and progress notes documented several instances where these medications were not administered due to unavailability, with staff noting delays in pharmacy delivery, back orders, and lack of stock at both the primary and backup pharmacies. Nursing staff and the pharmacy were aware of the ongoing issues, and the physician was notified of the inability to obtain the medications on several occasions. The facility's own policy required immediate action when medications were unavailable, including determining the reason, notifying the physician, and escalating the issue to nursing supervisors. Despite these requirements, the facility did not ensure that the necessary medications were available and administered as ordered, resulting in multiple missed doses for both residents. Interviews with staff and pharmacy representatives confirmed the lack of communication and follow-through in resolving the medication availability issues.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple instances where ordered medications were not administered as prescribed. One resident with HIV and COPD did not receive several doses of Dovato, an antiviral, and Formoterol, a COPD medication, on multiple occasions. The MAR confirmed these omissions, and a registered nurse acknowledged the missing doses during an interview. The facility's medication administration policy requires that medications be administered as ordered and that the six rights of medication administration are followed, but these requirements were not met in this case. Another resident with Parkinson's disease, diabetes, and osteomyelitis received three doses of Zosyn, an IV antibiotic, within a six-hour period, instead of the prescribed two doses. This error occurred due to a new nurse being unfamiliar with the unit and the medication administration process, resulting in improper documentation and failure to check the MAR before administering the medication. The error was identified during a shift change, and the nurse supervisor was notified after the fact. Additional deficiencies included a resident with hypopituitarism missing nine doses of Cortef (hydrocortisone) due to the medication not being available from the pharmacy, as documented in the MAR and progress notes. The pharmacy required prior authorization, which delayed delivery, and the resident's family ultimately paid out of pocket to obtain the medication. Another resident dependent on dialysis missed thirty-two out of seventy-three scheduled doses of Sevelamer due to ongoing issues with pharmacy supply, insurance coverage, and lack of timely communication with the dialysis center. These failures to provide ordered medications as prescribed directly contravened the facility's own policies and resulted in significant medication errors for multiple residents.
QAPI Program Fails to Address Ongoing Medication and Abuse Deficiencies
Penalty
Summary
The facility's Quality Assessment and Assurance (QAPI) program failed to effectively address ongoing quality of care issues, specifically related to staff-to-resident abuse, repeated medication errors by nursing staff, and the continued lack of medication availability from the pharmacy for multiple residents. Despite routine discussions of medication errors in QAPI meetings and periodic staff education, documentation lacked evidence of measurable goals, systemic changes, and ongoing monitoring to ensure sustained improvement. Medication audits were limited and infrequent, and the facility lacked a consistent Staff Development nurse, resulting in the inability to conduct a skills fair for staff. Additionally, the facility experienced ongoing issues with medication availability since October, with management relying on nursing staff to report when medications were not available. There were also two incidents of staff-to-resident abuse identified, but no current performance improvement plan (PIP) was in place for abuse, despite the topic being discussed at QAPI meetings. These deficiencies were confirmed through interviews and record reviews during the survey.
Failure to Train New LPNs in IV Medication Administration
Penalty
Summary
The facility failed to implement and maintain an effective training program for new LPN staff regarding intravenous (IV) medication administration. A new LPN, hired in July, was assigned to independently administer an IVSS antibiotic to a resident in February, despite having never received training on IV antibiotics during orientation. The LPN stated that there was no training provided because there were no residents in the facility requiring IV antibiotics at the time of orientation. Review of the resident's clinical record and staff interviews confirmed that the LPN had not completed a skills checkoff for IV medication administration prior to being assigned this responsibility. The facility's own assessment, completed seven months prior to the incident, had already identified insufficient staff skills and training in IV medication administration and documented an action plan to address this gap. However, the facility was unable to provide evidence of a training process or skills checkoff for new staff in IV medication administration, nor any documentation regarding the referenced action plan. The deficiency was confirmed during interviews and review of facility records, and findings were discussed with facility leadership and department managers.
Failure to Provide Appropriate Bed Size for Resident with Special Needs
Penalty
Summary
A resident with a large body habitus and multiple medical conditions, including anxiety, compressed lower back nerves, muscle weakness, nerve pain, and osteoporosis, was admitted to the facility. The resident experienced a fall from a standard-sized bed during incontinence care when a CNA did not ensure proper positioning safety before providing care. The resident was transported to the emergency room for evaluation and returned after 24 hours with no acute findings. Documentation and interviews revealed that the resident had little room to move side to side in the standard bed and expressed fear of falling, stating that the bed was not wide enough and she was always on the edge during turns and repositioning. Despite the resident's ongoing discomfort and expressed need for a larger bed, the facility did not provide one, citing that she did not meet the classification for a larger bed. The care plan was updated three months after the fall to require a two-person assist for all turns and repositioning, but the resident continued to express fear and discomfort related to the bed size. Staff interviews confirmed the resident's concerns and the facility's decision not to accommodate her request for a larger bed, resulting in a failure to reasonably accommodate her needs and preferences.
Deficient Abuse Policy Lacks Identification and Reporting Guidance
Penalty
Summary
The facility failed to develop a comprehensive written policy and procedure addressing the identification and reporting of abuse, neglect, and theft. Specifically, while the policy defined various types of abuse, neglect, and exploitation, it did not provide clear guidance in the identification section on how staff should recognize different forms of abuse based on resident outcomes, such as unwitnessed suspicious injuries, multiple injuries over time, or unexplained changes in resident behavior or activities. Additionally, the reporting section of the policy did not clearly specify the required reporting timeframes for abuse, neglect, or mistreatment in accordance with federal and state regulations, whichever is more stringent. These deficiencies were identified during a review of the facility's Resident Abuse Policies and Procedures and discussed with facility leadership and department representatives.
Late Submission of Abuse Investigation Follow-Up Report
Penalty
Summary
The facility failed to report the results of an abuse investigation to the State Agency within the required five working days for one resident. According to the facility's policy, a follow-up State Incident Report indicating the results of the investigation must be completed and sent electronically within five days. A resident with Parkinson's disease and dementia was involved in an alleged neglect incident, where it was reported that the resident had to wait an hour to be changed by a CNA. The incident was reported to the facility and subsequently to the State Agency, but the required five-day follow-up report was not submitted until eighteen days after the deadline. This delay was confirmed by facility leadership during the survey exit conference.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
For one resident with end stage renal disease and a dialysis fistula in the left arm, the facility failed to develop and implement a comprehensive, person-centered care plan that included specific instructions to avoid taking blood pressure on the left arm. Although the resident's orders required vital signs to be checked pre- and post-dialysis on certain days and monthly, the care plan only stated to monitor vital signs as ordered and did not specify the need to avoid the left arm. An LPN interviewed was aware of the requirement but there was no documentation of this order in the resident's electronic chart. For another resident with multiple diagnoses including large body habitus, anxiety, and osteoporosis, who experienced a fall and was subsequently provided with bed enabler bars for repositioning assistance, the facility failed to update the care plan to include this intervention. The care plan after the fall only documented bed mobility evaluation and continuation of at-risk interventions, omitting the addition of bed enabler bars, despite this being documented in a follow-up incident report. The DON confirmed that the care plan had not been revised to reflect the use of enablers after the fall.
Failure to Provide Ordered Palm Guard Due to EMR Entry Error
Penalty
Summary
A deficiency was identified when a resident with a right hand contracture did not receive a right-hand palm guard as ordered by a physician. The order for the palm guard was written in the electronic medical record (EMR) with instructions for application after morning care and removal before bedtime. However, observations on multiple occasions revealed that the resident was not wearing the palm guard, and the resident's right hand remained contracted with fingers pressed into the palm. Interviews with staff confirmed that the palm guard had never been applied, and the task was not listed on the Medication Administration Record (MAR), Treatment Administration Record (TAR), or CNA task list. Further investigation revealed that the order for the palm guard was entered incorrectly into the EMR, omitting the frequency for application and removal, which prevented it from appearing on any nursing task lists. Despite a daily 24-hour chart check process intended to verify new orders, the error was not detected, and the palm guard was not provided for over 10 months. Staff were unaware of the active order, and the resident did not receive the prescribed intervention to maintain or improve range of motion.
Insulin Pen Lacking Open Date Label on Medication Cart
Penalty
Summary
During a survey, it was observed that one of three medication carts did not comply with proper labeling and storage practices for insulin pens. Specifically, an insulin aspart pen that was open and in use for a resident was found without an open date labeled on it. This observation was confirmed through an interview with an LPN, who acknowledged the absence of the required open date on the insulin pen. The findings were reviewed with facility leadership and department representatives during the exit conference. No additional information about the resident's medical history or condition at the time of the deficiency was provided in the report.
Inaccurate Fall Risk Assessments and Incomplete Medical Records
Penalty
Summary
The facility failed to ensure that complete and accurate medical records were maintained for two residents reviewed for falls. For one resident with a history of falls, fractures, osteoporosis, and arthritis, post-fall risk assessments conducted on two occasions did not accurately document all predisposing diseases that increased her fall risk. Additionally, the assessments failed to record a recent fall and the resident's frequent incontinence, despite this information being present in other parts of the clinical record. These inaccuracies were confirmed by a registered nurse during an interview. For another resident, clinical records showed two separate falls, including one that resulted in a transfer to the emergency room. However, a subsequent fall risk evaluation incorrectly documented that the resident had no falls in the previous three months. This discrepancy was confirmed during an interview with the Director of Nursing, and no further information was provided to clarify the inaccuracy. The facility did not ensure that fall risk assessments accurately reflected the residents' clinical histories and fall events.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
A deficiency was identified when the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident who had an indwelling urinary catheter during their stay. According to the facility's own policy, EBP should be initiated for residents with indwelling medical devices, such as urinary catheters, to reduce the transmission of multidrug-resistant organisms (MDROs). The resident in question was admitted with diagnoses including emphysema, neurogenic bladder, and obstructive uropathy, and had a Foley catheter in place. Orders were present in the electronic medical record for Foley catheter care and regular flushing with sterile water, which are considered high-contact care activities requiring EBP. Despite these requirements, a review of the resident's medical record and interviews with facility staff revealed that no order for EBP was ever placed during the resident's admission. Staff interviews confirmed that the resident was not placed on any type of precautions related to the catheter, and the facility did not begin implementing EBP until after the relevant period. The deficiency was confirmed during the survey exit conference with facility leadership and department representatives.
Failure to Provide Functioning Call Bell System for Dependent Resident
Penalty
Summary
A resident admitted with end stage renal disease and completely dependent for activities of daily living was found to be without a functioning call bell system in their room during three separate surveyor observations. The resident's clinical record confirmed their total dependence on staff for care. Staff interviews revealed that the resident previously had a touch call bell, which was removed due to malfunction and not replaced prior to the surveyor's observations. The absence of a call bell system meant the resident was unable to request staff assistance as needed during this period.
Failure to Prevent Fall for High-Risk Resident
Penalty
Summary
The facility failed to prevent a fall for a resident (R30) who was at high risk for falls due to severe cognitive impairment and unsteadiness. The resident required extensive assistance for various activities of daily living, including dressing and toileting. On the day of the incident, a CNA was dressing R30 in her room. The CNA stood R30 up from a recliner without a gait belt and attempted to pull up her pants from behind. R30, who was known to be impulsive and unsteady, walked away and fell face down, resulting in a concussion and an abrasion to her forehead. The resident was hospitalized for eight days following the fall. The investigation revealed that the CNA did not follow the care plan, which required extensive assistance and the use of a gait belt for transfers and ambulation. Multiple staff members, including the RN who investigated the fall, confirmed that R30 was impulsive and had a history of trying to walk away during care. The CNA admitted to removing the gait belt after seating R30 in the recliner and standing her up without it, which led to the fall. The facility's policy on fall prevention was not adhered to, as the CNA did not ensure the resident's safety by requesting assistance or standing in front of her while dressing. Interviews with other staff members, including LPNs, CNAs, and the Staff Development Coordinator, corroborated that R30 was a high fall risk and required careful supervision during care. The Staff Development Coordinator acknowledged that training for nursing assistants on fall prevention had not yet been implemented. The Medical Director confirmed that R30 was a high fall risk due to her severe dementia and unsteadiness. The facility's failure to follow the care plan and ensure adequate supervision directly led to the resident's fall and subsequent hospitalization.
Failure to Assess and Implement Care for Decline in Urinary Continence
Penalty
Summary
The facility failed to ensure that a resident (R8) was properly assessed and provided with appropriate care following a decline in urinary continence. Initially, R8 was continent of urine and able to use a walker to go to the toilet with assistance. However, after losing the ability to use the walker due to a loss of function in her hand, R8 became incontinent and was placed in incontinence briefs. Despite this significant change, the facility did not complete the required assessments or implement a toileting program to maintain as much continence as possible for R8. The quarterly Bowel and Bladder Program Screener and the Elimination Pattern Evaluation tool were not completed as required by the facility's Bladder Management Program policy. Interviews with staff revealed that R8 was previously able to walk to the toilet and required assistance with toileting hygiene. However, after the decline in her physical abilities, R8 was no longer taken to the toilet and remained in bed, dependent on staff to change her incontinence brief. Staff confirmed that R8 was on a check and change program, where her brief was changed after it was wet, but no attempts were made to implement a toileting program. The care plan for R8 was not updated to reflect her current needs, and the facility failed to provide the necessary interventions following her decline in continence. The facility's failure to complete the required assessments and implement appropriate care for R8 was further confirmed by the MDS Coordinator and the Administrator. The MDS Coordinator acknowledged that the quarterly Bowel and Bladder Program Screener was not completed, and no toileting program was attempted despite R8 being identified as a good candidate. The Administrator verified that the voiding pattern form was not completed and attributed this to recent changes in the software used by the facility. The facility's Bladder Management Program policy clearly outlined the procedures for assessing and providing care for residents with continence issues, but these procedures were not followed in R8's case.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to provide feedback and/or resolutions to resident complaints and/or grievances discussed in the monthly resident council meetings in 12 of 13 meetings. The issues raised by residents included CNAs using their phones during care, long call light response times, and staff being rude or unresponsive. Despite these recurring complaints, there was no documented action taken by staff to resolve these issues, nor was there a thorough investigation or resolution provided to the group as noted in the resident council minutes. In several instances, residents reported specific grievances such as CNAs stopping care to answer their phones, taking 25-30 minutes to respond to call lights, and being rushed during showers. Additionally, there were complaints about staff talking loudly, slamming doors, and using ear buds, making it difficult for residents to communicate with them. These issues persisted over several months without any effective resolution or documented follow-up actions by the facility. Interviews with the Activities Director and the Social Services Director revealed that while the concerns were noted and communicated to the Administrator and the Director of Nursing, there was no formal process in place to elevate these grievances to a reportable incident or investigation. Residents expressed that their concerns were only resolved 60-70% of the time, indicating a significant gap in addressing and resolving resident grievances effectively.
Failure to Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate and document abuse allegations for three residents. One resident reported that a male staff member disconnected her call light after she had a bowel movement and waited over two hours to be changed. The investigation revealed that the assigned CNA had left early without notifying the RN Supervisor, leading to a delay in care. However, the investigation lacked interviews with the involved CNA, other staff members, and did not verify if the call light was disconnected as alleged. The grievance was deemed unsubstantiated without thorough evidence collection. Another resident reported that staff had been rough during care and one CNA yelled at her when she soiled her bed. The resident did not provide specific details but mentioned informing her nurse. The facility's investigation into this allegation was not comprehensive, lacking statements from all staff present at the time or other residents who might have witnessed the incident. A third resident mentioned that some staff were very rude, and his wife confirmed an incident a few weeks prior. The Social Services Director handled the grievance but did not conduct a thorough investigation, missing statements from all involved staff and other potential witnesses. The facility's policy required a thorough investigation, including interviews and documentation, which was not followed in these cases.
Sanitation Issues in Kitchen
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary condition, affecting 79 out of 82 residents. During an initial inspection, it was observed that three lids covering plates for meal service had food residue and crumbs, and a large tray stored as clean had scattered food crumbs. In the dry food storeroom, two spoodles were stored on top of five-gallon buckets with bulk foods, and a box of cornstarch was torn open, exposing its contents. Additionally, a resealable plastic bag with unidentified food was not labeled. The dish room had numerous food crumbs and particles on the counter, discolored residue along the walls and floor under the dish machine, and brown residue on the stainless-steel wall adjacent to the clean dishes. Several plastic cups stored as clean had food residue on the interior drinking surface. Further observations with the Dietary Manager revealed similar issues, including food crumbs and particles on the dish room counter, discolored residue along the walls and floor under the dish machine, and brown residue on the stainless-steel wall. Two bowls on the shelf for clean dishes had food residue, and an opened box of cornstarch was improperly stored. In the walk-in freezer, large bags of ice were stored directly on the floor, and the walk-in refrigerator had improperly labeled food items. The Registered Dietitian confirmed that foods should be completely covered when stored, clean scoops should be stored in holders, and bags of ice should not be stored directly on the floor. The facility's policies on food storage and warewashing were not adhered to, leading to these deficiencies.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure that a resident's physician was notified of a change in condition. The resident, who had hemiplegia and hemiparesis following a stroke, was documented as refusing to wear her left resting hand splint most of the time over a two-week period. Despite this, the physician was not informed, which could have led to a lack of necessary treatment modifications. The resident's refusal to wear the splint was noted in the Treatment Administration Record (TAR) for January and February 2024, but there was no documentation of physician notification in the physician notification book or any other evidence provided by the facility. Interviews with the resident, staff, and the physician confirmed that the physician had not been notified of the resident's refusal to wear the splint. The Director of Nursing (DON) and the Administrator acknowledged that the staff should have informed the physician. The facility's policy required the licensed nurse to notify the physician when there was a need to significantly alter treatment, but this procedure was not followed in this case. The lack of communication and documentation led to the deficiency identified by the surveyors.
Failure to Resolve and Document Grievances Promptly
Penalty
Summary
The facility failed to make prompt efforts to resolve grievances and report the findings in writing to the resident or family for one of the sampled residents. Resident 8, who had diagnoses including anxiety disorder, weakness, and chronic kidney disease, reported numerous instances of staff not answering her call light timely, not toileting her, or changing her soiled incontinence brief in a timely manner. These grievances were reported by the resident and her family members, but the facility did not document sufficient findings or provide written responses at the conclusion of the investigations. Specific grievances included incidents where the resident was left on the toilet for extended periods, did not receive requested medication, and experienced delays in being changed after soiling herself. In several cases, the facility's grievance files lacked staff statements, and there was no evidence of written responses being provided to the resident or her family. For example, one grievance reported that a CNA argued with the resident about whether her brief was wet, and another grievance noted that the resident's call light was not answered for over an hour. The Social Service Director, who was the Grievance Official, confirmed that there were no staff statements or written documentation following the grievances. The Administrator acknowledged that the grievance process had been updated recently, but the more recent grievances still lacked witness statements. The facility's policy required prompt efforts to resolve grievances and written decisions to be provided to the resident or representative, but this was not consistently followed in the cases reviewed.
Neglect Due to CNA Abandonment
Penalty
Summary
The facility failed to protect the residents' right to be free from neglect when a CNA left the facility without informing staff, resulting in eight residents not receiving care. One resident, who was severely cognitively impaired and required extensive assistance, sustained a fall during this period. The resident was found with her head on the floor and her pelvis on the bed by restorative CNAs, and she was subsequently sent to the emergency department for evaluation due to complaints of headache and neck soreness. The resident was treated with Eliquis, a blood thinner, and returned to the facility after a CT scan showed no injuries. The incident occurred when CNA1, who was assigned to care for eight residents on the 100 B Unit, left the facility without notifying any staff. The CNA had initially come to work for a special assignment but was reassigned to patient care due to another CNA testing positive for COVID-19. Despite being informed of the reassignment, CNA1 clocked out and left the building without informing anyone, leading to the neglect of the assigned residents. The fall of the resident was discovered by other CNAs during their rounds. Interviews with the facility staff revealed that the CNA did not communicate his refusal to take the new assignment and left the building shortly after being informed of the change. The facility's policy on resident abuse prevention and neglect was reviewed, indicating that the facility prohibits and does not tolerate neglect. The CNA was suspended and later terminated for job abandonment and misconduct. The facility's failure to ensure that the CNA fulfilled his duties led to the neglect of the residents and the subsequent fall of one resident.
Failure to Report Abuse and Neglect
Penalty
Summary
The facility failed to implement policies and procedures for ensuring the reporting of potential neglect and abuse within two hours for two allegations involving nine residents. One incident involved a resident who reported that her certified nursing assistant (CNA) unplugged her call light after she had waited over two hours to be changed following a bowel movement. The resident's family member confirmed the incident, and the Social Services Director (SSD) handled it as a grievance rather than reporting it to the State Survey Agency (SSA). The Administrator and Director of Nursing (DON) acknowledged that the incident could be considered abuse or neglect, but it was not reported to the SSA as required by facility policy and state regulations. Another incident involved a CNA who did not provide care for eight assigned residents for an hour and left the facility without informing anyone. This resulted in one resident falling and being transported to the hospital. The former DON did not report the neglect and abandonment of the eight residents to the SSA, as she was on leave at the time. The Administrator confirmed that the staff did not follow the abuse reporting policy and that the neglect should have been reported to the SSA. The facility's policy requires immediate reporting of alleged violations involving mistreatment, neglect, or abuse to the Administrator and the SSA, but this was not followed in these cases. The facility's failure to report these incidents in a timely manner highlights a significant deficiency in their abuse and neglect reporting procedures. The SSD and nursing staff did not recognize the incidents as reportable, and the facility lacked an abuse coordinator to ensure proper reporting. The Administrator and DON acknowledged the deficiencies in their interviews, confirming that the facility did not adhere to its own policies or state regulations regarding the reporting of potential abuse and neglect.
Failure to Provide Written Transfer Notices to Hospitalized Residents
Penalty
Summary
The facility failed to ensure that two residents, who were hospitalized, received written transfer notices upon their emergent transfer to the hospital. Resident 35, who had diagnoses including Parkinson's disease and feeding tube complications, was transferred to the hospital due to a clogged GJ tube. Although the resident's family member was notified in writing, the resident himself was not provided with a written notice. The Social Service Director (SSD) and the Administrator both confirmed that they were unaware of the requirement to notify the resident in writing, and the facility's policy did not include this requirement either. Similarly, Resident 51, who had a diagnosis of hemiplegia and gastrointestinal hemorrhage, was sent to the emergency room for evaluation of bleeding. While the resident's family member received a written transfer notice, the resident did not. The SSD confirmed that the resident, who was cognitively intact, was not provided with a copy of the transfer notice. The Administrator also stated that the facility's practice was to notify the resident's representative and not the resident, as they were unaware of the federal requirement to do so.
Failure to Provide Bed Hold Notices to Hospitalized Residents
Penalty
Summary
The facility failed to ensure that two residents, R35 and R51, were provided with bed hold notices within 24 hours of their emergent transfers to the hospital. For R35, who was admitted with diagnoses including Parkinson's disease and feeding tube complications, there was no documentation showing that a written bed hold notice was provided during a hospitalization for a clogged feeding tube. The Social Service Director (SSD) and the Administrator both confirmed that they were not aware of the requirement to notify both the resident and the family member in writing at the time of hospitalization. Similarly, R51, who was admitted with a diagnosis of hemiplegia and later readmitted with a gastrointestinal hemorrhage, did not receive a bed hold notice in writing during a hospitalization for bleeding. Although the bed hold policy was mailed to R51's family member, R51, who was cognitively intact, confirmed that he did not receive a copy. The SSD and the Administrator both acknowledged that the bed hold policy was only mailed to the resident's representative and not provided to the resident because they were in the hospital.
Failure to Update Care Plan Following Resident's Change in Condition
Penalty
Summary
The facility failed to update the care plan for one resident following a significant change in her ability to ambulate, transfer, use the toilet, and maintain continence. The resident, who was admitted with diagnoses including anxiety disorder, weakness, and chronic kidney disease, was initially able to walk with assistance and was continent of urine. However, a subsequent assessment revealed that the resident had become incontinent, no longer used the toilet, and required a Hoyer lift and two staff members for transfers. Despite these changes, the care plan was not updated to reflect the resident's current needs and condition. Interviews with the resident and staff confirmed that the resident's condition had deteriorated over the past few months, necessitating increased assistance and a change in her care routine. The resident reported that she no longer walked and was dependent on staff for changing her incontinence brief. Staff members corroborated that the resident was now on a check and change program and no longer used the toilet. The MDS Coordinator also verified that the care plan had not been updated to reflect these significant changes, despite the facility's policy requiring care plans to be revised when there is a change in the resident's condition.
Failure to Notify Wound Nurse Practitioner of New Wound
Penalty
Summary
The facility failed to notify the wound nurse practitioner when an alteration in skin was identified for a resident, leading to a delay in wound treatment. The resident, who was admitted with diagnoses including heart failure, Parkinson's disease, and vascular dementia, developed a coccyx wound upon admission. The wound was documented by the admitting nurse, but the necessary information was not entered into the wound logbook to alert the nurse practitioner, resulting in the wound not being assessed or treated by the nurse practitioner until several days later. The resident's wound was initially documented on the day of admission, and a one-day treatment order was entered. However, there was no documented evidence of wound treatment from the day after admission until six days later when a family member brought the wound to the attention of a nurse. The nurse then assessed the wound, applied a dressing, and entered a treatment order. The nurse practitioner was not aware of the wound until ten days after the resident's admission, at which point the wound had worsened. Interviews with staff revealed that the process for notifying the wound nurse practitioner was not followed. The Director of Nursing confirmed that the admitting nurse did not enter the wound information into the logbook, which was necessary for the nurse practitioner to be aware of and assess the wound. The facility's policies on pressure ulcer treatment and skin alteration management were not adhered to, leading to a significant delay in wound care for the resident.
Failure to Apply Hand Splint as Ordered
Penalty
Summary
The facility failed to ensure that a resident with hemiplegia and hemiparesis following a stroke received appropriate care to maintain range of motion (ROM) as prescribed. The resident had a physician's order for a left-hand resting splint to be applied in the morning and removed before bedtime. However, documentation revealed inconsistencies in the application of the splint, with several days showing no record of the splint being applied or the resident refusing it. Additionally, there was no documentation in the nursing progress notes regarding the resident's refusal to wear the splint, and the care plan did not include the use of the splint as an intervention despite the resident's condition and physician's orders. Observations during the survey confirmed that the resident was not wearing the left-hand splint on multiple occasions. Interviews with the resident and staff indicated that the splint had not been applied consistently, and some staff members were unaware of the order for the splint. The Director of Rehabilitation confirmed that the resident should be wearing the splint for contracture management, and the Director of Nursing acknowledged that refusals should be documented in the nursing notes. The Administrator noted that the resident's recent move within the facility might have contributed to the oversight. The facility's policy on the use of assistive devices emphasized the importance of a reliable process for the proper and consistent use of such devices. However, the failure to apply the left-hand splint as ordered and the lack of documentation regarding refusals or application in the care plan and progress notes indicate a lapse in adherence to this policy. This deficiency highlights the need for improved communication and documentation practices to ensure residents receive the care necessary to maintain their ROM and prevent complications such as contractures.
Latest citations in Delaware
Multiple cognitively impaired residents with known behavioral issues, including wandering, agitation, and physical aggression, were not adequately protected from resident‑to‑resident abuse. In one case, a resident with dementia and PTSD was pushed to the floor by another resident who had a history of combative behavior, resulting in multiple fractures and facial lacerations after staff initially documented the event as an unwitnessed fall. In another case, two residents with dementia and psychotic features engaged in a physical altercation in a dayroom after one placed his hand on the other’s chest, leading to mutual punching. A separate incident occurred when a resident with dementia and behavioral disturbances entered another resident’s room, pulled at the bedcovers, yelled that the room was his house, and allegedly struck the other resident, who was later noted with puffiness around one eye. In all incidents, the involved residents had documented behavioral care plans and significant cognitive impairment, yet physical confrontations still occurred.
A resident with dementia, spinal stenosis, and total dependence for transfers, care-planned for Hoyer lift use with two-person assist, was being transferred from a shower bed to a Geri-chair when the Hoyer lift tipped sideways. Staff reported the lift’s legs had been widened and that one CNA manually pushed the feet apart instead of using the control, and straps may have been unevenly positioned. The resident was lowered to the floor while still in the sling and sustained a small skin tear to the elbow; imaging later showed no fractures. The DON stated that three CNAs were involved, including one on light duty who was not supposed to be using the lift, and that no mechanical defect was found with the lift.
The facility failed to thoroughly investigate several allegations of verbal and potential physical abuse involving four cognitively intact residents with conditions including hemiplegia, rheumatoid arthritis, type 2 DM, epilepsy, and heart disease. In each case, the facility’s investigations were limited, often including only the directly involved resident and omitting interviews with other potentially knowledgeable residents or staff. One resident reported a verbal altercation with a CNA after a fall to the floor, another reported being verbally abused by a roommate’s family member, a third reported a male CNA was too rough and upset while changing linens, and a fourth reported a staff member insulted her and refused brief care. Investigation files lacked broader resident and staff interviews, timely physical and psychosocial assessments, and review of the accused staff member’s employee record, contrary to the facility’s abuse policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
A resident with rectal cancer and intact cognition reported that an RN on night shift confronted him when he returned from smoking off campus, spoke to him loudly about his smoking, used profanity, and threatened to have staff refuse to buzz him back into the building. A CNA corroborated that the RN was upset about being called in to work and used curse words toward the resident, but did not report the incident at the time because the RN was the night supervisor. The resident reported the event to the Social Services Director the next day, yet the facility initially treated it as a grievance rather than abuse and delayed submitting a report to the State Survey Agency until weeks later, after determining it was a reportable abuse incident.
Two residents did not receive required ADL and hygiene care as care planned. One resident with dementia and osteoarthritis, dependent for toileting and personal hygiene, was not toileted during an evening shift, with CNA documentation showing no toileting and the oncoming CNA finding the resident’s clothing, linens, and mattress saturated with urine; the assigned CNA reported care resistance but did not notify an RN or LPN. Another resident with dementia and stroke, requiring assistance with dressing and personal hygiene, remained in bed in pajamas into the afternoon without having received morning care, despite CNA documentation indicating dressing was completed; the CNA later confirmed that care was only provided after being questioned by an RN supervisor following a family complaint.
A resident with left-sided weakness after a stroke, high fall risk, and total dependence for ADLs and bed mobility was being turned onto their side for peri care by an aide when they fell from the bed to the floor, sustaining head trauma and a scalp laceration while on blood thinners. The care plan required extensive to total assistance with two-person support for bed mobility, but the fall occurred during care without documentation of the required level of assistance, indicating the facility did not provide adequate supervision and assistance to prevent accidents as outlined in its own fall prevention practices.
A resident with significant upper extremity weakness and recent surgery was discharged home to a multi-story residence without confirmed DME delivery, home health services, or caregiver support. Although referrals for home health, skilled nursing, and DME were made and family attended a discharge care plan meeting, staff did not verify that services were active, did not set or confirm a start-of-care date with the agency, and did not confirm delivery of a hospital bed. The resident, who lived alone and could not manage fine motor tasks, arrived home without in-home assistance, reported difficulty with eating and self-care, and was later found by an HHA RN in unsafe conditions, unable to access food or medications, leading to emergency transport back to the hospital.
A resident with dementia, Parkinson’s disease, CHF, and a history of AKI had documented fluid goals and was identified as at risk for dehydration and malnutrition, yet daily intake records repeatedly showed fluid consumption well below the recommended amounts. Despite severely impaired cognition, poor oral intake, and documented changes in mentation, lethargy, falls, and restlessness, the facility did not consistently implement or document enhanced monitoring, assistive feeding measures, or timely provider consultation focused on hydration. The resident was hospitalized twice with AKI, dehydration, hypotension, and anemia, and staff interviews confirmed that while expectations existed to encourage fluids and notify providers when goals were not met, there was no clear evidence that these expectations were carried out for this resident.
A resident with cardiac conditions was discharged home with a documented post-discharge plan for home health aide, home health RN/LPN, and PT/OT, but the facility did not complete the home health referral before discharge. The resident went home with a family member and, according to a complaint, did not receive PT, OT, or a nursing wellness check for about a week. The SW later confirmed the referral for home health and therapy services was not requested until several days after discharge, and services did not begin until even later, despite therapy recommendations that are typically communicated to social services to arrange home care.
The facility failed to consistently revise care plans to reflect residents’ current needs and behaviors and did not ensure a cognitively intact resident was involved in ongoing care planning. One resident participated in an initial care conference but was not included in later care plan updates. Another resident with an order for a palm protector was frequently observed without it and often refused it, yet the care plan did not address refusals. Two cognitively impaired residents whose MDS assessments showed dependence for bathing had care plans that still listed only setup or one‑person assist. A cognitively impaired resident with combative behaviors and an incident of striking another resident had a behavior care plan that was not updated to include attempts to hit other residents or the risk of resident‑to‑resident altercations.
Failure to Prevent Resident‑to‑Resident Physical Abuse Among Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from resident‑to‑resident physical abuse. One resident with dementia, agitation, depression, anxiety, and PTSD, and a BIMS score indicating moderate cognitive impairment, was pushed to the floor by another resident after that resident entered his room and followed him into the hallway. Staff initially documented the event as an unwitnessed fall after hearing loud screaming and finding the resident on the floor with complaints of right shoulder and left wrist pain, active bleeding from facial lacerations, and clamminess. Subsequent review of surveillance footage showed that another resident walked into the victim’s room, then followed him out and pushed him, causing the fall that resulted in multiple fractures, including a closed left distal radius fracture, a closed, displaced comminuted right proximal humerus fracture, and a closed, displaced distal clavicle fracture. The resident who pushed him had dementia with mood disturbances, bipolar disorder with psychotic features, PTSD, insomnia, and depression, and a BIMS score indicating severe cognitive impairment. His care plan identified a behavior problem related to bipolar disorder and dementia, including wandering, refusal of care, and physical aggression toward staff and others, such as biting a CNA and swinging a walker at a CNA. The care plan directed staff to anticipate and meet his needs, divert him with alternative objects or activities, intervene to protect the rights and safety of others, and conduct safety checks. Despite these identified risks and interventions, he was able to enter another resident’s room and subsequently push that resident in the hallway, resulting in serious injury. Another incident involved two residents with significant cognitive impairment and behavioral symptoms, including delusions, physical behaviors toward others, agitation, and a tendency to invade others’ personal space. One resident, who was described as aggressive toward others, easily agitated, and prone to getting into others’ personal space, walked next to another resident sitting in a dayroom chair and placed his hand on that resident’s chest. The seated resident responded by punching him in the face with the back of his fist, and the first resident then punched back. Staff and psychiatric documentation noted this altercation and ongoing behavioral concerns such as combativeness with care, agitation, and wandering, but the record contained no additional progress notes describing the incident itself beyond the brief psychiatric follow‑up entry. A further incident occurred when a resident with anxiety, major depressive disorder, dementia with behavioral disturbances, agitation, and severe cognitive impairment entered another resident’s room on the memory care unit. The resident in the room, who had depression, anxiety, dementia without behavioral disturbances, PTSD, insomnia, hallucinations, verbal behaviors toward others, other behavioral symptoms, and wandering, reported that he was hit in the face. Staff heard yelling and found the intruding resident pulling covers at the foot of the bed and yelling that the room was his house, while the other resident sat on the side of the bed and stated that he had been hit and told staff to get a gun and shoot the other resident. Slight puffiness was noted around the reporting resident’s left eye. The intruding resident’s care plan documented compulsiveness, invading others’ personal space, yelling, restlessness, physical aggression, and attempts to assist other residents he believed needed help, with interventions to divert him, familiarize him with his surroundings, and intervene to protect the rights and safety of others. Despite these identified behaviors and interventions, he was able to enter another resident’s room, engage in a confrontation, and allegedly strike the resident.
Resident Injury from Improper Hoyer Lift Operation During Transfer
Penalty
Summary
The deficiency involves the facility’s failure to prevent an accident during a Hoyer lift transfer, resulting in a fall and skin tear injury to a resident. The resident had diagnoses including spinal stenosis, Alzheimer’s disease, vascular dementia with behavioral disturbance, bipolar disorder, and pain, and was documented on the MDS as dependent on staff for transfers from bed to chair. The care plan and physician orders specified that the resident required a Hoyer lift with assistance of two staff for transfers. On the day of the incident, the resident was being transferred via Hoyer lift after a shower, from a shower bed back to a Geri-chair. Progress notes and the post-fall evaluation documented that the fall occurred in the bathroom during a Hoyer transfer with staff assistance of two, and that the Hoyer lift tipped sideways. The resident was found on the floor in the sling, with staff reporting that the Hoyer lift’s legs were widened and that as the resident was being positioned over the chair, the lift tipped to the side. Staff held the sling on each side of the resident’s head and lowered the resident to the floor, after which a skin tear measuring 1.0 cm x 0.1 cm was noted on the elbow. The facility’s investigation determined that the Hoyer tipped because one CNA pushed the lift’s feet apart manually instead of using the designated button to open the legs. Interviews indicated that the manual mechanical lift used at the time was considered less steady and required manual operation of a foot pedal to open the legs, and that the straps may have been more to one side than the other. The DON reported that three CNAs were involved with operating the lift at the time of the incident, including one CNA on light duty who was not supposed to be using the Hoyer lift, and that the lift itself was later found to have no mechanical problems. As a result of the tipping incident, the resident sustained a skin tear to the elbow and required diagnostic imaging to rule out fractures.
Incomplete Investigations of Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of verbal or potential physical abuse as required by its abuse, neglect, and exploitation policy. One cognitively intact resident with hemiplegia following a stroke reported a verbal altercation with a CNA after sliding to the floor while being assisted back to bed. The resident requested use of a Hoyer lift, the CNA told him he could get himself up, and an argument ensued in which the CNA told the resident it was not his room and did not leave until directed by an LPN. The facility’s investigation file for this incident contained only the resident’s interview and no interviews with other residents on the unit who might have had knowledge of similar verbal abuse by the CNA. Another cognitively intact resident with rheumatoid arthritis, hypertension, and peripheral vascular disease reported that her roommate’s daughter came into her room and verbally abused her after the roommate had been relocated due to aggression. The daughter allegedly cursed at the resident, calling her an offensive name and telling her she was going to hell. The investigation file for this incident contained no interviews with other residents on the unit to determine whether they had experienced verbal abuse by this family member or had knowledge of the event. The DON acknowledged that no such interviews were conducted. A third cognitively intact resident with type 2 diabetes and epilepsy reported, through her daughter, that a male CNA wearing a red shirt was too rough with her and appeared upset about having to change her linens. The facility’s investigation into this potential staff-to-resident abuse included an interview with the resident but did not include interviews with other interviewable residents in the same area who might have had knowledge of the incident. A fourth cognitively intact resident with type 2 diabetes and heart disease, later discharged, reported that a staff member entered her room, called her a poor excuse for a human being, and refused to assist with changing her brief. The investigation documentation for this allegation lacked interviews with additional residents or staff, did not show that the resident was promptly assessed physically and psychosocially in relation to the allegation, and did not include a review of the accused staff member’s employee record, resulting in an incomplete investigation contrary to facility policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
Failure to Protect Resident From Verbal Abuse and Delay in Reporting Incident
Penalty
Summary
The facility failed to protect a cognitively intact resident from verbal abuse by a staff member. The resident, admitted with rectal cancer and independently ambulatory with a rolling walker, reported that during an overnight shift he left the campus to smoke and, upon returning and walking toward the nursing station, was confronted by an RN. According to the resident’s report, the RN told him that when she was on the night shift he was not allowed to go outside, using profanity toward him, and further stated that if he went out the door she would instruct staff not to buzz him back into the building. A CNA later confirmed that the RN had been upset about being called in to work, spoke loudly to the resident about his smoking, and used curse words when he responded to her. The incident was not promptly reported to facility administration despite occurring during the night shift, with the CNA stating that the RN involved was the supervisor at the time. The resident reported the incident the following day to the Social Services Director, but the facility did not immediately recognize or treat the allegation as reportable abuse. Instead, the administration initially considered it a grievance and investigated it in that manner. The incident report was not submitted to the State Survey Agency until several weeks after the resident’s report, and only after the facility later determined that the event constituted a reportable abuse incident.
Failure to Provide Required ADL and Hygiene Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL assistance to maintain grooming and personal hygiene for two dependent residents. One resident with dementia, osteoarthritis, and moderately impaired cognition was care planned to receive partial to substantial assistance with personal and oral care, scheduled toileting every two hours, and assistance with toilet transfers. CNA documentation for an evening shift showed “N/A” for all scheduled toileting times, and a facility incident report stated that the CNA assigned to this resident failed to provide incontinence care during that shift. The oncoming night-shift CNA later found the resident’s clothing, linens, and mattress saturated and soaked with urine and provided the needed care, with the prior-shift LPN confirming the condition when notified. The assigned CNA reported the resident was resistant to care but did not notify the LPN or RN for assistance or document the issue. The second resident, with dementia, stroke, weakness, and moderately impaired cognition, was care planned for an ADL self-care deficit requiring setup or cleanup assistance with eating, partial to substantial assistance with personal hygiene and oral care, and substantial assistance with toileting, showering/bathing, and lower body dressing. On a morning shift, the resident’s daughter-in-law reported to the LSW that she did not believe the resident had received morning care because he was still in bed wearing pajamas and had not yet received his lunch tray. A CNA statement indicated the resident had eaten breakfast and was later found asleep in bed, and CNA documentation for that shift showed the dressing task as completed. However, the facility’s follow-up summary documented that the CNA confirmed care had not been provided to the resident prior to being questioned by the RN supervisor, and the LSW confirmed that the CNA changed the resident only after the family reported the concern and nursing was notified.
Failure to Provide Adequate Supervision and Assistance During Bed Mobility for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for a resident with significant functional and cognitive impairments. The resident was admitted with left-sided weakness after a stroke and was care planned as extensively to totally dependent for bed mobility, requiring the support of two persons. A fall risk evaluation documented a score of 10, indicating high fall risk, and a quarterly MDS assessment showed the resident was unable to participate in a cognitive assessment and was completely dependent on staff for all ADLs. Despite these identified needs and risks, the resident was being turned onto their side for peri care by an aide when they fell from the bed to the floor. During this incident, the resident sustained head trauma and a small scalp laceration, and was on blood thinners at the time of the fall. The fall occurred while the aide was providing peri care and turning the resident, but the report does not document the presence of a second staff member, despite the care plan indicating the need for two-person assistance for bed mobility. The facility’s own policy on falls emphasized instituting individualized practices to minimize fall risk and maximize safety for residents identified as high risk, but the resident’s documented high fall risk and total dependence were not adequately addressed in the supervision and assistance provided at the time of the fall.
Failure to Ensure Safe Discharge with Confirmed Home Services and Support
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s discharge home included confirmed durable medical equipment (DME), home health services, and adequate caregiver support. The resident was admitted with spinal stenosis, cervical disc disorder, muscle weakness, carpal tunnel syndrome, and a recent post-fasciotomy to the right arm, and was documented as cognitively intact with a BIMS score of 14/15. Despite these physical limitations, the facility discharged the resident home in the evening via medical transport to a three-story residence, where no caregiver support was present. The facility’s own policy required a post-discharge plan of care developed with the resident and representative, and orientation to ensure a safe and orderly transfer or discharge, but the record lacked evidence that services were confirmed as in place prior to discharge. Prior to discharge, the social worker documented that the resident would have a safe discharge home with services and supports in place, and that referrals for home health care, skilled nursing services, and DME had been made, with family members in attendance at the discharge care plan. However, the clinical record did not contain confirmation that these services were actually arranged and active before the resident left the facility. The resident was discharged with medications called to the pharmacy for home delivery, but there was no documentation that the hospital bed had been delivered or that home health nursing, therapy, or home health aide services were scheduled to start at the time of discharge. The social worker later acknowledged not informing the agency of a specific start-of-care date, assuming the agency and VA would contact the resident, and confirmed not calling to verify delivery of the hospital bed. After discharge, it was discovered that the hospital bed ordered days earlier was not delivered until the morning after the resident arrived home, and that therapy, RN, and HHA services had not yet begun or contacted the resident by the time the facility followed up. The resident reported living alone, being unable to use their hands, needing a caretaker, and having to rely on a sister-in-law for limited assistance with hygiene, meals, and rearranging furniture for the bed that arrived later. The significant other confirmed that no one lived with the resident, that they had their own health issues, and that neither they nor their son stayed with the resident after discharge. When a home health RN eventually visited, the resident was found sitting on a couch in minimal clothing, reporting not having eaten adequately for two days, having little or no accessible food, and being unable to open medications or bottles due to impaired fine motor skills. The RN observed the resident’s inability to grip or perform fine motor tasks, assisted with toileting, and then contacted the agency director and emergency services due to the unsafe conditions in which the resident had been left. These events led surveyors to determine that the facility failed to ensure services and caregiver support were in place prior to discharge, resulting in an immediate jeopardy situation.
Removal Plan
- Audited discharge documentation related to home health services, appropriate caregiver/family support, and any necessary services to meet residents' care needs to determine if any residents were affected.
- Reviewed planned discharges by the Administrator, DON, Director of Social Services, and Director of Rehabilitation to ensure home health services, appropriate caregiver/family support, and necessary services to meet the resident's care needs are in place before discharge.
- Completed a root cause analysis identifying failure to have a robust discharge care plan meeting with the interdisciplinary team (IDT), resident, and resident representative.
- Reviewed the procedure for safe and effective discharge planning with the IDT.
- Re-educated the discharge planning IDT on the discharge policy and procedure to ensure sufficient preparation and orientation for a safe discharge.
- Implemented review of residents scheduled to be discharged to ensure appropriate discharge planning is in place.
- Implemented review of residents scheduled for discharge to ensure ADL support is in place, durable medical equipment is available prior to or on the discharge date, medications are available upon discharge, and identified needs/support are available.
- Implemented review of residents scheduled for discharge to ensure safe discharge planning is in place and to address any issues identified.
- Implemented oversight during utilization review by the NHA/designee to ensure discharge planning preparation and services are in place prior to discharge.
- Initiated audits and educational in-services to the IDT team and conducted staff interviews to confirm education received regarding discharge to the community and/or transfers to other facilities.
Failure to Maintain Adequate Hydration Resulting in Recurrent AKI and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate hydration for a resident with significant medical conditions, including acute kidney injury (AKI), congestive heart failure (CHF), dementia, and Parkinson’s disease. Upon admission, the resident’s care plan identified potential for altered nutrition and included interventions such as assisting at meals, encouraging oral fluids, and monitoring for additional nutrition interventions. A nutrition assessment established an initial fluid goal of 1943–2098 mL/day and documented that the resident was at risk for dehydration and malnutrition, with early labs showing a BUN of 29, creatinine of 1.4, and eGFR of 53. The admission MDS documented that the resident was severely cognitively impaired and required setup assistance for feeding and hydration. Daily fluid intake records from CNA task flow sheets and the MAR showed that the resident’s intake frequently fell below the recommended fluid goals, with multiple days of intake under 1200 mL and some days as low as 360–720 mL. A malnutrition risk assessment identified the resident as at risk for malnutrition due to severe dementia and tremors. A subsequent nutrition note on 5/12/25 documented that the resident’s average fluid intake was 330 mL/day, recommended discontinuing a prescribed hydration pass due to CHF, and set a new fluid goal of 1635–1766 mL/day, while continuing to recommend encouraging oral fluids. Despite these documented risks and low intakes, there is no evidence in the record of intensified monitoring or additional interventions to ensure the resident met the revised fluid goals. The resident experienced multiple clinical deteriorations associated with poor intake and changes in condition. On 6/1/25, after a day with only 360 mL of recorded intake, the resident was transferred to the hospital following falls, hypotension, and confusion, and was admitted with AKI and dehydration. After readmission to the facility, nursing documentation noted low oral intake and a plan to discuss adding the resident to an assist-to-feeding list, but the record lacked evidence that this occurred. Subsequent notes documented lethargy, increased confusion, agitation, restlessness, and continued poor intake, yet a physician progress note following two unwitnessed falls did not include an assessment of hydration status or interventions to improve hydration. On 6/19/25, labs showed a BUN of 62 mg/dL and creatinine of 1.7 mg/dL, and the resident was again sent to the hospital and admitted with AKI, hypotension, and anemia, requiring IV fluid resuscitation. Staff interviews confirmed expectations to monitor intake, encourage fluids, and notify providers when fluid goals were not met, but there was no documentation that the provider was consistently notified or that appropriate interventions were implemented in response to the resident’s ongoing inadequate fluid intake and changes in condition.
Failure to Arrange Timely Home Health Services Prior to Discharge
Penalty
Summary
The facility failed to ensure a timely referral for home health care services prior to discharge for one resident. Facility policy dated 5/1/25 required sufficient preparation and orientation to residents to ensure an orderly transfer or discharge. The resident was admitted on 7/28/25 with diagnoses including aortic valve replacement, aortic regurgitation, and congestive heart failure. A discharge summary dated 8/11/25 documented a post-discharge plan for home health aide, home health RN/LPN, and occupational and physical therapy. The resident was discharged home with a family member on 8/12/25. A complaint received by the Division on 9/30/25 stated that the resident was discharged to a family member's home without a home health care agency referral and that, after one week at home, the resident had not received any physical or occupational therapy or a wellness check from a nurse. During an interview on 2/16/26, the social worker reported needing to check if a referral was made and later confirmed that the referral for home health and therapy services was not requested until 8/15/25, with services opened on 8/20/25. The director of therapy confirmed that physical and occupational therapy were recommended for the resident and stated that such recommendations are typically communicated to social services to set up home care. Findings were reviewed with facility leadership during the exit conference.
Failure to Revise Care Plans and Involve Resident in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise person‑centered care plans and to involve a cognitively intact resident and/or representative in the care planning process. One resident with an intact BIMS score of 15 was admitted and had a documented care conference shortly after admission, but there was no evidence of any subsequent care conferences during the following year despite multiple care plan updates. The resident reported not recalling quarterly care plan meetings, and staff confirmed that no care conferences occurred after the initial one, with no documentation that the resident or representative participated in the later care plan revisions. Additional residents’ care plans were not revised to reflect current, individualized needs and behaviors. One resident had a physician’s order for a right palm protector or substitute, was repeatedly observed without it in place, and routinely refused it according to nursing and CNA interviews, yet the care plan did not address potential refusals. Two cognitively impaired residents whose MDS assessments documented dependence for bathing had care plans that continued to list only setup assistance or one‑person assist, without updating to reflect full dependence. Another cognitively impaired resident with documented combative behaviors toward staff and a reported incident of striking another resident with a remote had a behavior care plan that was not revised to include the new behavior of attempting to hit other residents or the potential for resident‑to‑resident altercations.
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