Pike Creek Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, Delaware.
- Location
- 5651 Limestone Road, Wilmington, Delaware 19808
- CMS Provider Number
- 085033
- Inspections on file
- 24
- Latest survey
- August 13, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Pike Creek Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that residents were served meals without cups or glasses, requiring them to drink directly from plastic or paper containers, and staff frequently entered resident rooms without asking permission. One cognitively intact resident expressed discomfort with the lack of proper drinkware, and multiple staff members, including LPNs, CNAs, and housekeeping aides, were observed entering rooms without seeking consent, contrary to facility expectations.
Two residents did not have complete, person-centered care plans addressing all their medical needs. One resident with a gastrostomy lacked care plan approaches for tube blockage and dislodgment, while another with chronic pain and opioid use did not have non-pharmacological pain interventions included. Facility leadership confirmed these omissions during interviews.
Two residents did not receive care according to physician orders and professional standards. One resident with a surgical wound did not have a required vascular surgery follow-up appointment scheduled despite multiple recommendations, resulting in hospital transfer for worsening symptoms. Another resident on hospice did not have a hospice plan of care available or integrated into the facility’s care plan, and staff could not access up-to-date hospice interventions.
For eight days, the facility did not post daily nurse staffing information that included the resident census and total hours worked by licensed and unlicensed nursing staff per shift. This deficiency was confirmed through observation, record review, and interviews with facility leadership.
The facility failed to ensure that 29 licensed nurses had the necessary competencies, resulting in significant medication errors. An RN administered incorrect medications to a resident, leading to ICU admission, and an LPN made a similar error. The facility lacked evidence of competency validation for these nurses and others, indicating systemic issues in maintaining nursing staff competencies.
The facility failed to prevent significant medication errors, including administering incorrect medications to residents and not timing insulin administration properly. One resident was hospitalized in critical condition after receiving another's medications, while another received their roommate's medications due to a nurse's distraction. Additionally, two residents received insulin well before their meals, risking blood glucose fluctuations.
The facility failed to create comprehensive care plans for residents, particularly in addressing bladder and bowel continence and a hand contracture. Residents reported inadequate assistance with toileting, and assessments were not conducted to promote continence. Additionally, a resident's hand contracture was not addressed with a care plan, despite therapy recommendations. These issues were acknowledged by facility leadership.
The facility failed to conduct bowel and bladder assessments for five residents, resulting in the lack of individualized care plans to maintain continence. Residents were not offered toileting programs despite being cognitively intact and capable of using the toilet. Clinical records showed numerous incontinence episodes without proper assessments, and interviews confirmed the absence of personalized care plans.
The facility failed to consider resident meal preferences, as observed with two residents whose dining tickets lacked meal descriptions and preferences. Both residents expressed frustration over not receiving meal menus for months, preventing them from selecting their meals. The Dietary Services Director and Supervisor acknowledged the issue, citing ongoing updates in the computer system and the absence of a staff member responsible for menu distribution as contributing factors.
The facility failed to serve meals at appetizing temperatures, affecting several residents. One resident's lunch tray was left unattended for over an hour, resulting in cold food. Another resident did not receive sugar packets with their breakfast, which they preferred. Multiple residents reported consistently receiving cold meals, indicating a pattern of inadequate meal temperature maintenance.
The facility failed to label and date food items in nourishment refrigerators across three units, as required by their policy. Observations revealed unlabeled and undated food items in the first floor left wing, first floor right wing, and second floor unit refrigerators, confirmed by staff members including an RN, LPNs, and UMs. These findings were reviewed with the NHA, DON, ADON, VPO, and a State of DE Ombudsman.
The facility did not ensure that two agency nursing staff members, an RN and an LPN, completed the required QAPI training. The absence of training records for these staff members was confirmed by the Staff Educator and discussed with the Nursing Home Administrator and other key personnel.
The facility failed to ensure that two nursing staff members completed the required Compliance and Ethics Program training. An Agency RN and an Agency LPN, who began their assignments earlier in the year, did not have evidence of this training in their records. This was confirmed by the Staff Educator and discussed with the facility's leadership.
The facility failed to provide required Behavioral Health training to five nursing staff members, including RNs and LPNs, as confirmed by the Staff Educator. The deficiency was identified through a review of training records and interviews, and discussed with the NHA, DON, and VPO.
The facility did not ensure that all direct care staff received required training on effective communication, including the use of auxiliary aids and alternative communication methods for residents with limited English proficiency or communication impairments. The staff development coordinator confirmed that this training was not included in orientation or annual education, and there was no evidence it had been provided previously.
A resident with severe cognitive impairment and requiring total assistance was observed multiple times with an uncovered urinary collection bag on the floor, visible from the door. The facility failed to adhere to the care plan, which included maintaining a catheter privacy bag, compromising the resident's dignity.
The facility failed to report alleged abuse involving two residents within the required timeframe. In one case, a resident's abuse allegation was delayed due to a DON not reviewing a statement promptly. In another case, a resident reported sexual abuse to a therapist who did not report it immediately, believing it had already been reported. The facility reported the incident to the state agency more than 24 hours later.
The facility failed to review and revise care plans for two residents, leading to deficiencies in their care. One resident's care plan did not include the use of a urinal, despite an incident related to its use. Another resident's care plan for Passive Range of Motion was canceled by the electronic health record system and not updated upon readmission, resulting in a lapse in necessary care.
A resident with multiple sclerosis did not receive the necessary treatment to prevent further contractures in their left hand due to the facility's failure to consistently apply a prescribed palm guard. Despite the care plan's requirement for the palm guard to be worn at all times, observations and interviews revealed it was often not applied, leading to a deficiency in care.
Three residents experienced falls due to inadequate supervision and failure to use assistive devices as per care plans. One resident was manually transferred without a hoyer lift, another fell from bed due to lack of support, and a third fell from a wheelchair without footrests during transport.
A facility failed to provide safe and sanitary nephrostomy catheter care for a resident, resulting in a urinary tract infection. The resident, admitted with a urinary tract infection and a nephrostomy tube, had no documented urology consult despite hospital discharge instructions. Observations showed the urinary collection bag was undated and improperly placed, and the catheter container was found on the floor. These issues were confirmed by staff, and the resident was later treated for a UTI.
A resident with heart disease, high blood pressure, asthma, and hypoxemia did not receive oxygen therapy as ordered. Observations showed the oxygen tubing on the floor, indicating non-compliance with the prescribed treatment. This was confirmed by an LPN and reviewed with facility leadership and a state ombudsman.
A resident who underwent a recent amputation was admitted to the facility with a prescription for oxycodone to manage severe pain. However, the facility failed to administer the medication until eight hours after admission, resulting in the resident experiencing significant pain. The facility's records lacked documentation of pain assessments and communication with a physician, and staff interviews revealed confusion about medication availability and administration.
The facility did not complete annual performance reviews for two CNAs, E25 and E26, as required. This deficiency was confirmed by HR and discussed with the DON, ADON, NHA, VPO, and a State Ombudsman.
A facility failed to act on a pharmacy medication review recommendation for a resident assessed as a high fall risk. The facility's policy requires a monthly drug regimen review by a pharmacist and a physician's acknowledgment of any irregularities. Although the physician signed the review, there was no documentation of acknowledgment of the pharmacist's recommendation regarding medications causing dizziness and drowsiness. This deficiency was confirmed by the DON and discussed with facility leadership and a State Ombudsman.
A resident with cerebral palsy and bipolar disorder, who was cognitively intact, reported mouth pain and had chipped and broken teeth. Despite these issues, there was no evidence of a dental consult in the resident's records. The ADON acknowledged the oversight and stated the resident would be added to the dental list.
A resident with a documented allergy to aspartame was served a breakfast tray containing aspartame sweetener packets. This oversight was confirmed by a CNA and reviewed with facility leadership and a State Ombudsman.
A significant medication error occurred when a resident was given another resident's medications by an RN, leading to the resident's hospitalization. The facility did not conduct a quality assurance activity to address this error, and there was no evidence of the RN's competency in medication administration. This deficiency was confirmed by the staff educator and discussed with the nursing home administrator.
The facility failed to provide evidence that the Pneumococcal and influenza vaccines were offered or declined for two residents. Despite policies requiring documentation of vaccine administration or declination, records for both residents lacked this evidence. The ADON confirmed the absence of documentation during an interview.
A facility failed to document whether a resident consented to or declined the COVID-19 vaccine. Despite receiving education on the vaccine, the resident's immunization record lacked evidence of vaccination or declination. This was confirmed by the ADON and ICP during an interview.
The facility failed to provide required annual training on abuse, neglect, exploitation, and dementia care for several employees. Specifically, three employees lacked documentation of training on abuse and dementia care, while another employee lacked dementia training. These deficiencies were confirmed through interviews and record reviews with facility staff and a State Ombudsman.
A resident experienced a fall, and the facility did not notify the resident's POA as required. The POA learned of the incident directly from the resident, and staff interviews confirmed uncertainty about whether proper notification occurred. Documentation lacked evidence that the POA was informed of the fall.
A resident with COPD, asthma, and respiratory failure repeatedly refused prescribed inhalers over several days, but neither the physician nor the resident's representative were notified as required. Nursing staff interviews confirmed that the refusals were not communicated.
Two residents' grievances were not resolved promptly as required by facility policy. One resident's family waited eight months for reimbursement after dentures went missing, despite repeated follow-up. Another resident and family did not receive clear communication or documentation regarding a fall incident, and the concern form was incomplete and unsigned by the NHA.
A resident with cerebral palsy and bipolar disorder, who was cognitively intact, was verbally and emotionally abused by a staff member who repeatedly accused the resident of theft after taking leftover chips from a staff party, despite the resident's explanation that the chips were available. The incident was witnessed by others and substantiated by facility investigation.
Two dependent residents did not receive required toileting and hygiene care during a day shift, resulting in both being found with soiled clothing and bedding, and with moisture-associated skin damage. Documentation of care and meal intake was also missing for both residents, and staff interviews confirmed that care was not provided as required.
A resident at very high risk for pressure ulcers did not consistently receive prescribed interventions such as an adaptive pillow for ear protection and a foot cradle to prevent pressure from linens. Observations showed these devices were often missing, and the resident's feet were frequently covered despite orders to keep them uncovered. Staff interviews confirmed inconsistent implementation of the care plan, contributing to ongoing issues with pressure ulcer management.
Surveyors found that one medication cart contained several opened bottles of oral liquid and powdered medications without open date labels, contrary to facility policy requiring dating upon opening. An LPN confirmed the findings, which were later reviewed with the NHA and DON.
A resident with left-sided paralysis, weakness from a stroke, and anxiety experienced three falls within twelve hours. Facility nurses completed post-fall investigation reports that inaccurately documented the resident's medication regimen and failed to include relevant diagnoses such as hemiplegia and weakness, resulting in incomplete and inaccurate medical records.
Three CNAs did not complete the required twelve hours of annual in-service training, with two having no documented training hours and one having less than the required amount. This was confirmed through staff records and interviews with HR and nursing leadership.
Failure to Promote Resident Dignity During Meal Service and Room Entry
Penalty
Summary
The facility failed to promote resident dignity in two key areas: meal service and staff entry into resident rooms. Observations revealed that residents, including one who was cognitively intact and had chronic respiratory failure and polyneuropathy, were served meals with only plastic, aluminum-sealed juice containers and paper milk cartons, without any cups or glasses provided. This practice was confirmed by the Director of Dietary, who stated that residents are not given cups or glasses with meals. One resident expressed dissatisfaction with this arrangement, stating a preference for a cup and discomfort with drinking from containers that others touch. Additional observations confirmed that meal trays throughout the unit lacked appropriate drinkware. Surveyors also observed multiple instances where staff, including LPNs, CNAs, housekeeping aides, and a contracted nurse practitioner, entered resident rooms without asking permission, despite sometimes knocking or announcing their presence. In several cases, staff entered rooms while residents were present, and in one instance, a staff member entered without knocking. During an interview, the Director of Nursing confirmed that the expectation is for staff to knock and ask permission before entering resident rooms. These actions were reviewed with facility leadership and management representatives during the exit conference.
Failure to Develop Comprehensive Care Plans for Residents with Complex Medical Needs
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for two residents with specific medical needs. One resident, admitted with a history of stroke, dysphagia, and a gastrostomy, had a care plan that did not include approaches for managing potential complications such as gastrostomy tube blockage and dislodgment. This omission was confirmed by the Assistant Director of Nursing upon review. Another resident, admitted with lupus and chronic pain, had care plans addressing pain and opioid use but lacked evidence of non-pharmacological interventions for pain management. These deficiencies were acknowledged by facility leadership during interviews and the exit conference.
Failure to Follow Physician Orders and Coordinate Hospice Care
Penalty
Summary
Two residents did not receive care and services in accordance with professional standards, their care plans, and physician orders. One resident was admitted with an infection of a left lower extremity amputation stump and had discharge orders to follow up with vascular surgery within 2–7 days. Despite wound care progress notes on multiple occasions recommending vascular surgery follow-up due to worsening wound condition, there was no documentation that the appointment was scheduled. The unit clerk was tasked with scheduling the appointment, but as of the date the resident was transferred to the hospital for increased redness and changes at the surgical site, the appointment had not been made. Another resident, admitted with chronic obstructive pulmonary disease and chronic congestive heart failure, was placed on hospice services. The facility failed to ensure the hospice plan of care was available and integrated into the resident’s comprehensive care plan. Staff interviews revealed that the hospice binder, which should have contained the hospice plan of care, was empty and not accessible at the nurse’s station. The facility-generated care plan did not incorporate the hospice plan, and there was no evidence of collaboration with hospice staff to address the resident’s end-of-life needs and interventions. The DON confirmed that the hospice plan of care was expected to be current and available, but this was not the case.
Failure to Post Required Daily Nurse Staffing Information
Penalty
Summary
For eight consecutive days during the survey period, the facility failed to post required daily nurse staffing information. Specifically, the postings did not include the resident census or the total number of hours worked by both licensed and unlicensed nursing staff per shift, as required. This deficiency was identified through observation and review of the facility's daily nurse staffing postings, which consistently lacked the necessary details. The issue was confirmed during interviews with facility leadership, including the Nursing Home Administrator, and was discussed during the exit conference with additional facility and management representatives. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Nursing Competency Deficiencies Lead to Medication Errors
Penalty
Summary
The facility failed to ensure that 29 out of 29 licensed nurses had the necessary competencies and skills to care for the residents' needs, leading to significant medication errors. On one occasion, an RN administered another resident's medications to a resident, resulting in a serious adverse outcome that required the resident to be admitted to the ICU for treatment and monitoring. The facility did not validate the RN's competency in medication administration during orientation and allowed the RN to continue administering medications for over two weeks after the incident without evidence of competency validation. Another incident involved an LPN who administered medications prescribed for one resident to another. The facility lacked evidence of the LPN's competency and skill set validation for medication administration during her orientation. Additionally, the facility's staff educator confirmed that the skills validation records were not being returned timely, and the LPN's record was incomplete and improperly signed off by an agency RN without proper documentation of the skills reviewed and validated. The facility was unable to provide the surveyor with the most recent skills validation records for several scheduled nurses, indicating a systemic issue in ensuring nursing staff competencies. The facility's failure to complete the required nursing skills validation checklist for all reviewed nursing staff further highlights the deficiency in maintaining a system to ensure that all licensed nurses possess the necessary competencies to meet the current residents' needs.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving incorrect medication administration. One resident, admitted for short-term rehabilitation with complex medical conditions, was mistakenly given another resident's medications, including multiple blood pressure and diabetic medications. This error led to the resident being sent to the hospital in critical condition, requiring intensive care for hypoglycemia and hypotension. The error was attributed to the nurse's failure to properly identify the resident before administering the medication. Another incident involved a resident receiving medications intended for their roommate, including Tramadol, Ambien, and Alprazolam. The nurse involved admitted to being distracted and not following proper identification procedures, leading to the administration of the wrong medications. The resident, who had cognitive impairment, was monitored for adverse effects but remained in the facility without immediate negative outcomes. Additionally, the facility failed to administer insulin to two residents within the appropriate time frame relative to their meals. Both residents received their insulin doses hours before their meals, contrary to the prescribed guidelines for fast-acting insulin administration. This delay in meal service after insulin administration posed a risk of blood glucose fluctuations, which was not adequately addressed by the facility.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for six residents, focusing on bladder and bowel continence and a specific case of a hand contracture. For residents with bladder and bowel issues, the facility did not conduct proper assessments or create personalized care plans to promote continence. For instance, one resident was admitted with heart disease and high blood pressure, initially assessed as continent, but later documented as occasionally incontinent without a care plan to address this change. Another resident with a history of urinary tract infection and kidney stones was occasionally incontinent but lacked a personalized toileting care plan. Several residents expressed dissatisfaction with the care provided, indicating a lack of assistance with toileting. One resident, admitted with a knee fracture and high blood pressure, reported never being taken to the toilet and having to wait long periods for assistance. Another resident, with muscle weakness and urinary retention, attempted to use a urinal but was not assessed for a toileting program, resulting in frequent incontinence episodes. The facility's failure to conduct a 3-day voiding diary on admission further highlights the lack of personalized care planning. Additionally, the facility did not address a resident's right hand contracture with a care plan, despite recommendations from occupational therapy to use a palm guard for comfort. The Director of Nursing acknowledged the absence of a care plan for this condition. These deficiencies were discussed with facility leadership and a state ombudsman, indicating a systemic issue in care planning and implementation.
Failure to Conduct Bowel and Bladder Assessments
Penalty
Summary
The facility failed to conduct bowel and bladder assessments for five residents, which led to the absence of individualized care plans to restore and maintain continence. Resident R90 was admitted with diagnoses including heart disease and high blood pressure, and initially assessed as continent. However, the care plan inaccurately documented incontinence, and no personalized toileting program was offered. Interviews revealed that R90 was not educated on a toileting program, and clinical records showed numerous episodes of incontinence without evidence of a bowel and bladder assessment. Resident R111, admitted with urinary tract infection and kidney issues, was documented as occasionally incontinent but was not provided with a personalized toileting care plan. Interviews indicated that R111 was not offered a toileting program, and clinical records showed multiple episodes of incontinence without a proper assessment. Similarly, Resident R118, with high blood pressure and diabetes, was labeled as frequently incontinent without an assessment to support this determination. Despite being cognitively intact, R118 was not offered assistance to use the toilet, leading to numerous incontinence episodes. Residents R165 and R170 also lacked individualized toileting care plans. R165, admitted with a knee fracture, was documented as incontinent without a proper assessment, despite being able to ambulate with supervision. Interviews revealed dissatisfaction with the care provided, and clinical records showed significant incontinence episodes. R170, admitted with muscle weakness and urinary issues, was frequently incontinent, and no evidence of a voiding diary or toileting plan was found. Interviews confirmed the absence of a toileting program, and clinical records documented numerous incontinence episodes.
Failure to Provide Resident Meal Preferences
Penalty
Summary
The facility failed to provide food to residents while considering their preferences, as evidenced by the lack of meal descriptions and menu selections for residents R119 and R126. During observations, it was noted that the dining tickets for both residents were missing crucial information, such as tray notes, instructions, dislikes, and meal contents. Both residents expressed frustration during interviews, stating that they had not received meal menus for several months, preventing them from selecting their meal preferences and leaving them unaware of what food they would be served. The Dietary Services Director and Dietary Supervisor acknowledged the issue, explaining that the resident meal tickets were blank due to ongoing updates in the computer system for diet, tray notes, instructions, and dislikes. They mentioned that the menu selection feature had been turned off temporarily until the updates were completed. Additionally, the staff member responsible for presenting and collecting menus had recently returned to work after an absence, contributing to the lapse in menu selection. The facility's dining services lacked a process for involving residents in their menu selections, leading to the deficiency.
Failure to Serve Meals at Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at appetizing temperatures and was palatable for several residents. During a dining observation, a resident's lunch tray was delivered but not attended to for over an hour, resulting in cold food and melted ice cream. The food temperatures were significantly lower than the initial cooking temperatures recorded in the kitchen's log. Another resident did not receive sugar packets with their breakfast tray, which they preferred for their oatmeal and coffee, and the coffee cart on their floor also lacked sugar packets. Multiple residents reported consistently receiving cold meals. One resident, who was cognitively intact, repeatedly expressed dissatisfaction with the temperature of their meals over several days. Another resident, also cognitively intact, reported that their meals were cold almost all the time and expressed uncertainty about the food they were eating due to its temperature. These observations and resident statements indicate a pattern of the facility failing to maintain food at appetizing temperatures, affecting the residents' dining experience.
Failure to Label and Date Food Items in Refrigerators
Penalty
Summary
The facility failed to ensure that food items in the nourishment refrigerators across three units were labeled and dated, as required by their policy. The policy mandates that food and beverages brought in from outside sources that require refrigeration or freezing must be labeled with the patient's or resident's name and date. During observations, it was found that the first floor left wing unit refrigerator contained two unlabeled and undated food items, confirmed by an RN and UM. Similarly, the first floor right wing unit refrigerator had four unlabeled and undated food items, confirmed by an LPN and UM. Additionally, the second floor unit refrigerator contained two unlabeled and undated items, and the freezer had two more unlabeled and undated food items, confirmed by an LPN and UM. These findings were reviewed with the Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, Vice President of Operations, and a State of Delaware Ombudsman via telephone.
Failure to Complete QAPI Training for Agency Nursing Staff
Penalty
Summary
The facility failed to ensure that the required Quality Assurance and Performance Improvement (QAPI) training was completed for two out of five nursing staff reviewed. Specifically, agency staff members E57, an RN, and E58, an LPN, did not have records of QAPI training in their files. E57 began working at the facility on March 25, 2024, and E58 on July 16, 2024. On August 26, 2024, a review of the agency staff training records revealed the absence of evidence for their QAPI training. This finding was confirmed during an interview with E48, the Staff Educator, and subsequently discussed with E1, the Nursing Home Administrator, and later reviewed with E1, E2, the Director of Nursing, and E10, the Vice President of Operations.
Failure to Complete Compliance and Ethics Training for Nursing Staff
Penalty
Summary
The facility failed to ensure that the required training on the Compliance and Ethics Program was completed for two out of five nursing staff reviewed. Specifically, the training records for an Agency RN and an Agency LPN, who started their assignments on March 25, 2024, and July 16, 2024, respectively, lacked evidence of completion of the Compliance and Ethics Program training. This deficiency was confirmed during an interview with the Staff Educator, who acknowledged the absence of training records for these staff members. The findings were subsequently discussed with the Nursing Home Administrator, Director of Nursing, and Vice President of Operations.
Failure to Provide Behavioral Health Training to Nursing Staff
Penalty
Summary
The facility failed to ensure that the required Behavioral Health training was completed for five nursing staff members. The deficiency was identified through interviews and a review of facility documentation. Specifically, the training records for five staff members, including two Registered Nurses (RNs) and three Licensed Practical Nurses (LPNs), showed no evidence of completed Behavioral Health training. These staff members had been employed or assigned to the facility between March and July 2024. During an interview, the Staff Educator confirmed the absence of training records for these individuals. The findings were subsequently discussed with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Vice President of Operations (VPO).
Failure to Provide Mandatory Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to ensure that all direct care staff completed mandatory training on effective communication, as required by its own policy and procedure for LEP/Auxiliary Aid Services. The policy specified that the facility would provide appropriate auxiliary aids and services, including qualified sign language interpreters and aids for those with vision impairment or limited English proficiency, and that all employees and contract staff would receive mandatory ADA training. This training was to be included in new hire orientation and provided annually to all employees. During an interview, the staff development coordinator, who began working at the facility in April 2024, stated that communication training was not part of the current orientation or annual training for direct care staff. She also confirmed that there was no evidence the previous staff educator had provided this training. The surveyor and staff development coordinator reviewed that staff education should include alternative communication methods for residents who do not use English, such as translation services and communication boards. The findings were reviewed with facility leadership and a state ombudsman.
Failure to Ensure Privacy for Resident's Urinary Collection Bag
Penalty
Summary
The facility failed to maintain the privacy and dignity of a resident, identified as R422, by not ensuring that the urinary collection container was placed in a privacy bag. R422 was admitted to the facility with diagnoses including obstructive uropathy and bladder dysfunction and required total assistance from staff with all activities of daily living due to severe cognitive impairment, as indicated by a BIMS score of 00. The care plan for R422 included maintaining a catheter privacy bag. However, on multiple occasions on July 30, 2024, the resident was observed with an uncovered and undated urinary collection bag visibly placed on the floor beside the bed, which was confirmed by the Director of Nursing (DON). The clinical records lacked documentation of a privacy bag, indicating a failure to adhere to the care plan and maintain the resident's dignity.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report alleged abuse involving two residents within the required timeframe. In the first case, a resident's handwritten statement alleging abuse was collected by a social worker and handed to the Director of Nursing (DON) on August 30th. However, the DON did not review the statement until September 3rd, resulting in a delay in reporting the allegation to the state agency. The DON confirmed that the allegation was not reported within the mandated two-hour window. In the second case, a resident reported an incident of sexual abuse by a roommate to a physical therapist on August 6th. The therapist did not report the allegation immediately, believing it had already been reported. The facility eventually reported the incident to the state agency on August 7th, more than 24 hours after the resident initially disclosed the abuse. Interviews with staff confirmed that the therapist was not familiar with mandatory reporting requirements, contributing to the delay.
Failure to Review and Revise Care Plans for Residents
Penalty
Summary
The facility failed to adequately review and revise the care plans for two residents, leading to deficiencies in their care. For one resident, identified as R320, the care plan was not person-centered and did not include the use of a urinal, despite the resident's incident of sliding off the bed while reaching for a urinal. This oversight occurred after the resident was admitted with a primary diagnosis of a urinary tract infection and was care planned for incontinence of bladder and bowel. The care plan only included recording bowel movements and referring to occupational therapy as needed, without addressing the resident's specific needs related to urinal use. Another resident, identified as R31, experienced a lapse in their care plan regarding the Restorative Nursing Program for Passive Range of Motion (PROM) to bilateral lower extremities. The care plan intervention, which was initiated to address bilateral lower extremity contractures, was inadvertently canceled by the electronic health record system when the resident was sent to the hospital. Upon the resident's readmission, the care plan was not reviewed or updated, resulting in the omission of the necessary PROM intervention. This failure was acknowledged by the Director of Nursing and the Director of Rehabilitation, who confirmed that the intervention should have remained current in the resident's care plan.
Failure to Apply Palm Guard for Resident with Multiple Sclerosis
Penalty
Summary
The facility failed to ensure that a resident, identified as R105, received the necessary treatment and services to prevent further avoidable reduction of range of motion (ROM) and mobility. R105 was admitted with diagnoses including multiple sclerosis, chronic pain, and muscle weakness. The care plan for R105 included the use of a left hand palm guard to be worn at all times, except during skin assessments and hygiene. However, observations and interviews revealed that the palm guard was not consistently applied as required. R105 reported that the splint was not put on after morning care, and there was confusion about whether the nurse or aide was responsible for its application. Multiple observations confirmed that R105 was not wearing the palm guard during various activities and while in bed, with the device found in a wire basket instead. Interviews with staff, including the LPN-UM and the Rehab Director, acknowledged the oversight and the need for staff education regarding the application of the palm guard. The facility lacked evidence that the palm device was applied as recommended to prevent further contractures in R105's left hand. These findings were confirmed with the Director of Nursing, Assistant Director of Nursing, and other administrative staff, as well as a State Ombudsman.
Inadequate Supervision and Assistive Device Use Leads to Resident Falls
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistive devices for three residents, leading to incidents that could have been prevented. For one resident, R324, the facility did not follow the care plan which required the use of a hoyer lift with two staff members for transfers. Instead, the resident was manually transferred by a CNA, resulting in the resident feeling weak and being lowered to the ground to prevent a fall. This incident highlights a failure to adhere to the prescribed transfer method, which was crucial given the resident's condition, including a history of brain surgery and being bedbound. Another resident, R170, experienced a fall due to inadequate supervision during care. Despite being at high risk for falls and having left-sided weakness, the resident was left unsupported by a CNA who turned away to dispose of soiled linen. This lapse in supervision allowed the resident to roll off the bed, resulting in a skin tear and necessitating a hospital visit. The resident's care plan included fall risk interventions, but these were not effectively implemented during the incident. The third resident, R270, fell from a wheelchair during transport to dialysis because the footrests were not attached. This oversight occurred despite the resident's high fall risk and poor safety awareness. The absence of footrests allowed the resident's foot to contact the floor, causing the fall. The incident underscores a failure to ensure that necessary safety equipment was in place during assisted mobility, which was critical for the resident's safety given their fall risk history.
Failure in Nephrostomy Catheter Care Leads to UTI
Penalty
Summary
The facility failed to provide safe and sanitary nephrostomy catheter care for a resident, leading to a urinary tract infection. The resident was admitted with a urinary tract infection, acute pyelonephritis, and a right nephrostomy tube due to kidney stones. The hospital discharge records indicated a need for a follow-up urology consult, which was not documented in the resident's clinical records. Observations on multiple occasions revealed that the urinary collection bag was undated and consistently left on the left-hand side of the bed, and later on the floor, indicating a lack of proper catheter care. The resident's clinical records lacked evidence of a urology consult, and the urinary catheter collection container was observed on the floor on several occasions. These findings were confirmed with facility staff, including an LPN and the DON. Subsequently, a urine sample was obtained, and the resident was prescribed antibiotics for a urinary tract infection. The facility's failure to maintain sanitary conditions for the nephrostomy catheter contributed to the resident's urinary tract infection.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident, identified as R90, who was admitted with diagnoses including heart disease, high blood pressure, asthma, and hypoxemia. The resident's care plan required the administration of oxygen as ordered due to the risk of respiratory complications. On multiple occasions, surveyors observed that the oxygen tubing was on the floor instead of being used by the resident, indicating that the resident was not receiving the prescribed oxygen therapy. These observations were confirmed with a Licensed Practical Nurse (LPN) and later reviewed with the Nursing Home Administrator (NHA), Director of Nursing (DON), Assistant Director of Nursing (ADON), Vice President of Operations (VPO), and a State of Delaware Ombudsman via telephone.
Failure to Provide Timely Pain Management for Resident Post-Amputation
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R173, who was admitted following a recent amputation. Upon admission, the resident had a prescription for oxycodone to manage severe pain, but the facility did not administer any pain medication until approximately eight hours after admission. The resident's medical records indicated a lack of communication with a physician regarding the need for additional pain management interventions, despite the resident's complaints of significant pain. The facility's pain management policy required notifying a provider if pain was not relieved, but there was no evidence that this was done. The resident's Medication Administration Record (MAR) lacked documentation of pain medication administration and pain assessments, which were inconsistent with the resident's reported pain levels. Interviews with staff revealed confusion and a lack of clarity regarding the availability and administration of the prescribed pain medication. The resident reported experiencing severe pain, reaching a level of 10/10, and did not receive pain relief until the following morning. Staff interviews indicated that there was a delay in obtaining the necessary prescriptions and a lack of proper documentation and communication with the physician. The facility's failure to adhere to its pain management policy resulted in the resident experiencing unnecessary pain for an extended period.
Failure to Conduct Timely Performance Reviews for CNAs
Penalty
Summary
The facility failed to conduct performance reviews for two Certified Nursing Assistants (CNAs), identified as E25 and E26, within the required twelve-month period. E25, who was hired on March 20, 2007, and E26, hired on March 4, 2008, both lacked evidence of a performance evaluation for the past year. This deficiency was confirmed by E34 from Human Resources. The findings were further corroborated during discussions with the Director of Nursing (DON), Assistant Director of Nursing (ADON), Nursing Home Administrator (NHA), Vice President of Operations (VPO), and a State of Delaware Ombudsman.
Failure to Act on Pharmacy Medication Review Recommendation
Penalty
Summary
The facility failed to act on a pharmacy medication review recommendation for one resident, identified as R107, who was reviewed for unnecessary medications. According to the facility's Medication Regimen Review (MRR) policy, a licensed pharmacist is required to review each patient's drug regimen monthly, and the physician must review and sign the MRR, documenting any identified irregularities within 30 days. R107 was admitted to the facility and later assessed as a high fall risk. A pharmacy medication review conducted noted that the medications R107 was taking could cause dizziness and drowsiness, and recommended a fall assessment review. Although the medication review was signed by the physician, E15, there was no documentation that the pharmacist's recommendation was acknowledged or reviewed by E15. This deficiency was confirmed during an interview with the Director of Nursing (DON), E2, and discussed with the Nursing Home Administrator (NHA), Assistant Director of Nursing (ADON), Vice President of Operations (VPO), and a State Ombudsman.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for a resident, identified as R109, who was admitted with diagnoses including cerebral palsy and bipolar disorder. On July 8, 2024, R109's quarterly MDS assessment indicated a cognitively intact status with a BIMS score of 14 and documented complaints of mouth or facial pain, discomfort, or difficulty with chewing. Despite these complaints, there was no evidence of a dental consult in R109's clinical records. On July 29, 2024, R109 was observed with chipped and broken front teeth and expressed concern about the worsening condition of their teeth, although they did not recall being offered a dental consultation. The Assistant Director of Nursing (ADON) later stated that R109 would be added to the dental list, indicating a lapse in addressing the resident's dental needs in a timely manner.
Failure to Accommodate Resident's Aspartame Allergy
Penalty
Summary
The facility failed to provide food that accommodated a resident's allergies, specifically an allergy to aspartame. The resident was admitted to the facility on March 6, 2023, and their allergy list was updated on February 13, 2024, to include aspartame, an artificial sweetener. On August 1, 2024, during a random dining observation, it was noted that the resident's breakfast tray contained two aspartame sweetener packets, despite the meal ticket documenting the resident's aspartame allergy. This was confirmed by a CNA during an interview. The findings were later reviewed with the Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, Vice President of Operations, and a State of Delaware Ombudsman via telephone.
Failure to Implement Quality Assurance After Medication Error
Penalty
Summary
The facility failed to conduct a quality assurance and performance improvement activity in response to a significant medication error involving a resident, identified as R322. On 7/6/24, R322 was administered another resident's medications by a registered nurse, E43, which resulted in R322 being emergently transferred to the hospital and admitted to the Intensive Care Unit for treatment and monitoring. The facility's assessment, last updated in July 2024, indicated that all staff members should have a competency checklist completed upon hire, including medication and treatment administration. However, there was no evidence that E43 had completed a medication administration competency and skill set upon orientation. This deficiency was confirmed during an interview with the staff educator, E48, who had no evidence of E43's competency in this area. The issue was reviewed during an exit conference with the nursing home administrator, E1.
Failure to Document Vaccine Administration or Declination
Penalty
Summary
The facility failed to provide evidence that the Pneumococcal vaccine was offered or declined for one resident, identified as R21, out of five residents reviewed for immunizations. According to the facility's policy on pneumococcal vaccination, updated on 8/4/23, vaccination against pneumonia should be offered to patients, and if not provided, the reasoning should be documented in the medical record. R21 was admitted to the facility on 2/11/23, but a review of their clinical record on 8/5/24 revealed a lack of evidence of administration or declination of the pneumococcal vaccine. An email request was sent to the Assistant Director of Nursing (ADON) for evidence, but it could not be located. Similarly, the facility failed to provide evidence that the influenza vaccine was offered or declined for another resident, identified as R26. The facility's policy on influenza immunization, updated on 5/1/23, states that the influenza vaccine should be offered annually, and if not provided, the reasoning should be documented. R26 was admitted on 6/29/23 and received education on the influenza vaccine on 11/28/23. However, a review of their immunization record on 8/5/24 showed no evidence of administration or declination of the influenza vaccine. The ADON confirmed during an interview that the documentation for both residents' vaccinations could not be found.
Failure to Document COVID-19 Vaccine Consent or Declination
Penalty
Summary
The facility failed to provide evidence that a resident, identified as R26, had consented to or declined the COVID-19 vaccine. According to the facility's policy, updated on March 11, 2024, education on the COVID-19 vaccine should be provided, and attempts and refusals should be documented. R26 was admitted to the facility on June 29, 2023, and received education on the COVID-19 vaccine on November 28, 2023. However, a review conducted on August 5, 2024, revealed that R26's immunization record lacked evidence of any COVID-19 vaccination or declination. This was confirmed during an interview on August 6, 2024, with the Assistant Director of Nursing (ADON) and Infection Control Practitioner (ICP), who acknowledged the absence of documentation regarding R26's vaccination status.
Deficiency in Staff Training on Abuse and Dementia Care
Penalty
Summary
The facility failed to provide mandatory annual training on abuse, neglect, exploitation, and dementia care for three out of nine sampled employees. Specifically, employees E14, E27, and E28 did not have documented evidence of receiving training on abuse and dementia care, while E21 lacked documentation of dementia training. These deficiencies were confirmed during interviews and record reviews with the facility's HR representative, E34, and later corroborated with the Director of Nursing (DON), Assistant Director of Nursing (ADON), Nursing Home Administrator (NHA), Vice President of Operations (VPO), and a State of Delaware Ombudsman via telephone.
Failure to Notify POA of Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to inform a resident's representative/Power of Attorney (POA) about a fall experienced by the resident. The clinical record for the resident indicated that there was no evidence of notification to the POA following the incident. Although the assigned nurse was responsible for notifying both the physician and the family, interviews with facility staff revealed uncertainty about whether the family member was actually informed. The resident's POA reported learning about the fall directly from the resident, not from facility staff, and stated that the facility never contacted him regarding the incident. Documentation and interviews confirmed the lack of communication to the POA about the fall event.
Failure to Notify Physician and Representative of Repeated Medication Refusals
Penalty
Summary
A deficiency was identified when a resident with chronic obstructive pulmonary disease (COPD), asthma, and acute and chronic respiratory failure with hypoxia was admitted and prescribed daily Breo Ellipta and Spiriva inhalers. Review of the electronic medication administration records (eMAR) for July and August 2024 showed that the resident refused both medications on the majority of days. Despite these repeated refusals, there was no evidence that the resident's physician or resident representative were notified as required by the plan of care. Interviews with nursing staff confirmed a lack of awareness and notification regarding the medication refusals.
Failure to Resolve Resident Grievances in a Timely Manner
Penalty
Summary
The facility failed to resolve grievances in a timely manner for two residents. In the first case, a resident was admitted with both upper and lower dentures, but the dentures were reported missing the day after admission. The family was informed that the facility would reimburse the cost of replacement dentures, but despite submitting the bill, the family experienced an eight-month delay in receiving reimbursement. The facility's own policy required prompt action and resolution of concerns within 48 hours, but this was not followed. In the second case, a resident who had a history of multiple fractures from a motor vehicle collision experienced a fall while transferring from a wheelchair to bed. The resident and family requested information about the incident and a copy of the incident report. The concern form indicated that several staff were designated to address the issue, but it was unclear what specific actions were taken or communicated to the resident and family. Additionally, the concern form was not properly completed or signed by the NHA as required by facility policy, and it was not clear if the resident was informed about the proper procedure for lifting after a fall.
Failure to Protect Resident from Verbal and Emotional Abuse
Penalty
Summary
A resident with a history of cerebral palsy and bipolar disorder, who was cognitively intact at the time of the incident, was subjected to verbal and emotional abuse by a facility staff member. The staff member accused the resident of stealing chips that were left over from a staff party, despite the resident's explanation that he had been told the leftovers were available for residents. The staff member persisted in calling the resident a thief and took the chips away, causing the resident significant distress. The incident was witnessed by several staff members and other residents. The facility's investigation substantiated the resident's allegation of verbal and emotional abuse by the staff member. The deficiency occurred because the facility failed to protect the resident from this abuse.
Failure to Provide ADL Care and Hygiene for Dependent Residents
Penalty
Summary
Two residents who were dependent on staff for activities of daily living (ADLs), including toileting and personal hygiene, did not receive necessary care during a day shift. One resident, who was care planned for incontinence and required one-person assistance with toileting, was not provided with hygiene or toileting care from 7 AM to 3 PM. This resident was found in bed with soiled clothing and bedding, and reported to staff that care had not been provided despite using the call bell multiple times. The resident was noted to have redness in the peri-area and moisture-associated skin damage (MASD) on the sacrum. Another resident, admitted with a history of stroke and hemiplegia and also care planned for incontinence, did not receive documented care or meal intake during the same shift. This resident was found by the next shift's CNA to be incontinent, with wet clothing and bed linens, and had increased redness in an area of pre-existing MASD. The assigned CNA did not provide care during the shift, as confirmed by facility investigation and staff interviews. In both cases, there was a lack of documentation for care and meal intake during the day shift, and both residents were dependent on staff for their ADLs. The deficiencies were identified through observation, record review, and interviews with residents and staff, confirming that necessary services to maintain grooming and personal hygiene were not provided as required.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A deficiency was identified when a resident with a history of traumatic brain injury, convulsions, and muscle weakness, who was at very high risk for pressure ulcer development, did not consistently receive prescribed pressure ulcer prevention interventions. The resident's care plan included the use of an adaptive pillow to relieve pressure on the right ear and a foot cradle to prevent pressure from linens on the feet, as well as instructions to keep the feet uncovered. Despite these documented interventions and physician orders, multiple observations revealed that the adaptive pillow was frequently absent, the foot cradle was not in place, and the resident's feet were often covered with blankets. Staff interviews confirmed a lack of consistent implementation of these interventions, with some staff unaware of the specific orders or reporting ongoing issues with compliance. Additionally, wound assessments documented the presence and progression of pressure ulcers, including a stage 3 ulcer on the right ear and unstageable ulcers on the toes, with some wounds reopening during the survey period. Observations also noted red stains on the resident's bedding, indicating possible wound drainage or bleeding. The lack of adherence to the care plan and physician orders for pressure ulcer prevention and management contributed to the failure to promote healing and prevent new ulcers, as required by facility policy and standard care practices.
Failure to Properly Label Opened Medications in Medication Cart
Penalty
Summary
During a medication storage review on the second floor, surveyors observed that one out of three medication carts, specifically the Heritage II medication cart, contained four opened bottles of oral liquid medications and one opened bottle of powdered oral medication, all lacking open date labels. The facility's policy, last updated in August 2020, requires that containers or vials be dated when the original manufacturer's seal is broken. These findings were immediately confirmed by an LPN present during the review. The issue was subsequently discussed with the nursing home administrator and the director of nursing during the exit conference. No information regarding specific residents, their medical history, or condition at the time of the deficiency was provided in the report.
Inaccurate Medical Record Documentation Following Multiple Resident Falls
Penalty
Summary
A deficiency was identified when the facility failed to maintain accurate medical records for one resident with multiple diagnoses, including left-sided paralysis, weakness from a stroke, and anxiety. The resident was prescribed clonazepam for anxiety, a medication known to cause drowsiness and dizziness, and was identified as a fall risk due to a history of falls, impaired balance, poor coordination, and left-sided weakness. Over a twelve-hour period, the resident experienced three falls, each documented in the electronic medical record (Emr) with post-fall investigation reports completed by facility nurses. The post-fall investigation reports contained inaccuracies regarding the resident's medication and medical diagnoses. Specifically, the reports incorrectly stated that the resident was not taking antianxiety medication, despite an active order for clonazepam, and in one instance, incorrectly documented the use of a narcotic, which the resident was not taking. Additionally, the reports failed to note the resident's hemiplegia/hemiparesis and weakness under clinical considerations, omitting relevant clinical factors related to the falls. These documentation errors resulted in incomplete and inaccurate records regarding the circumstances and contributing factors of the resident's repeated falls.
Failure to Ensure Mandatory Annual In-Service Training for CNAs
Penalty
Summary
Three certified nursing assistants (CNAs) were found to be non-compliant with the mandatory twelve hours of annual in-service training required by the facility. Specifically, one CNA with a hire date of 9/1/22 and another with a hire date of 7/22/08 had zero hours of annual in-service training documented, while a third CNA with a hire date of 3/4/08 had only 11.25 hours completed. These findings were confirmed through review of staff training documentation and interviews with the facility's human resources representative, as well as the Director of Nursing (DON) and Assistant Director of Nursing (ADON). The facility lacked evidence that these employees completed the required annual in-service training.
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Multiple cognitively impaired residents with known behavioral issues, including wandering, agitation, and physical aggression, were not adequately protected from resident‑to‑resident abuse. In one case, a resident with dementia and PTSD was pushed to the floor by another resident who had a history of combative behavior, resulting in multiple fractures and facial lacerations after staff initially documented the event as an unwitnessed fall. In another case, two residents with dementia and psychotic features engaged in a physical altercation in a dayroom after one placed his hand on the other’s chest, leading to mutual punching. A separate incident occurred when a resident with dementia and behavioral disturbances entered another resident’s room, pulled at the bedcovers, yelled that the room was his house, and allegedly struck the other resident, who was later noted with puffiness around one eye. In all incidents, the involved residents had documented behavioral care plans and significant cognitive impairment, yet physical confrontations still occurred.
A resident with dementia, spinal stenosis, and total dependence for transfers, care-planned for Hoyer lift use with two-person assist, was being transferred from a shower bed to a Geri-chair when the Hoyer lift tipped sideways. Staff reported the lift’s legs had been widened and that one CNA manually pushed the feet apart instead of using the control, and straps may have been unevenly positioned. The resident was lowered to the floor while still in the sling and sustained a small skin tear to the elbow; imaging later showed no fractures. The DON stated that three CNAs were involved, including one on light duty who was not supposed to be using the lift, and that no mechanical defect was found with the lift.
The facility failed to thoroughly investigate several allegations of verbal and potential physical abuse involving four cognitively intact residents with conditions including hemiplegia, rheumatoid arthritis, type 2 DM, epilepsy, and heart disease. In each case, the facility’s investigations were limited, often including only the directly involved resident and omitting interviews with other potentially knowledgeable residents or staff. One resident reported a verbal altercation with a CNA after a fall to the floor, another reported being verbally abused by a roommate’s family member, a third reported a male CNA was too rough and upset while changing linens, and a fourth reported a staff member insulted her and refused brief care. Investigation files lacked broader resident and staff interviews, timely physical and psychosocial assessments, and review of the accused staff member’s employee record, contrary to the facility’s abuse policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
A resident with rectal cancer and intact cognition reported that an RN on night shift confronted him when he returned from smoking off campus, spoke to him loudly about his smoking, used profanity, and threatened to have staff refuse to buzz him back into the building. A CNA corroborated that the RN was upset about being called in to work and used curse words toward the resident, but did not report the incident at the time because the RN was the night supervisor. The resident reported the event to the Social Services Director the next day, yet the facility initially treated it as a grievance rather than abuse and delayed submitting a report to the State Survey Agency until weeks later, after determining it was a reportable abuse incident.
Two residents did not receive required ADL and hygiene care as care planned. One resident with dementia and osteoarthritis, dependent for toileting and personal hygiene, was not toileted during an evening shift, with CNA documentation showing no toileting and the oncoming CNA finding the resident’s clothing, linens, and mattress saturated with urine; the assigned CNA reported care resistance but did not notify an RN or LPN. Another resident with dementia and stroke, requiring assistance with dressing and personal hygiene, remained in bed in pajamas into the afternoon without having received morning care, despite CNA documentation indicating dressing was completed; the CNA later confirmed that care was only provided after being questioned by an RN supervisor following a family complaint.
A resident with left-sided weakness after a stroke, high fall risk, and total dependence for ADLs and bed mobility was being turned onto their side for peri care by an aide when they fell from the bed to the floor, sustaining head trauma and a scalp laceration while on blood thinners. The care plan required extensive to total assistance with two-person support for bed mobility, but the fall occurred during care without documentation of the required level of assistance, indicating the facility did not provide adequate supervision and assistance to prevent accidents as outlined in its own fall prevention practices.
A resident with significant upper extremity weakness and recent surgery was discharged home to a multi-story residence without confirmed DME delivery, home health services, or caregiver support. Although referrals for home health, skilled nursing, and DME were made and family attended a discharge care plan meeting, staff did not verify that services were active, did not set or confirm a start-of-care date with the agency, and did not confirm delivery of a hospital bed. The resident, who lived alone and could not manage fine motor tasks, arrived home without in-home assistance, reported difficulty with eating and self-care, and was later found by an HHA RN in unsafe conditions, unable to access food or medications, leading to emergency transport back to the hospital.
A resident with dementia, Parkinson’s disease, CHF, and a history of AKI had documented fluid goals and was identified as at risk for dehydration and malnutrition, yet daily intake records repeatedly showed fluid consumption well below the recommended amounts. Despite severely impaired cognition, poor oral intake, and documented changes in mentation, lethargy, falls, and restlessness, the facility did not consistently implement or document enhanced monitoring, assistive feeding measures, or timely provider consultation focused on hydration. The resident was hospitalized twice with AKI, dehydration, hypotension, and anemia, and staff interviews confirmed that while expectations existed to encourage fluids and notify providers when goals were not met, there was no clear evidence that these expectations were carried out for this resident.
A resident with cardiac conditions was discharged home with a documented post-discharge plan for home health aide, home health RN/LPN, and PT/OT, but the facility did not complete the home health referral before discharge. The resident went home with a family member and, according to a complaint, did not receive PT, OT, or a nursing wellness check for about a week. The SW later confirmed the referral for home health and therapy services was not requested until several days after discharge, and services did not begin until even later, despite therapy recommendations that are typically communicated to social services to arrange home care.
The facility failed to consistently revise care plans to reflect residents’ current needs and behaviors and did not ensure a cognitively intact resident was involved in ongoing care planning. One resident participated in an initial care conference but was not included in later care plan updates. Another resident with an order for a palm protector was frequently observed without it and often refused it, yet the care plan did not address refusals. Two cognitively impaired residents whose MDS assessments showed dependence for bathing had care plans that still listed only setup or one‑person assist. A cognitively impaired resident with combative behaviors and an incident of striking another resident had a behavior care plan that was not updated to include attempts to hit other residents or the risk of resident‑to‑resident altercations.
Failure to Prevent Resident‑to‑Resident Physical Abuse Among Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from resident‑to‑resident physical abuse. One resident with dementia, agitation, depression, anxiety, and PTSD, and a BIMS score indicating moderate cognitive impairment, was pushed to the floor by another resident after that resident entered his room and followed him into the hallway. Staff initially documented the event as an unwitnessed fall after hearing loud screaming and finding the resident on the floor with complaints of right shoulder and left wrist pain, active bleeding from facial lacerations, and clamminess. Subsequent review of surveillance footage showed that another resident walked into the victim’s room, then followed him out and pushed him, causing the fall that resulted in multiple fractures, including a closed left distal radius fracture, a closed, displaced comminuted right proximal humerus fracture, and a closed, displaced distal clavicle fracture. The resident who pushed him had dementia with mood disturbances, bipolar disorder with psychotic features, PTSD, insomnia, and depression, and a BIMS score indicating severe cognitive impairment. His care plan identified a behavior problem related to bipolar disorder and dementia, including wandering, refusal of care, and physical aggression toward staff and others, such as biting a CNA and swinging a walker at a CNA. The care plan directed staff to anticipate and meet his needs, divert him with alternative objects or activities, intervene to protect the rights and safety of others, and conduct safety checks. Despite these identified risks and interventions, he was able to enter another resident’s room and subsequently push that resident in the hallway, resulting in serious injury. Another incident involved two residents with significant cognitive impairment and behavioral symptoms, including delusions, physical behaviors toward others, agitation, and a tendency to invade others’ personal space. One resident, who was described as aggressive toward others, easily agitated, and prone to getting into others’ personal space, walked next to another resident sitting in a dayroom chair and placed his hand on that resident’s chest. The seated resident responded by punching him in the face with the back of his fist, and the first resident then punched back. Staff and psychiatric documentation noted this altercation and ongoing behavioral concerns such as combativeness with care, agitation, and wandering, but the record contained no additional progress notes describing the incident itself beyond the brief psychiatric follow‑up entry. A further incident occurred when a resident with anxiety, major depressive disorder, dementia with behavioral disturbances, agitation, and severe cognitive impairment entered another resident’s room on the memory care unit. The resident in the room, who had depression, anxiety, dementia without behavioral disturbances, PTSD, insomnia, hallucinations, verbal behaviors toward others, other behavioral symptoms, and wandering, reported that he was hit in the face. Staff heard yelling and found the intruding resident pulling covers at the foot of the bed and yelling that the room was his house, while the other resident sat on the side of the bed and stated that he had been hit and told staff to get a gun and shoot the other resident. Slight puffiness was noted around the reporting resident’s left eye. The intruding resident’s care plan documented compulsiveness, invading others’ personal space, yelling, restlessness, physical aggression, and attempts to assist other residents he believed needed help, with interventions to divert him, familiarize him with his surroundings, and intervene to protect the rights and safety of others. Despite these identified behaviors and interventions, he was able to enter another resident’s room, engage in a confrontation, and allegedly strike the resident.
Resident Injury from Improper Hoyer Lift Operation During Transfer
Penalty
Summary
The deficiency involves the facility’s failure to prevent an accident during a Hoyer lift transfer, resulting in a fall and skin tear injury to a resident. The resident had diagnoses including spinal stenosis, Alzheimer’s disease, vascular dementia with behavioral disturbance, bipolar disorder, and pain, and was documented on the MDS as dependent on staff for transfers from bed to chair. The care plan and physician orders specified that the resident required a Hoyer lift with assistance of two staff for transfers. On the day of the incident, the resident was being transferred via Hoyer lift after a shower, from a shower bed back to a Geri-chair. Progress notes and the post-fall evaluation documented that the fall occurred in the bathroom during a Hoyer transfer with staff assistance of two, and that the Hoyer lift tipped sideways. The resident was found on the floor in the sling, with staff reporting that the Hoyer lift’s legs were widened and that as the resident was being positioned over the chair, the lift tipped to the side. Staff held the sling on each side of the resident’s head and lowered the resident to the floor, after which a skin tear measuring 1.0 cm x 0.1 cm was noted on the elbow. The facility’s investigation determined that the Hoyer tipped because one CNA pushed the lift’s feet apart manually instead of using the designated button to open the legs. Interviews indicated that the manual mechanical lift used at the time was considered less steady and required manual operation of a foot pedal to open the legs, and that the straps may have been more to one side than the other. The DON reported that three CNAs were involved with operating the lift at the time of the incident, including one CNA on light duty who was not supposed to be using the Hoyer lift, and that the lift itself was later found to have no mechanical problems. As a result of the tipping incident, the resident sustained a skin tear to the elbow and required diagnostic imaging to rule out fractures.
Incomplete Investigations of Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of verbal or potential physical abuse as required by its abuse, neglect, and exploitation policy. One cognitively intact resident with hemiplegia following a stroke reported a verbal altercation with a CNA after sliding to the floor while being assisted back to bed. The resident requested use of a Hoyer lift, the CNA told him he could get himself up, and an argument ensued in which the CNA told the resident it was not his room and did not leave until directed by an LPN. The facility’s investigation file for this incident contained only the resident’s interview and no interviews with other residents on the unit who might have had knowledge of similar verbal abuse by the CNA. Another cognitively intact resident with rheumatoid arthritis, hypertension, and peripheral vascular disease reported that her roommate’s daughter came into her room and verbally abused her after the roommate had been relocated due to aggression. The daughter allegedly cursed at the resident, calling her an offensive name and telling her she was going to hell. The investigation file for this incident contained no interviews with other residents on the unit to determine whether they had experienced verbal abuse by this family member or had knowledge of the event. The DON acknowledged that no such interviews were conducted. A third cognitively intact resident with type 2 diabetes and epilepsy reported, through her daughter, that a male CNA wearing a red shirt was too rough with her and appeared upset about having to change her linens. The facility’s investigation into this potential staff-to-resident abuse included an interview with the resident but did not include interviews with other interviewable residents in the same area who might have had knowledge of the incident. A fourth cognitively intact resident with type 2 diabetes and heart disease, later discharged, reported that a staff member entered her room, called her a poor excuse for a human being, and refused to assist with changing her brief. The investigation documentation for this allegation lacked interviews with additional residents or staff, did not show that the resident was promptly assessed physically and psychosocially in relation to the allegation, and did not include a review of the accused staff member’s employee record, resulting in an incomplete investigation contrary to facility policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
Failure to Protect Resident From Verbal Abuse and Delay in Reporting Incident
Penalty
Summary
The facility failed to protect a cognitively intact resident from verbal abuse by a staff member. The resident, admitted with rectal cancer and independently ambulatory with a rolling walker, reported that during an overnight shift he left the campus to smoke and, upon returning and walking toward the nursing station, was confronted by an RN. According to the resident’s report, the RN told him that when she was on the night shift he was not allowed to go outside, using profanity toward him, and further stated that if he went out the door she would instruct staff not to buzz him back into the building. A CNA later confirmed that the RN had been upset about being called in to work, spoke loudly to the resident about his smoking, and used curse words when he responded to her. The incident was not promptly reported to facility administration despite occurring during the night shift, with the CNA stating that the RN involved was the supervisor at the time. The resident reported the incident the following day to the Social Services Director, but the facility did not immediately recognize or treat the allegation as reportable abuse. Instead, the administration initially considered it a grievance and investigated it in that manner. The incident report was not submitted to the State Survey Agency until several weeks after the resident’s report, and only after the facility later determined that the event constituted a reportable abuse incident.
Failure to Provide Required ADL and Hygiene Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL assistance to maintain grooming and personal hygiene for two dependent residents. One resident with dementia, osteoarthritis, and moderately impaired cognition was care planned to receive partial to substantial assistance with personal and oral care, scheduled toileting every two hours, and assistance with toilet transfers. CNA documentation for an evening shift showed “N/A” for all scheduled toileting times, and a facility incident report stated that the CNA assigned to this resident failed to provide incontinence care during that shift. The oncoming night-shift CNA later found the resident’s clothing, linens, and mattress saturated and soaked with urine and provided the needed care, with the prior-shift LPN confirming the condition when notified. The assigned CNA reported the resident was resistant to care but did not notify the LPN or RN for assistance or document the issue. The second resident, with dementia, stroke, weakness, and moderately impaired cognition, was care planned for an ADL self-care deficit requiring setup or cleanup assistance with eating, partial to substantial assistance with personal hygiene and oral care, and substantial assistance with toileting, showering/bathing, and lower body dressing. On a morning shift, the resident’s daughter-in-law reported to the LSW that she did not believe the resident had received morning care because he was still in bed wearing pajamas and had not yet received his lunch tray. A CNA statement indicated the resident had eaten breakfast and was later found asleep in bed, and CNA documentation for that shift showed the dressing task as completed. However, the facility’s follow-up summary documented that the CNA confirmed care had not been provided to the resident prior to being questioned by the RN supervisor, and the LSW confirmed that the CNA changed the resident only after the family reported the concern and nursing was notified.
Failure to Provide Adequate Supervision and Assistance During Bed Mobility for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for a resident with significant functional and cognitive impairments. The resident was admitted with left-sided weakness after a stroke and was care planned as extensively to totally dependent for bed mobility, requiring the support of two persons. A fall risk evaluation documented a score of 10, indicating high fall risk, and a quarterly MDS assessment showed the resident was unable to participate in a cognitive assessment and was completely dependent on staff for all ADLs. Despite these identified needs and risks, the resident was being turned onto their side for peri care by an aide when they fell from the bed to the floor. During this incident, the resident sustained head trauma and a small scalp laceration, and was on blood thinners at the time of the fall. The fall occurred while the aide was providing peri care and turning the resident, but the report does not document the presence of a second staff member, despite the care plan indicating the need for two-person assistance for bed mobility. The facility’s own policy on falls emphasized instituting individualized practices to minimize fall risk and maximize safety for residents identified as high risk, but the resident’s documented high fall risk and total dependence were not adequately addressed in the supervision and assistance provided at the time of the fall.
Failure to Ensure Safe Discharge with Confirmed Home Services and Support
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s discharge home included confirmed durable medical equipment (DME), home health services, and adequate caregiver support. The resident was admitted with spinal stenosis, cervical disc disorder, muscle weakness, carpal tunnel syndrome, and a recent post-fasciotomy to the right arm, and was documented as cognitively intact with a BIMS score of 14/15. Despite these physical limitations, the facility discharged the resident home in the evening via medical transport to a three-story residence, where no caregiver support was present. The facility’s own policy required a post-discharge plan of care developed with the resident and representative, and orientation to ensure a safe and orderly transfer or discharge, but the record lacked evidence that services were confirmed as in place prior to discharge. Prior to discharge, the social worker documented that the resident would have a safe discharge home with services and supports in place, and that referrals for home health care, skilled nursing services, and DME had been made, with family members in attendance at the discharge care plan. However, the clinical record did not contain confirmation that these services were actually arranged and active before the resident left the facility. The resident was discharged with medications called to the pharmacy for home delivery, but there was no documentation that the hospital bed had been delivered or that home health nursing, therapy, or home health aide services were scheduled to start at the time of discharge. The social worker later acknowledged not informing the agency of a specific start-of-care date, assuming the agency and VA would contact the resident, and confirmed not calling to verify delivery of the hospital bed. After discharge, it was discovered that the hospital bed ordered days earlier was not delivered until the morning after the resident arrived home, and that therapy, RN, and HHA services had not yet begun or contacted the resident by the time the facility followed up. The resident reported living alone, being unable to use their hands, needing a caretaker, and having to rely on a sister-in-law for limited assistance with hygiene, meals, and rearranging furniture for the bed that arrived later. The significant other confirmed that no one lived with the resident, that they had their own health issues, and that neither they nor their son stayed with the resident after discharge. When a home health RN eventually visited, the resident was found sitting on a couch in minimal clothing, reporting not having eaten adequately for two days, having little or no accessible food, and being unable to open medications or bottles due to impaired fine motor skills. The RN observed the resident’s inability to grip or perform fine motor tasks, assisted with toileting, and then contacted the agency director and emergency services due to the unsafe conditions in which the resident had been left. These events led surveyors to determine that the facility failed to ensure services and caregiver support were in place prior to discharge, resulting in an immediate jeopardy situation.
Removal Plan
- Audited discharge documentation related to home health services, appropriate caregiver/family support, and any necessary services to meet residents' care needs to determine if any residents were affected.
- Reviewed planned discharges by the Administrator, DON, Director of Social Services, and Director of Rehabilitation to ensure home health services, appropriate caregiver/family support, and necessary services to meet the resident's care needs are in place before discharge.
- Completed a root cause analysis identifying failure to have a robust discharge care plan meeting with the interdisciplinary team (IDT), resident, and resident representative.
- Reviewed the procedure for safe and effective discharge planning with the IDT.
- Re-educated the discharge planning IDT on the discharge policy and procedure to ensure sufficient preparation and orientation for a safe discharge.
- Implemented review of residents scheduled to be discharged to ensure appropriate discharge planning is in place.
- Implemented review of residents scheduled for discharge to ensure ADL support is in place, durable medical equipment is available prior to or on the discharge date, medications are available upon discharge, and identified needs/support are available.
- Implemented review of residents scheduled for discharge to ensure safe discharge planning is in place and to address any issues identified.
- Implemented oversight during utilization review by the NHA/designee to ensure discharge planning preparation and services are in place prior to discharge.
- Initiated audits and educational in-services to the IDT team and conducted staff interviews to confirm education received regarding discharge to the community and/or transfers to other facilities.
Failure to Maintain Adequate Hydration Resulting in Recurrent AKI and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate hydration for a resident with significant medical conditions, including acute kidney injury (AKI), congestive heart failure (CHF), dementia, and Parkinson’s disease. Upon admission, the resident’s care plan identified potential for altered nutrition and included interventions such as assisting at meals, encouraging oral fluids, and monitoring for additional nutrition interventions. A nutrition assessment established an initial fluid goal of 1943–2098 mL/day and documented that the resident was at risk for dehydration and malnutrition, with early labs showing a BUN of 29, creatinine of 1.4, and eGFR of 53. The admission MDS documented that the resident was severely cognitively impaired and required setup assistance for feeding and hydration. Daily fluid intake records from CNA task flow sheets and the MAR showed that the resident’s intake frequently fell below the recommended fluid goals, with multiple days of intake under 1200 mL and some days as low as 360–720 mL. A malnutrition risk assessment identified the resident as at risk for malnutrition due to severe dementia and tremors. A subsequent nutrition note on 5/12/25 documented that the resident’s average fluid intake was 330 mL/day, recommended discontinuing a prescribed hydration pass due to CHF, and set a new fluid goal of 1635–1766 mL/day, while continuing to recommend encouraging oral fluids. Despite these documented risks and low intakes, there is no evidence in the record of intensified monitoring or additional interventions to ensure the resident met the revised fluid goals. The resident experienced multiple clinical deteriorations associated with poor intake and changes in condition. On 6/1/25, after a day with only 360 mL of recorded intake, the resident was transferred to the hospital following falls, hypotension, and confusion, and was admitted with AKI and dehydration. After readmission to the facility, nursing documentation noted low oral intake and a plan to discuss adding the resident to an assist-to-feeding list, but the record lacked evidence that this occurred. Subsequent notes documented lethargy, increased confusion, agitation, restlessness, and continued poor intake, yet a physician progress note following two unwitnessed falls did not include an assessment of hydration status or interventions to improve hydration. On 6/19/25, labs showed a BUN of 62 mg/dL and creatinine of 1.7 mg/dL, and the resident was again sent to the hospital and admitted with AKI, hypotension, and anemia, requiring IV fluid resuscitation. Staff interviews confirmed expectations to monitor intake, encourage fluids, and notify providers when fluid goals were not met, but there was no documentation that the provider was consistently notified or that appropriate interventions were implemented in response to the resident’s ongoing inadequate fluid intake and changes in condition.
Failure to Arrange Timely Home Health Services Prior to Discharge
Penalty
Summary
The facility failed to ensure a timely referral for home health care services prior to discharge for one resident. Facility policy dated 5/1/25 required sufficient preparation and orientation to residents to ensure an orderly transfer or discharge. The resident was admitted on 7/28/25 with diagnoses including aortic valve replacement, aortic regurgitation, and congestive heart failure. A discharge summary dated 8/11/25 documented a post-discharge plan for home health aide, home health RN/LPN, and occupational and physical therapy. The resident was discharged home with a family member on 8/12/25. A complaint received by the Division on 9/30/25 stated that the resident was discharged to a family member's home without a home health care agency referral and that, after one week at home, the resident had not received any physical or occupational therapy or a wellness check from a nurse. During an interview on 2/16/26, the social worker reported needing to check if a referral was made and later confirmed that the referral for home health and therapy services was not requested until 8/15/25, with services opened on 8/20/25. The director of therapy confirmed that physical and occupational therapy were recommended for the resident and stated that such recommendations are typically communicated to social services to set up home care. Findings were reviewed with facility leadership during the exit conference.
Failure to Revise Care Plans and Involve Resident in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise person‑centered care plans and to involve a cognitively intact resident and/or representative in the care planning process. One resident with an intact BIMS score of 15 was admitted and had a documented care conference shortly after admission, but there was no evidence of any subsequent care conferences during the following year despite multiple care plan updates. The resident reported not recalling quarterly care plan meetings, and staff confirmed that no care conferences occurred after the initial one, with no documentation that the resident or representative participated in the later care plan revisions. Additional residents’ care plans were not revised to reflect current, individualized needs and behaviors. One resident had a physician’s order for a right palm protector or substitute, was repeatedly observed without it in place, and routinely refused it according to nursing and CNA interviews, yet the care plan did not address potential refusals. Two cognitively impaired residents whose MDS assessments documented dependence for bathing had care plans that continued to list only setup assistance or one‑person assist, without updating to reflect full dependence. Another cognitively impaired resident with documented combative behaviors toward staff and a reported incident of striking another resident with a remote had a behavior care plan that was not revised to include the new behavior of attempting to hit other residents or the potential for resident‑to‑resident altercations.
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