Ocean Grove Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Millsboro, Delaware.
- Location
- 231 South Washington Street, Millsboro, Delaware 19966
- CMS Provider Number
- 085037
- Inspections on file
- 24
- Latest survey
- July 8, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Ocean Grove Post Acute during CMS and state inspections, most recent first.
Surveyors found that a resident unit was not maintained in a clean and homelike condition, with multiple rooms exhibiting brown stains near an air conditioning unit, ceiling, and closet, as well as a leaking shower head, slippery substances on shower tiles, and missing tiles and baseboards. Maintenance staff confirmed these areas were in disrepair.
A resident with multiple wounds did not consistently receive daily wound care as ordered by the physician. Documentation showed missed treatments on several days, with no evidence of resident refusal or absence. Interviews with the resident and staff confirmed that wound care was not always performed due to staffing issues, and the unit manager was unaware of the missed treatments.
A resident with diabetes did not receive prescribed injections of Ozempic and Bydureon as ordered, due to pharmacy dispensing errors, medication order changes, and product unavailability. Documentation and interviews confirmed that the medications were not administered on multiple occasions, and facility staff acknowledged the lack of timely delivery and communication regarding the resident's medication needs.
A resident with severe cognitive impairment and GERD was served meals containing foods such as tomato products and onions, which were specifically listed as intolerances in their care plan. Staff and dietary personnel were unaware of these restrictions, and meal tickets did not reflect the need to avoid these foods, resulting in the resident receiving inappropriate meals.
Three residents experienced deficiencies in clinical documentation, including unsigned medication administration records for pain medication and an incorrect nutritional assessment for tube feeding. Although medications were administered and orders were followed, the records did not accurately reflect the care provided due to documentation errors by nursing staff.
The facility failed to create comprehensive care plans for four residents, including those with incontinence, cognitive impairment, and the need for anti-coagulation therapy. Despite assessments indicating these needs, care plans were not developed, as confirmed by staff interviews.
The facility failed to ensure required IDT members participated in care plan meetings for several residents, with missing input from physicians, nurses, and nutrition staff. One resident's care plan inaccurately included dentures, and another's did not reflect current tracheostomy needs. Additionally, a resident's care plan did not accurately reflect interventions for dementia-related resistance to care.
The facility failed to ensure required IDT members participated in care plan meetings for six residents, and inaccurately included dentures in one care plan. Additionally, LPNs, instead of RNs, completed admission assessments and baseline care plans, contrary to Delaware State regulations. This was confirmed through record reviews and staff interviews.
The facility failed to properly store, prepare, and serve food, risking foodborne illness. An undated Nutritional Shake was found in a nourishment refrigerator, and the walk-in refrigerator had rusted shelves, a wet floor, and ice buildup. Additionally, the sanitizing solution in a prep area bucket was insufficient for proper sanitization.
The facility failed to implement proper infection control measures for three residents. One resident with a tracheostomy did not have necessary supplies for enhanced barrier precautions, and an LPN did not use a gown or face shield during care. Another resident with a PICC line and staph infection was not cared for with required precautions, as an LPN only wore gloves during medication administration. A third resident's catheter bag was repeatedly observed on the floor, violating infection control protocols.
A facility failed to notify a resident's authorized representative about the termination of Medicare coverage. The resident, with severe cognitive impairment, was given a Notice of Medicare Non-Coverage, but the resident's sister, listed as an emergency contact, was not informed or offered an opportunity to appeal. The facility lacked evidence of attempts to notify the emergency contacts.
The facility did not maintain a clean and homelike environment in the Ocean Gardens unit. A broken handrail with jagged edges in the 300 hallway was not covered, and the baseboards in the 400 hallway were dirty and dusty, with a dark substance spilled on the wall. These issues persisted over several days, despite the Maintenance Director's awareness.
A resident with severe cognitive impairment was not protected from misappropriation of funds when the facility's staff assisted them in writing checks despite their inability to understand financial transactions. The facility failed to report the incident of missing funds to the State agency, and the checks were returned for insufficient funds.
A resident with severe cognitive impairment was financially exploited when their checkbook, secured in the facility safe, was used to write checks that later bounced due to missing funds. Despite discovering the issue, the NHA did not report it to Adult Protective Services until prompted by a surveyor, indicating a failure to follow timely reporting protocols.
The facility failed to address incontinence issues for two residents, who experienced frequent episodes of bladder incontinence without a structured plan to restore continence. Despite assessments indicating the ability to use adaptive equipment, the facility did not implement a toileting program or utilize such equipment, as confirmed by staff interviews.
The facility failed to maintain a safe and sanitary environment in the clean laundry room, where pipes were dripping water onto the floor and into a trash can. The pipes had black staining, some appearing fuzzy, and wet towels were found on the floor. A laundry staff member confirmed the issue had persisted for several months.
A facility failed to maintain a resident's dignity by not using a privacy bag for a urinary collection bag, as required by policy. The resident, with an indwelling catheter for neurogenic bladder, was observed multiple times with the catheter bag visible and uncovered. An employee confirmed the deficiency and covered the bag after it was pointed out. The issue was reviewed with facility leadership.
A resident's bathing preferences were not honored, as the facility scheduled showers based on room assignment rather than individual choice. Despite the resident's preference for morning showers, the schedule was set for specific days and times without their input. Staff interviews confirmed the scheduling practice, and the issue was reviewed with facility leadership.
A resident with severe cognitive impairment was allowed to leave the facility multiple times with unrelated persons without family consent, due to the facility's lack of policies for residents without a legal decision maker. Staff interviews confirmed the absence of procedures or restrictions for such residents, leading to this deficiency.
A facility failed to notify a resident's family representative and the Ombudsman of two hospital transfers. The resident, with severe cognitive impairment, was incorrectly listed as the responsible party for notifications. The facility's records showed the resident's son as the emergency contact, but he was not informed of the transfers. Additionally, the transfers were not included in the Ombudsman Admission/Discharge Notice. These findings were reviewed with facility staff.
A facility failed to notify a resident's family representative of the bed-hold policy during two hospitalizations. The resident, with severe cognitive impairment, was incorrectly listed as the responsible party for receiving the notices, despite their son being the emergency contact.
The facility failed to ensure accurate assessments for two residents, leading to discrepancies in their care plans. One resident was incorrectly documented as edentulous despite having broken teeth, while another resident's MDS inaccurately noted the absence of a wander guard, despite its confirmed presence. These inaccuracies were confirmed through staff interviews.
The facility failed to complete necessary PASARR screenings for three residents, leading to a deficiency. One resident, admitted with mental health diagnoses, did not receive a Level II PASARR despite new diagnoses of dementia and violent behavior. Another resident, initially exempt from Level II, developed mood disorder and dementia but was not reassessed until much later. A third resident, with new diagnoses of dementia and psychotic disturbance, also lacked a Level II PASARR. The absence of a psych nurse practitioner contributed to these oversights.
A resident with cerebral infarction and hemiplegia was not assisted to get out of bed as per physician's orders, despite being cognitively intact. Observations showed the resident remained in bed, and staff interviews confirmed no refusals were documented. A CNA admitted they did not ask the resident if he wanted to get up, leading to a deficiency finding.
A resident with atrial fibrillation and other conditions was not managed effectively for warfarin dosing, resulting in consistently subtherapeutic INR levels. Despite dosage adjustments, the facility failed to achieve the therapeutic INR range, leading to the resident's hospitalization for further anticoagulation treatment. Interviews confirmed the prolonged failure to reach the INR goal, and the issue was discussed with facility leadership.
The facility failed to provide appropriate respiratory care for two residents. One resident with a tracheostomy had discrepancies in trach size documentation and lacked proper emergency equipment. Another resident with acute respiratory failure had unlabeled oxygen tubing, contrary to physician's orders. These issues indicate lapses in maintaining accurate records and equipment management.
A facility failed to ensure a resident's physician's orders included necessary details for tracheostomy care. The orders lacked information on the current trach size and brand, and emergency instructions were inaccurate. This was confirmed by an LPN and a nurse practitioner, and discussed with facility leadership during the exit conference.
The facility failed to ensure nursing staff had the necessary competencies to care for a resident with a tracheostomy. A resident with a traumatic brain injury and tracheostomy status required specific care, but interviews revealed staff were unsure of emergency procedures. The facility lacked evidence of verifying competencies for agency nurses and staff in emergency tracheostomy procedures.
A facility failed to provide necessary social services to a cognitively impaired resident who lacked a legal decision maker. The resident, with a severe cognitive deficit, signed an Admission Agreement without understanding it. The facility did not identify a responsible party or initiate a timely capacity determination. The resident was signed out by unauthorized persons, and the facility failed to inform the family about Medicare coverage changes or report potential financial exploitation.
A facility failed to maintain accurate documentation for a resident who was required to be out of bed for at least two hours daily. Despite observations and the resident's statement confirming they remained in bed, the treatment administration record inaccurately indicated compliance with the order. Interviews with staff revealed a lack of documentation for refusals, highlighting a failure to adhere to professional standards.
The facility's QAPI program failed to address previously cited deficiencies in the MRR policy, which lacked specified time frames for pharmacist responses and facility actions. Despite a Plan of Correction, the policy remained unchanged, as confirmed by the NHA. These issues were discussed with key staff during the exit conference.
A resident with hemiplegia fell from a wheelchair during transport in a facility van due to improper restraining, resulting in a head injury. The van driver did not use the shoulder belt as per facility guidelines, leading to the resident's fall and subsequent hospital treatment.
The facility failed to maintain accurate Controlled Drug Count Records for May 2024, with missing evidence of narcotic counts and discrepancies in records, such as scribbled-out entries and incomplete categories. These issues were confirmed by the NHA and DON, indicating a failure to reconcile controlled drugs between shifts.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
Surveyors observed that one out of four resident units failed to maintain a clean and homelike environment. In the Ocean Gardens unit, multiple rooms were found with significant issues: two large brown areas, approximately six inches in length, were noted by the air conditioning unit in one room, which maintenance staff confirmed had recently been replaced due to leaking. Another room had approximately six circular brown areas in a linear pattern on the ceiling and a large brown area, about twelve inches long, in the closet. Additionally, a third room had a leaking shower head, and the shower tiles were covered with a pink and gray slippery substance; several tiles and baseboard lining were missing from the bathroom wall and floor. Maintenance staff confirmed these areas were in disrepair during interviews.
Failure to Provide Wound Care per Physician Orders
Penalty
Summary
A deficiency occurred when wound care for a resident with multiple wounds related to diabetes and poor circulation was not performed according to the physician's ordered frequency. The facility's policy required wound treatments to be provided as ordered and documented in the electronic health record. However, review of the resident's treatment administration record (TAR) showed that daily wound care treatments were not documented as completed on several specific dates. There was also no documentation in the progress notes to indicate that the resident was absent or refused care on those dates. Interviews with the resident and staff confirmed that wound care was not consistently provided as ordered. The resident reported that dressings were not changed every day due to staffing issues. The wound care nurse acknowledged that treatments were sometimes missed and confirmed the gaps in the TAR. The unit manager also confirmed the findings and stated unawareness of the missed treatments. These actions and inactions led to the failure to provide wound care in accordance with physician orders.
Failure to Provide Ordered Diabetes Medications Due to Pharmacy and Order Issues
Penalty
Summary
A deficiency occurred when the facility failed to provide medications as ordered for a resident with diabetes. Upon admission, the resident had a physician's order for Ozempic injections, which was later changed to Bydureon and then to Exenatide due to medication availability issues. The facility's policy required timely receipt of medications from the pharmacy, but documentation showed that Ozempic was not administered on two scheduled dates, and Bydureon was not administered as ordered. The resident's Medication Administration Record (MAR) confirmed these missed doses. Interviews with facility staff and the consulting pharmacist revealed that the pharmacy did not dispense the ordered medications due to order changes and product discontinuation. The pharmacist acknowledged a missed opportunity to dispense the second order and confirmed that Bydureon was unavailable due to manufacturer discontinuation. The resident reported not receiving their prescribed medication, and facility leadership confirmed the lack of evidence for medication delivery from the pharmacy.
Failure to Accommodate Dietary Intolerances for Resident with GERD
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of gastroesophageal reflux disease (GERD) and a feeding tube was not provided with food that accommodated their dietary intolerances as outlined in their care plan. The care plan specifically directed avoidance of foods and beverages that could irritate the esophageal lining, such as tomato products, onions, garlic, and other acidic or spicy foods, and encouraged a bland diet. Despite these documented needs, the resident was observed being fed meals containing tomato sauce, garlic bread, tomato juice, and steak with onions and peppers. The lunch tickets accompanying the meals did not indicate the need to avoid these foods, and the dietary department was unaware of the resident's dietary intolerances related to GERD. Staff interviews confirmed that only texture restrictions were known and followed, and the dietary department had not been informed of the resident's GERD-related dietary needs. The assigned RN reviewed the care plan and acknowledged that the meals provided did not avoid the resident's documented dietary intolerances. These findings were confirmed during the survey exit conference with facility leadership.
Failure to Maintain Accurate Clinical Documentation for Medication and Nutrition Orders
Penalty
Summary
The facility failed to ensure accurate and complete clinical documentation for three residents. For two residents who were prescribed morphine sulfate ER for pain management, the medication administration records contained blank, unsigned entries for scheduled doses. However, a review of the controlled drug administration record and the backup pharmacy dispensary log confirmed that the medication was administered as ordered, but the responsible nurse did not document the administration in the electronic medication administration record at the time of administration. For another resident with a feeding tube, there was a discrepancy between the physician's order and the nutritional assessment. The physician's order specified that the resident should receive liquid nutrition through the feeding tube if more than 50% of a meal was consumed, but the nutritional assessment incorrectly documented that tube feeding should occur when less than 50% of a meal was consumed. This inconsistency was due to a documentation error in the nutritional assessment, which did not align with the physician's order or the hospital discharge records.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for four residents in the investigative sample. For one resident, who was admitted in February 2024 and initially assessed as continent, the facility did not create an incontinence care plan despite a later assessment indicating frequent incontinence. Another resident, admitted in April 2024, was occasionally incontinent, yet also lacked an incontinence care plan. Interviews with facility staff confirmed the absence of these care plans. Additionally, a resident with severe cognitive impairment, as indicated by a BIMS score of three, did not have a care plan addressing cognitive impairment. Another resident, admitted with atrial fibrillation, deep vein thrombosis, and a genetic mutation predisposing them to blood clots, lacked a care plan for necessary anti-coagulation therapy. These deficiencies were confirmed through interviews with facility staff and discussed during an exit conference with key personnel.
Deficiencies in Care Plan Meetings and Documentation
Penalty
Summary
The facility failed to ensure that the required interdisciplinary team (IDT) members participated in care plan meetings for six residents. For one resident, the quarterly care plan meeting lacked input from the physician, registered nurse, nurse aide, and food/nutrition services staff, and there was no evidence of a quarterly care plan meeting in December 2023. Another resident's care plan meetings were undated and lacked evidence of participation from the necessary IDT members, with no documentation for previous meetings. Additionally, a resident's care plan inaccurately included dentures, and the facility failed to hold quarterly care plan meetings as required. Further deficiencies were noted in the care plans of other residents. One resident's care plan did not reflect the current needs related to their tracheostomy, including the tracheostomy size and emergency needs if it dislodges. Another resident's care plan did not accurately reflect interventions for their resistance to care due to dementia, as confirmed by a staff member. These findings were reviewed with the facility's administration and nursing staff during the exit conference.
Failure to Ensure Proper IDT Participation and RN-Led Assessments
Penalty
Summary
The facility failed to ensure that the required interdisciplinary team (IDT) members participated in care plan meetings for six residents out of thirty-three in the investigative sample. Additionally, one resident's care plan inaccurately included dentures. This deficiency was identified through record reviews and interviews, revealing that the necessary IDT members were not involved in the care planning process, which is a critical component of ensuring comprehensive and individualized care for residents. Furthermore, the facility did not comply with the Delaware State regulation for the Board of Nursing Scope of Practice, which mandates that a Registered Nurse (RN) must complete admission assessments and baseline care plans. Instead, Licensed Practical Nurses (LPNs) were responsible for these tasks for several residents, including completing various assessments and generating baseline care plans. This practice was confirmed through interviews with staff members, who indicated that LPNs were performing duties that should have been completed by RNs, as per state regulations.
Food Storage and Sanitization Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in a manner that prevents foodborne illness to the residents. During an observation, a carton of Nutritional Shake was found undated in the nourishment refrigerator at the nurse's station, despite instructions indicating it should be discarded after four days once opened. Additionally, the food storage shelves in the walk-in refrigerator were covered in rust, the floor was wet, and there was ice buildup in the walk-in freezer. Furthermore, the sanitizing solution in a bucket from the prep area was found to have an insufficient chemical concentration for proper sanitization, as observed during a kitchen tour with the Dining Services Director and Assistant Dining Services Director.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control measures for three residents, leading to deficiencies in care. For one resident with a tracheostomy, the facility did not provide the necessary supplies for enhanced barrier precautions, and a Licensed Practical Nurse (LPN) failed to use a gown or face shield during tracheostomy care. This resident's care plan required enhanced barrier precautions due to the presence of a tracheostomy, but these precautions were not followed during an observed care session. Another resident with a peripherally inserted central catheter (PICC) line and a staph infection did not receive care with the required enhanced barrier precautions. During medication administration, an LPN was observed wearing only gloves, without the necessary gown. Additionally, a third resident with an indwelling catheter had their catheter collection bag repeatedly observed lying on the floor or dragging along the floor, which is against the facility's policy. Despite attempts to correct the issue, the catheter bag was not consistently kept off the floor, indicating a failure to adhere to infection control protocols.
Failure to Notify Resident's Representative of Medicare Coverage Termination
Penalty
Summary
The facility failed to provide proper notification of service changes to a resident's authorized representative. The resident, identified as R146, was admitted to the facility with a severe cognitive impairment, as indicated by a BIMS score of three. On April 12, 2024, the resident was given a Notice of Medicare Non-Coverage (NOMNC), indicating that Medicare coverage would end on April 17, 2024. The document was signed by facility staff with a note stating the resident was unable to sign due to the BIMS score. However, the resident's sister, listed as the emergency contact, reported not being informed about the end of Medicare coverage or given the opportunity to appeal. The facility could not provide evidence of any attempt to notify the emergency contacts listed in the resident's records.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in one of its resident units, specifically the Ocean Gardens unit. Observations on multiple occasions revealed a broken handrail with jagged edges in the 300 hallway, which was not covered, posing a potential safety hazard. Additionally, the baseboards in the 400 hallway were found to be dirty and dusty, with a dark substance spilled on the wall, creating a stain. These observations were consistent over several days, indicating a lack of timely maintenance and cleaning in these areas. Interviews with the Maintenance Director confirmed awareness of these issues, but they remained unaddressed over the observed period.
Failure to Protect Resident from Misappropriation of Funds
Penalty
Summary
The facility failed to protect a resident, identified as R146, from the misappropriation of their property and funds. R146, who was admitted to the facility with a severe cognitive impairment as indicated by a BIMS score of three, was involved in a financial transaction that they were not capable of understanding. Despite the resident's cognitive limitations, the facility's Business Office Manager and Nursing Home Administrator assisted R146 in writing checks for room and board and a deposit for an assisted living facility. This action was taken without proper consideration of R146's cognitive capacity, as documented by a psychologist and later confirmed by a physician's affidavit for guardianship, which stated that R146 lacked the capacity to make healthcare decisions. The facility also failed to report the incident of missing funds to the State agency, as required. The Business Office Manager and the Nursing Home Administrator were the only individuals with access to the safe where R146's checkbook was stored. Despite being aware of the resident's cognitive impairment, they facilitated the financial transaction, which resulted in a check being returned for insufficient funds. The facility did not provide evidence that the allegation of missing resident funds was reported to Adult Protective Services, highlighting a failure in safeguarding the resident's property and adhering to reporting protocols.
Failure to Report Financial Exploitation of Resident
Penalty
Summary
The facility failed to immediately recognize and report an allegation of financial exploitation involving a resident with severe cognitive impairment. The resident, who was admitted to the facility with a BIMS score indicating severe cognitive impairment, had their financial documents, including a checkbook, secured in the facility safe. Despite a family member's request that the resident not sign anything without family present, the facility's NHA and Business Office Manager assisted the resident in writing checks for room and board and a deposit for an assisted living facility. It was only after these checks bounced that the facility became aware of a potential issue with the resident's finances. The Business Office Manager and NHA discovered the financial discrepancy when the checks bounced, indicating that the funds were missing. Despite this discovery, the NHA did not report the issue to Adult Protective Services as required. It was not until prompted by a surveyor's inquiry that the Director of Nursing reported the situation to the local police. This delay in reporting the suspected financial exploitation represents a failure to adhere to protocols for timely reporting of abuse, neglect, or theft.
Failure to Address Incontinence in Residents
Penalty
Summary
The facility failed to provide appropriate care for two residents, R123 and R143, in terms of responding to and providing services to restore bladder continence. R123 was initially assessed as continent of bowel and bladder upon admission, but subsequent assessments and task flow sheets revealed a significant decline in continence, with frequent episodes of incontinence recorded over several months. Despite this decline, there was no evidence that the facility implemented a toileting program or utilized adaptive equipment such as a urinal or commode, which R123 was assessed to be able to use safely. Interviews with staff confirmed the lack of a structured plan to address R123's incontinence. Similarly, R143 was admitted as occasionally incontinent of bowel and bladder, but task flow sheets indicated frequent incontinence episodes. Although a voiding diary was completed, there was no evidence of a plan to restore continence. Interviews with staff revealed that R143 was independent in managing incontinence, but the facility still lacked a formal response to the resident's decreased continence. The facility's failure to address these issues was confirmed during interviews with various staff members, including the Nursing Home Administrator and Director of Nursing.
Unsafe and Unsanitary Conditions in Laundry Room
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for staff in the clean laundry room. Several pipes in the ceiling were observed dripping water onto the floor and into a trash can placed under the leaking area. The pipes had numerous areas of black staining, some of which appeared fuzzy, indicating potential mold growth. Three wet and stained towels were found on the floor under the leaks. During an interview, a laundry staff member confirmed the ongoing issue, stating that the water had been dripping and pooling on the floor for several months. These findings were reviewed with the nursing home administrator, director of nursing, quality assurance/infection preventionist, corporate registered nurse, and assistant director of nursing at the exit conference.
Failure to Use Privacy Bag for Urinary Collection
Penalty
Summary
The facility failed to uphold the dignity of a resident by not using a privacy bag for a urinary collection bag, as required by their policy. The resident, who was admitted to the facility with an indwelling catheter for neurogenic bladder, was observed on multiple occasions with the catheter collection bag visible from the hallway and not covered by a privacy bag. These observations occurred on different days, including when the resident was lying in bed and when being transported in a wheelchair. An employee confirmed the absence of a privacy cover and subsequently covered the bag after the deficiency was pointed out. The findings were reviewed with the nursing home administrator, director of nursing, quality assurance/infection preventionist, corporate registered nurse, and assistant director of nursing during the exit conference.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor the care preferences of a resident, identified as R143, regarding their bathing schedule. Upon admission, R143 was not assessed for shower or bathing preferences, despite an admission recreation assessment indicating that choosing between different types of baths was very important to them. A physician's order specified shower days and times, but R143 expressed dissatisfaction, stating a preference for morning showers, which was not accommodated. Interviews with facility staff, including the Activities Assistant Director and Licensed Practical Nurses, revealed that the shower schedule was determined based on room assignment rather than individual resident preferences. These findings were discussed with facility leadership during the exit conference.
Lack of Policy for Residents with Cognitive Impairment
Penalty
Summary
The facility failed to have written policies and procedures regarding the visitation rights of residents with cognitive impairments who do not have a legal decision maker. This deficiency was identified in the case of a resident with severe cognitive impairment, who was admitted with diagnoses including altered mental status. The resident scored 3/15 on the BIMS assessment, indicating severe cognitive deficit, and was documented by a psychologist as having impaired judgment and insight, rendering her incapable of making her own healthcare decisions. Despite this, the resident was allowed to leave the facility on multiple occasions with unrelated persons without the consent of her family, who were listed as emergency contacts. Interviews with facility staff, including the Nursing Home Administrator, Social Work Director, and Nurse Practitioner, revealed that there were no existing policies or procedures for residents deemed not to have capacity and without a legal guardian or power of attorney. The staff acknowledged the absence of special orders or restrictions for such residents, and there was no precedent for contacting family members or appointing a guardian ad litem. This lack of policy and oversight led to the resident leaving the facility without appropriate consent, highlighting a significant gap in the facility's management of residents with severe cognitive impairments.
Failure to Notify Family and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the family representative and the Ombudsman of a resident's transfers to the hospital on two occasions. The resident, who was admitted to the facility's locked dementia unit, had a diagnosis of dementia with agitation and a BIMS score indicating severe cognitive impairment. Despite this, the facility listed the resident as the responsible party for notification purposes. On March 15, 2024, the resident was transferred to the hospital due to gastrointestinal bleeding and returned to the facility on an unspecified date. Again, on March 25, 2024, the resident was transferred for a syncopal episode and returned on an unspecified date. The facility's records showed that the resident's son was listed as the emergency contact, yet he was not notified of the hospital transfers. Additionally, the facility failed to include the resident's transfers in the Ombudsman Admission/Discharge Notice for March 2024. This oversight was confirmed during a review of the resident's electronic medical records and transfer notices, which revealed that the resident was incorrectly listed as the responsible party. The findings were discussed with the facility's administration and nursing staff during an exit conference.
Failure to Notify Resident Representative of Bed-Hold Policy
Penalty
Summary
The facility failed to notify the appropriate resident representative of the bed-hold policy for a resident with severe cognitive impairment. The resident, who was admitted to the facility's locked dementia unit with a diagnosis of dementia with agitation, had a BIMS score of five, indicating severe cognitive impairment. During two separate hospitalizations for medical issues, the facility listed the resident as the responsible party for receiving the bed-hold policy notices, despite the resident's son being listed as the emergency contact. This oversight resulted in the family representative not being informed of the facility's bed-hold policy during the resident's hospitalizations.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care plans. For one resident, the clinical record inaccurately documented the resident as edentulous, despite the presence of broken teeth. Interviews with staff and the resident confirmed the resident had teeth in disrepair and did not use dentures, contradicting the MDS assessment. Another resident's admission MDS assessment indicated severe cognitive impairment, and a wander guard was ordered. However, the quarterly MDS inaccurately documented the absence of a wander guard, despite staff confirming its presence. These discrepancies were confirmed during interviews with facility staff, highlighting a failure in maintaining accurate resident assessments.
Failure to Complete PASARR Screenings for Residents
Penalty
Summary
The facility failed to ensure that a referral for a PASARR screening was completed for three residents, leading to a deficiency. Resident R14 had a Level I PASARR completed in May 2021, but after being admitted with diagnoses including major depressive disorder and delusional disorder, and later diagnosed with dementia and violent behavior, a Level II PASARR was not completed. This was confirmed by the Social Work Director during an interview. Resident R37 was admitted in November 2018 and had a Level I PASARR indicating mental illness, but a Level II was not deemed necessary at the time. However, with new diagnoses of mood disorder and dementia in May 2023, a Level II PASARR was still not completed until July 2024, as confirmed by the Nursing Home Administrator. Resident R98 had a Level I PASARR completed at the hospital in December 2020, indicating no need for a Level II. After being admitted with cerebral infarction and altered mental status, new diagnoses of dementia with psychotic disturbance and violent behavior were added in 2023. Despite multiple psychiatry visits, a Level II PASARR was not submitted, which was confirmed by the Social Work Director. The facility's lack of a psych nurse practitioner with a definitive schedule contributed to the oversight, resulting in missed screenings for some residents.
Failure to Assist Resident with Mobility
Penalty
Summary
The facility failed to ensure that a resident, identified as R128, was provided with mobility assistance from bed to chair as per the physician's order. R128 was admitted with diagnoses including cerebral infarction and hemiplegia affecting the nondominant left side. The resident's clinical record indicated a physician's order for R128 to be out of bed for a minimum of two hours every day, with nursing staff required to document and notify the family of any refusals during the day shift. Despite this order, observations on multiple occasions revealed that R128 remained in bed and did not receive the necessary assistance to get out of bed. Interviews with the resident and staff confirmed that R128 did not get out of bed on a specific day, and there was no documentation of any refusal by the resident to do so. A CNA admitted that they did not ask R128 if he wanted to get up, and an LPN stated that refusals should be documented in the electronic notes. However, there was no facility documentation of any refusals by R128 on the day in question. This lack of action and documentation led to the deficiency being identified during the survey.
Failure to Manage Warfarin Dosing
Penalty
Summary
The facility failed to manage a resident's warfarin dosing in accordance with professional standards of practice, leading to subtherapeutic INR levels. The resident, who was admitted with conditions including atrial fibrillation, deep vein thrombosis, and factor V Leiden mutation, was prescribed warfarin with a therapeutic goal INR range of 2.0 to 3.0. Despite adjustments to the warfarin dosage, the resident's INR levels consistently remained below the therapeutic range, indicating inadequate anticoagulation management. Throughout the resident's stay, multiple INR tests showed results below the desired therapeutic range, with no evidence of appropriate interventions to address these subtherapeutic levels. The facility's medical staff made incremental increases to the warfarin dosage, but these adjustments did not align with professional guidelines for achieving therapeutic INR levels. The resident was hospitalized due to shortness of breath and was treated with Lovenox, a heparin injection, to reach the desired anticoagulation goal, highlighting the facility's failure to manage the resident's anticoagulation therapy effectively. Interviews with facility staff, including a nurse practitioner and a medical doctor, confirmed the ongoing issue with achieving the resident's INR goal. Despite recognizing that the timeframe to reach the therapeutic goal was excessively long, the facility did not provide evidence of successful anticoagulation management by the time of the survey team's exit. This deficiency in managing the resident's warfarin therapy was discussed with facility leadership during the exit conference.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, R47 and R121, as per professional standards. R47, who was admitted with a traumatic brain injury and tracheostomy status, had a physician's order for an emergency trach supply list to be kept at the bedside. However, there was a lack of evidence in the electronic medical record (EMR) regarding the current tracheostomy size and brand. Interviews with staff revealed uncertainty about R47's trach size, and it was confirmed that the facility did not have the proper equipment to accommodate the required trach size. Observations showed discrepancies between the trach sizes available at the bedside and the physician's order, indicating a failure to maintain accurate and accessible records for emergency tracheostomy care. For R121, who was admitted with acute respiratory failure with hypoxia, there was a physician's order for continuous oxygen via nasal cannula, with specific instructions for changing and labeling the oxygen tubing. During an observation, it was noted that the oxygen tubing was not labeled with the date and initials, as required. This was confirmed by an LPN, indicating a failure to adhere to the prescribed protocol for oxygen equipment management. These deficiencies highlight lapses in maintaining accurate records and ensuring the availability of appropriate respiratory care equipment and procedures.
Deficiency in Tracheostomy Order Management
Penalty
Summary
The facility failed to ensure that a resident's physician's orders included the necessary details for respiratory care, specifically regarding tracheostomy management. The resident, who was admitted to the facility in 2016, had a physician's order from 2022 for an emergency tracheostomy supply list, which included items such as a trach of the same size, a smaller trach, an Ambu bag, and other necessary supplies. However, a review conducted in 2024 revealed that the physician's orders lacked information on the current tracheostomy size and brand. An interview with an LPN Unit Manager confirmed that the electronic medical record did not indicate the resident's trach size and type. Further, a nurse practitioner confirmed that the emergency order instructions were not accurate for the resident's plan of care. These findings were discussed with the nursing home administrator, director of nursing, quality assurance/infection preventionist, corporate RN, and assistant director of nursing during the exit conference.
Inadequate Tracheostomy Care Competency
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skills to provide care for a resident with a tracheostomy. The resident, admitted with a traumatic brain injury and tracheostomy status, required tracheostomy care as indicated in an annual MDS. Interviews with nursing staff revealed a lack of knowledge and preparedness in handling tracheostomy emergencies. One RN was unsure of the trach size, and an agency LPN admitted to not knowing the emergency procedures, stating they would call a supervisor for help. Additionally, the facility lacked evidence of verifying competencies for all agency nurses and staff regarding emergency tracheostomy procedures, as noted in the review of competency checklists by the Staff Educator RN.
Failure to Provide Medically Related Social Services to Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide medically related social services to a resident, identified as R146, who was cognitively impaired and lacked a legal decision maker. Upon admission, R146 signed the facility's Admission Agreement despite having a severe cognitive deficit, as indicated by a BIMS score of 3. The facility did not identify a responsible party for R146, nor did they initiate a referral for a capacity determination in a timely manner. This oversight led to R146 being unable to make informed decisions about her care and financial matters. Throughout her stay, R146 was involved in several incidents where she was signed out of the facility by unrelated persons without proper authorization. The facility did not verify the authorization of these individuals, which further compromised R146's safety and well-being. Additionally, the facility failed to inform R146's family about significant changes in her Medicare coverage and did not offer them the opportunity to appeal the decision. The facility's lack of a policy or procedure for residents deemed not to have capacity contributed to the ongoing issues. Despite being aware of R146's cognitive impairment, the facility did not take appropriate steps to ensure her protection and support. This included failing to report potential financial exploitation to Adult Protective Services and not updating R146's face sheet to reflect her lack of capacity and need for a legal guardian.
Inaccurate Documentation of Resident's Out-of-Bed Status
Penalty
Summary
The facility failed to ensure accurate documentation in the clinical record for one resident, identified as R128, out of a sample of thirty-three residents. R128 was admitted to the facility on August 11, 2023, and had a physician's order dated April 23, 2024, requiring the resident to be out of bed for a minimum of two hours every day, with nursing staff documenting and notifying the family of any refusals during the day shift. Despite this order, observations on July 10 and July 11, 2024, noted that R128 remained in bed, and during an interview on July 12, 2024, R128 confirmed not being out of bed on July 11, 2024. The treatment administration record inaccurately indicated that the task was completed, as confirmed by LPN E8, who stated that the checkmark meant the resident was out of bed. Further interviews revealed that CNA E25 confirmed R128 was not out of bed on July 11, 2024, and they did not offer assistance to get the resident out of bed. LPN E26 mentioned the requirement to document refusals in the electronic notes, yet there was no documentation of any refusals by R128 on that day. The facility inaccurately documented that R128 was out of bed, despite evidence to the contrary, indicating a failure to maintain accurate clinical records in accordance with professional standards.
Failure to Update Medication Regimen Review Policy
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) program failed to address previously cited deficiencies related to the Medication Regimen Review (MRR) policy. A review of the facility's undated MRR policy revealed a lack of specified time frames for pharmacist responses, both urgent and non-urgent medication recommendations, and facility responses to these recommendations. This deficiency was previously cited during the facility's annual survey on 7/14/23. An interview with the Nursing Home Administrator (NHA) confirmed that the MRR policy provided was current, yet it had not been updated as per the Plan of Correction dated 9/6/23, which indicated that the facility would revise and update the policy. These findings were discussed with the NHA, Director of Nursing (DON), Quality Assurance/Infection Preventionist (QA/IP), Corporate Registered Nurse (RN), and Assistant Director of Nursing (ADON) during the exit conference.
Failure to Properly Restrain Resident During Transport
Penalty
Summary
The facility failed to ensure a safe environment for a resident, identified as R15, during transportation in a facility van, leading to an accident. R15, who has a history of hemiplegia and hemiparesis affecting the left side, was being transported in a wheelchair when he fell due to improper restraining. The facility's Driver/Operator Instruction Guide specifies the use of both lap and shoulder belts for securing passengers, but the van driver, E13, did not recall being trained on the use of the shoulder belt and only secured the lap belt. During the transport, R15 fell out of the wheelchair when the van took a sharp turn, resulting in a laceration to his forehead and requiring hospital treatment. Interviews and observations revealed that the lap belt was not properly secured, as confirmed by the EMT who found R15 without any belt upon arrival. The driver, E13, admitted to not using the shoulder belt, which she believed was ineffective. The incident was reviewed with facility leadership, including the Nursing Home Administrator and Director of Nursing, highlighting the failure to adhere to safety protocols for resident transportation, which directly led to the resident's injury.
Inaccurate Controlled Drug Count Records
Penalty
Summary
The facility failed to maintain accurate and complete Controlled Drug Count Records for the month of May 2024, as required by accepted professional standards and practices. The deficiencies were identified through a review of records and interviews with facility staff. Specific instances of non-compliance included missing evidence of narcotic counts being completed during various shifts, such as the 3:00 PM - 11:00 PM shift on May 2, 2024, and the 11:00 PM - 7:00 AM shift on May 3, 2024. Additionally, there were discrepancies in the records, such as scribbled-out entries and numbers that were difficult to decipher, indicating a lack of proper reconciliation of controlled drugs between shifts. Further issues were noted on multiple dates, including incomplete categories for narcotic counts, such as 'Completed/Disposed', 'Received from Pharmacy', and '# Items in Drawer'. For example, on May 8, 2024, and May 9, 2024, these categories were not completed for the 11:00 PM - 7:00 AM shift. On May 11, 2024, there was a discrepancy in the number of items in the drawer, and on May 13, 2024, an entry was overwritten, making it difficult to decipher. These findings were confirmed in interviews with the Nursing Home Administrator (NHA) and the Director of Nursing (DON), who acknowledged the failure to accurately reconcile the transfer of controlled drugs from one shift to another.
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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