Newark Manor Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Newark, Delaware.
- Location
- 254 West Main Street, Newark, Delaware 19711
- CMS Provider Number
- 08A020
- Inspections on file
- 17
- Latest survey
- October 24, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Newark Manor Nursing Home during CMS and state inspections, most recent first.
Two residents with severe cognitive and physical impairments were not adequately supervised, resulting in one sustaining a fracture from contact with a bed enabler and another suffering a head laceration and sacral fracture after being left unsupervised in a bathroom. The facility failed to identify accident hazards, implement person-centered fall interventions, and provide timely emergency response, with staff misrepresenting incident details and care plans lacking clear supervision instructions.
A resident with increased pain and decreased movement in the left arm had a STAT x-ray ordered and completed, but the results were delayed for about 48 hours. During this time, an RN learned of the delay from the x-ray company but did not notify the on-call provider. The provider was only notified after the resident's POA insisted on sending the resident to the ER. There was no documentation that the provider was informed of the delay as required.
A resident with dementia and vision loss was left unattended in a bathroom by a CNA, resulting in a fall and head injury. The CNA misrepresented the location of the fall, and the facility did not thoroughly investigate the incident or clarify the circumstances until nearly two weeks later. Documentation and staff interviews revealed gaps in assessment and reporting, with the true details only emerging during a later care conference.
A resident with dementia, legal blindness, and a pacemaker did not have a person-centered care plan addressing all aspects of pacemaker management. The care plan lacked details such as device type, settings, battery status, education for the resident/family, and monitoring of the pacemaker site, as confirmed by staff interviews and record review.
The facility did not ensure that bed rail care plans for three residents were person-centered or included necessary monitoring, ongoing assessment, risk evaluation, or identification of responsible staff for discontinuation. In one case, a resident was observed with both bed rails up despite a care plan for only one. These deficiencies were confirmed through record review, observation, and interviews with the DON.
Surveyors found that the facility did not ensure proper assessment, monitoring, or maintenance of bed rails for several residents. In multiple cases, residents were fully dependent on staff for mobility and unable to use bed rails as intended, yet the rails remained in use without documented reassessment. Additionally, there was no evidence of required preventive maintenance or safety checks for the bed rails, as confirmed by staff interviews.
A resident experiencing increased pain and decreased movement of the left arm had a STAT x-ray ordered, but the facility did not receive the results, which showed an acute nondisplaced fracture, until about 48 hours later due to limited weekend staff coverage by the x-ray provider. STAT x-ray results are typically completed within two hours, but this delay failed to meet the resident's acute medical needs.
A resident with dementia and severe cognitive impairment suffered a broken nose and facial lacerations after being physically assaulted by a roommate with a history of aggressive behavior. Despite care plans and safety checks in place, the incident occurred when staff were not present to intervene, and prior behavioral history from another facility was not fully communicated before admission.
A resident did not receive multiple doses of prescribed medications for depression and an enlarged prostate due to delays in pharmacy delivery and insurance-related issues. Facility staff documented repeated unavailability of the medications and confirmed that confusion over pharmacy responsibilities and prescription requirements led to the missed doses. The attending physician was not promptly notified of the delays.
The facility failed to provide written transfer notices to residents, their responsible parties, and the LTC Ombudsman when residents were transferred to the hospital. This deficiency was identified for two residents, and interviews with staff confirmed that the facility's policy did not address the need for written notifications. The Director of Nursing was unaware of the requirement for written notifications, and the Ombudsman confirmed not receiving any notifications over the past year.
The facility did not provide written bed hold notices to two residents or their families during hospital transfers, as required by policy. Interviews confirmed that while the policy was communicated upon admission, it was not reiterated during transfers. The DON noted a discrepancy in the bed hold duration used by the facility.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that two residents received adequate supervision and were protected from accident hazards, resulting in harm. One resident, who was dependent, cognitively impaired, and legally blind, sustained a left upper extremity fracture after accidental contact with a bed enabler during care. The facility did not identify the left bed rail as a potential hazard, despite the resident's significant physical and cognitive limitations. Documentation showed that the resident was dependent for all activities of daily living, required a Hoyer lift for transfers, and had a history of pain complaints, but there was no evidence that the risk posed by the bed enabler was adequately assessed or mitigated. Another resident, also severely cognitively impaired and dependent for all activities of daily living, experienced multiple falls over several months, including unwitnessed falls in various locations. The resident's care plan identified a high risk for falls but lacked person-centered interventions tailored to her needs. On one occasion, the resident was left unsupervised in a bathroom by a CNA who left to obtain an incontinent brief, resulting in a fall that caused a scalp laceration and a subtle sacral fracture. The CNA misrepresented the location and details of the incident, and the facility did not thoroughly investigate the true circumstances of the fall until 12 days later. Additionally, after the unwitnessed fall with a head injury, the facility failed to implement timely emergency interventions. The resident was not assessed by a registered nurse at the scene before being moved, and there was a delay of nearly three hours before the resident was sent to the emergency room. Interviews with staff revealed gaps in communication and documentation, as well as a lack of clear instructions for staff regarding supervision requirements for high-risk residents. The facility's documentation and care plans did not provide adequate guidance to prevent such incidents, despite the residents' extensive histories of falls and cognitive impairment.
Failure to Notify Provider of Delayed STAT X-ray Results
Penalty
Summary
A deficiency occurred when the facility failed to notify the on-call provider regarding delayed STAT x-ray results for a resident who was experiencing increased pain and decreased movement in the left arm. A STAT elbow x-ray was ordered and completed, but the results were not received for approximately 48 hours. During this period, a registered nurse contacted the mobile x-ray company and learned of the delay but did not inform the on-call provider about the missing results. The lack of timely notification to the provider persisted until the resident's power of attorney became upset and requested that the resident be sent to the emergency room, at which point the provider was finally notified and an order was obtained to send the resident out for further evaluation. The clinical record review and staff interview confirmed that there was no evidence of provider notification about the delay in receiving the STAT x-ray results, which was required by facility policy and regulations.
Failure to Investigate and Accurately Report Resident Fall
Penalty
Summary
A resident with dementia, permanent vision loss, and difficulty walking was admitted to the facility and had a care plan noting poor safety awareness and impulse control. On the day of the incident, the resident was left unattended in a bathroom by a CNA who left to obtain an incontinent brief. During this time, the resident fell and sustained a superficial laceration to the back of the head. The CNA returned, found the resident on the floor, placed the resident in a wheelchair, and misrepresented the location of the fall to the supervisor, stating it occurred in the dining room. The facility did not thoroughly investigate the true circumstances and location of the fall until 12 days after the event, despite conflicting reports and documentation. The LPN who documented the incident did not assess the resident post-fall, as she was on break and relied on information from the RN supervisor. The actual details of the incident were only clarified during a multidisciplinary care conference, revealing the CNA's misrepresentation and the resident being left unattended. The findings were confirmed with the DON and reviewed during the exit conference with facility leadership.
Failure to Develop Person-Centered Pacemaker Care Plan
Penalty
Summary
A deficiency was identified when a resident with dementia, legal blindness, and sick sinus syndrome was admitted to the facility with a pacemaker. The clinical record documented the presence of the pacemaker and included a care plan with general goals and interventions, such as monitoring vital signs and reporting symptoms of pacemaker malfunction. However, the care plan did not include specific, person-centered details related to the resident's pacemaker. The care plan lacked essential information such as the pacemaker's type, settings, programmed rate, and battery status. Additionally, there was no documentation of education provided to the resident or family regarding the pacemaker's purpose, function, potential complications, or the importance of follow-up with a cardiologist. The plan also omitted monitoring of skin integrity at the pacemaker site. These omissions were confirmed during interviews with facility staff and during the exit conference.
Failure to Maintain Person-Centered Bed Rail Care Plans and Monitoring
Penalty
Summary
The facility failed to ensure that bed rail care plans for three residents were adequately reviewed and revised to be person-centered and to meet their medical needs. For each of these residents, the care plans included interventions such as documenting the use of bed rails as enablers, ensuring valid consent, and obtaining physician orders. However, the care plans lacked documentation of monitoring and supervision during bed rail use, ongoing assessment to confirm the bed rail continued to meet the resident's needs, evaluation of risks, identification of the person responsible for discontinuing the bed rail, and interventions to address any adverse effects from bed rail use. Observations and record reviews revealed that, despite care plans specifying the use of a single bed rail as an enabler, one resident was observed with bilateral bed rails in the up position. Interviews with the DON confirmed these findings. The deficiencies were discussed with facility leadership during the survey process, and the lack of comprehensive, individualized care planning and monitoring for bed rail use was consistently identified across the reviewed cases.
Failure to Ensure Appropriate Use and Monitoring of Bed Rails
Penalty
Summary
Surveyors identified that the facility failed to ensure appropriate use and ongoing monitoring of bed rails for three out of seven residents reviewed. The facility's policy required assessment by physical therapy, physician orders, informed consent, proper installation, care plan updates, and reassessment every six months. However, documentation and observations revealed that these steps were not consistently followed. For example, one resident had a left bed enabler for assistance with positioning, but subsequent assessments showed the resident was fully dependent on staff for all activities of daily living (ADLs) and required a Hoyer lift, with no evidence that the continued use of the bed rail was reviewed for appropriateness. Another resident had a right side bed enabler ordered for assistance with turning and repositioning, but was documented as dependent for bed mobility and required two staff for rolling in bed. During care, the resident was unable to use the bed rail due to a contracted hand, and staff confirmed the resident's dependence for turning. A third resident had a physician's order for a single bed rail, but was observed with bilateral bed rails in use. This resident also required two staff for turning and repositioning, and was unable to use one of the bed rails as intended during care. Additionally, the facility lacked evidence of preventive maintenance or safety checks for the bed rails in use. Staff confirmed that there was no documentation of such checks, despite the manufacturer's guidelines being available. These findings indicate that the facility did not ensure bed rails were used according to policy and did not maintain ongoing safety monitoring for residents using bed rails.
Delay in STAT X-ray Results for Acute Medical Need
Penalty
Summary
The facility failed to meet the acute medical needs of a resident by not obtaining timely STAT x-ray results following a physician's order for an elbow x-ray due to increased pain and decreased movement of the left arm. The order was placed on 7/18/25, but the x-ray results, which revealed an acute nondisplaced fracture of the left humeral neck, were not received and faxed to the facility until approximately 48 hours later. According to a representative from the x-ray company, STAT x-ray results are typically completed within two hours on the same day, but limited staff coverage over the weekend delayed the reading and notification to the facility.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A resident with severe cognitive impairment and dementia (R462) was physically abused by their roommate (R461), resulting in a broken nose and laceration to the bridge of the nose. R462 had no prior behavioral symptoms, while R461 had a history of depression, insomnia, adult personality and behavior disorder, and was care planned for impaired thought process and aggressive behaviors. R461's care plan included multiple interventions to address physical and verbal aggression, particularly during night shift hours, and required frequent safety checks. Despite these interventions, an incident occurred late at night when staff were called to the room and found R462 actively bleeding from the face after being struck by R461. Both residents were separated and sent to the emergency department for evaluation, where R462 was diagnosed with a nasal fracture and facial lacerations. Documentation indicated that R461 had accused R462 of stealing, which precipitated the physical altercation. The facility's records also revealed that some information about R461's aggressive behaviors from a previous facility was not communicated prior to admission. Family members reported that they were told the facility would provide close monitoring of R461, especially when he was up and near his roommate, but it appeared that no one was present to supervise at the time of the incident. The facility failed to ensure that R462 was protected from physical abuse by R461, resulting in significant harm.
Failure to Administer Physician-Ordered Medications Due to Pharmacy and Insurance Delays
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received prescribed medications according to physician orders. The resident had active orders for tamsulosin HCL for an enlarged prostate, and aripiprazole and escitalopram oxalate for depression. Review of the Medication Administration Record for May 2024 revealed multiple missed doses of these medications over several days. Nurse progress notes repeatedly documented that the medications were unavailable and that the facility was awaiting delivery from the pharmacy. Interviews with facility staff confirmed that the missed doses were due to delays in obtaining the medications, which stemmed from insurance issues and confusion regarding which pharmacy was responsible for filling the prescriptions. The facility pharmacy provider was unable to fill the medications due to insurance restrictions, and the alternate pharmacy required prescriptions from a specific physician, causing further delays. The attending physician was not notified of the ongoing delays until several days after the missed doses began.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written transfer notices to residents and their responsible parties, as well as to the Long Term Care Ombudsman, when residents were transferred to the hospital. This deficiency was identified for two residents out of a sample of 26. The facility's policy on discharge to a hospital or another LTC facility did not include the requirement for written notices, which led to the oversight. Specifically, Resident 54 was transferred to the hospital without any documented evidence of written notification to the responsible party or the Ombudsman. Similarly, Resident 312 was sent to the hospital for further evaluation and treatment without a written transfer notice being provided to the resident, their family, or the Ombudsman. Interviews with facility staff, including the Social Services Director and the Director of Nursing, confirmed that the facility's policy did not address the need for written notifications of transfers. The Director of Nursing admitted to notifying responsible parties by telephone but was unaware of the requirement for written notifications to both the responsible parties and the Ombudsman. The Long Term Care Ombudsman also confirmed not receiving any notifications of resident transfers from the facility over the past year.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written information regarding its bed hold policy to residents and their responsible parties at the time of transfer to a hospital or within 24 hours of the transfer. This deficiency was identified for two residents, R54 and R312, out of a sample of 26 residents reviewed for hospitalizations. The facility's policy, as outlined in the admission package, states that for Medicaid residents, the bed will be held for up to seven days, and for private pay residents, a fee of $150 per day applies. However, there was no evidence in the electronic medical records or thinned charts that bed hold notices were given to R54 and R312 or their families upon their transfers to the hospital. Interviews with facility staff, including the Social Services Director and the Director of Nursing, confirmed that bed hold notices were not provided at the time of transfer or within 24 hours. The Director of Nursing acknowledged that while residents and their responsible parties were informed of the bed hold policy upon admission, this information was not reiterated during hospital transfers. Additionally, the Director of Nursing mentioned that the facility was using a 30-day bed hold policy instead of the seven days stated in the policy. The Long-Term Care Ombudsman also expressed concerns about not receiving bed hold notices for the past year.
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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