Polaris Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Milford, Delaware.
- Location
- 21 W Clarke Avenue, Milford, Delaware 19963
- CMS Provider Number
- 085058
- Inspections on file
- 23
- Latest survey
- August 11, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Polaris Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not provide enough nursing staff to meet resident needs, resulting in multiple instances where residents experienced prolonged call bell response times and delays in receiving assistance with ADLs such as toileting, changing, and being put to bed. Several residents reported waiting from 20 minutes to over an hour for help, with some left in soiled conditions or requiring family intervention due to staff unavailability. These delays were confirmed through observations, interviews, and facility documentation.
A resident repeatedly requested extraction of her remaining lower teeth and the provision of full dentures, as documented in multiple dental progress notes and interviews. Despite these ongoing requests and the facility's ability to perform extractions, the resident was not scheduled for the necessary procedure, resulting in a significant delay in receiving dental services.
Two cognitively intact residents experienced significant delays in accessing their personal funds due to a vacancy and transition in the business office manager position. Despite multiple requests, both residents waited longer than the facility's policy allows before receiving their money, and there was no evidence that residents were informed about interim procedures for fund access during the staffing gap.
A resident reported unauthorized charges on a credit card and a loan taken out in their name, but staff did not recognize or report this as an allegation of misappropriation of funds to the State Agency within the required timeframe. Multiple staff members were aware of the grievance, but it was not identified as a reportable incident, resulting in non-compliance with federal reporting requirements.
A resident reported that a former employee was stealing money, and while the facility notified the police and submitted an incident report, no internal investigation was conducted. The DON confirmed that no interviews or statements were obtained, and no investigation documentation was available.
A resident with a history of severe mental health conditions was transferred to the hospital for suicidal ideation and later denied readmission to the facility after discharge from an inpatient psychiatric facility. Staff interviews confirmed the denial was due to a large outstanding bill, and the facility did not comply with discharge requirements.
A resident with multiple sclerosis and paraplegia, dependent for bed mobility and unable to perform ADLs without assistance, was left unsupervised on her side during care when a CNA stepped into the bathroom, resulting in the resident rolling off the bed and sustaining a head laceration that required hospital treatment. Staff interviews confirmed the resident could not maintain her position without support, and the care plan required extensive assistance and supervision.
A resident with a right heel wound did not receive proper physician supervision for pressure ulcer care. Progress notes from follow-up visits lacked documentation of a physical wound assessment by the provider, who stated that wound care was managed by a wound NP and her involvement was limited to ordering medications. The absence of documented wound assessments indicated a failure to ensure appropriate medical supervision.
A resident had abnormal lab results indicating an elevated white blood cell count following a physician's order for CBC and CMP. There was no documented evidence that the provider was promptly notified of these results, as confirmed by the RN UM and facility leadership.
A resident with a new order for thickened liquids was served thin liquids at a meal, resulting in coughing, because the order was not properly communicated to dietary staff. The CNA was not informed of the change, the order was not entered as a dietary order in the EMR, and no dietary communication slip was provided, leaving the dietician unaware of the resident's needs.
A resident with baseline confusion experienced an unwitnessed fall, and the required neurological assessments were not fully documented in the medical record as per facility policy. The RN involved recorded assessment details on a personal notepad with the intention to later transfer them to the official form, but this was not completed, resulting in incomplete documentation in the clinical record.
The facility failed to maintain nourishment refrigerators in a sanitary condition, with improperly stored food items and spills observed. Items included outdated Boost drinks, undated sandwiches, and unlabeled leftovers. These issues were confirmed and discussed with the DON.
The facility failed to maintain the dignity and respect of three residents during care. Two residents were exposed to the hallway while receiving care with the door open, confirmed by the CNAs involved. Another resident experienced inappropriate behavior from a former CNA, who spoke in a loud and aggressive manner during care, corroborated by an agency RN. The resident reported feeling upset and crying after the incident.
A resident's diet was downgraded to a dysphagia mechanical soft texture for safety, but the facility failed to notify the resident's contact person of this change. The registered dietitian assumed nursing would handle the notification, but the clinical record showed no evidence of this communication. This deficiency was identified during a review and discussed with the NHA and DON.
The facility failed to provide accessible call bell systems for two quadriplegic residents. One resident was given call bells that were out of reach and unusable, despite communicating this to staff. The issue was only addressed after a surveyor's observation. Another resident had a sip and puff call bell positioned out of reach, confirmed by a respiratory therapist. These deficiencies were discussed with the facility's NHA and DON.
A facility failed to provide a resident with the Notice to Medicare Provider Non-Coverage (NOMIC) form before terminating services. The resident was discharged home without receiving the form, which is crucial for informing beneficiaries of their right to an expedited review of service termination. This issue was confirmed by the Nursing Home Administrator and discussed during an exit conference with the Director of Nursing.
A facility failed to recognize and report an abuse incident between two residents. One resident admitted to throwing soda cans and using derogatory language, but the incident was not reported as abuse because the can did not hit the other resident. Interviews revealed a lack of awareness and acknowledgment of the incident as abuse.
A facility failed to ensure the accuracy of the MDS assessment for a resident, as the admission assessment did not include evaluations for cognitive function, behaviors, mood, and pain levels. This omission was confirmed by the Director of Reimbursement Services, who acknowledged that the assessment was missed and the resident should have been interviewed.
A facility failed to conduct timely PASARR screenings for a resident with mental health disabilities, including bipolar disorder, anxiety disorder, and major depressive disorder. The resident remained in the facility beyond the authorized 60-day period without a new PASARR Level I and II screening. Interviews confirmed the oversight, and the resident was not discharged as planned, despite the short-term approval without specialized services.
A facility failed to develop a care plan for a resident prescribed an anticoagulant medication. The resident was admitted with a physician's order for anticoagulant use, documented in both admission and quarterly MDS assessments. However, the care plans lacked evidence of addressing the anticoagulant use. This deficiency was confirmed by the Director of Reimbursement Services and discussed with the NHA and DON during the exit conference.
The facility failed to include all required interdisciplinary team members in care plan meetings for several residents. Care plan meetings lacked input from physicians, CNAs, dietary, activities, and the medical director. Interviews revealed that CNAs were generally not involved unless requested by residents, and there was no formal documentation of their input. The NHA confirmed these deficiencies during the exit conference.
The facility failed to reposition two residents, both at high risk for skin breakdown, every two hours as required. One resident with hypoxic ischemic encephalopathy was observed lying on her back for four hours without being turned, despite a care plan indicating the need for repositioning. Similarly, another resident with quadriplegia was also observed lying on her back for four hours without repositioning. Interviews with CNAs and the residents confirmed the lack of adherence to repositioning protocols.
A resident admitted to the facility was identified as incontinent and a candidate for scheduled prompted voiding, but the facility failed to implement a toileting program. Staff did not assist the resident with toileting, and the resident was not offered a urinal or bedpan, despite being able to verbalize the need to use the bathroom. The facility's continence check program was not documented, and staff did not follow recommendations to promote continence.
The facility failed to provide adequate respiratory care for two residents. One resident with COPD did not have their oxygen tubing and humidifier bottle changed or labeled weekly, as required. Another resident with acute respiratory failure had their tracheal suction machine equipment unchanged since January, despite a physician's order for weekly changes. These issues were confirmed by staff and discussed with facility leadership.
The facility did not ensure that pharmacist recommendations were reviewed by the attending physician for a resident. The facility's policy requires the physician to document any irregularities and actions taken. A Pharmacist Consultant Note recommended evaluating the discontinuation of vitamin C and adjusting a laxative's timeframe, but no physician response was found. The Nursing Home Administrator confirmed the absence of documentation during an interview.
A facility failed to conduct AIMS testing every six months for a resident on antipsychotic medication, as required by its policy. The resident received an AIMS test in July, but by the following April, testing had not been completed for nine months. This deficiency was confirmed by the ADON and discussed with the NHA and DON.
The facility failed to ensure cleanliness in a resident's room, where a large brown stain on the floor persisted for several days despite daily cleaning routines. Initially, the room also had stained bedding and balled paper napkins on the floor. A housekeeper confirmed the stain's presence, noting that the facility employs daily cleaning staff, yet the stain remained until it was eventually removed.
Insufficient Nursing Staff Leads to Delayed Resident Care and Unmet Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in prolonged call bell response times and unmet care needs for multiple residents. The facility assessment indicated that a significant number of residents required assistance from one or two staff members, and over fifty residents were dependent on staff for activities of daily living (ADLs). Despite this, several residents experienced delays in receiving assistance, particularly with toileting, changing, and being put to bed. Observations and interviews revealed instances where residents waited from 20 minutes to over an hour for staff response, with some residents reporting that staff would turn off call lights without providing the needed care. Specific examples included a resident waiting over an hour for toileting assistance, another resident's call bell ringing for 40 minutes before staff responded, and a resident not being placed in bed until late at night. Additional reports documented residents being left in soiled conditions and family members intervening to provide care due to staff unavailability. These findings were corroborated by staff interviews and concern forms, confirming that the facility did not ensure adequate staff availability to respond to resident care needs in a timely manner.
Failure to Provide Timely Dental Extractions and Dentures
Penalty
Summary
A resident was admitted to the facility and, over the course of nearly a year, repeatedly requested dental services, specifically the extraction of her remaining lower teeth and the provision of full dentures. Multiple dental progress notes documented the resident's ongoing requests for extractions and dentures, with the treatment plan reflecting these needs. Despite these documented requests and the resident's continued desire for dental intervention, the necessary extractions and denture process were not initiated in a timely manner. During interviews, the resident reported having four loose lower teeth and expressed frustration at the lack of progress, demonstrating the mobility of one of her teeth. Facility staff confirmed awareness of the resident's requests and the dental team's ability to perform extractions on-site. However, the resident was not scheduled for extractions, and the upcoming dental appointment was only for an initial exam with a new dentist, not for the requested procedure. The delay in providing the required dental services was acknowledged by facility leadership.
Failure to Provide Timely Access to Resident Personal Funds
Penalty
Summary
The facility failed to ensure that two cognitively intact residents had timely access to their personal funds, as required by facility policy. The policy states that residents should have access to funds of fifty dollars or less within twenty-four hours, and access to larger amounts within three banking days. One resident reported requesting funds at the beginning of the month to send Christmas cards but did not receive the money until two days before Christmas, despite multiple requests to staff. Another resident also experienced a delay in accessing personal funds after requesting a withdrawal, which was not fulfilled until a new business office manager (BOM) was acclimated to the position. During the period when the BOM position was vacant, there was no documented evidence of how residents were informed about accessing their funds or who was responsible for disbursing them. Facility records showed no disbursements of personal funds for a ten-day period in December, and interviews with staff confirmed that coverage was provided by a regional person and reception, but this information was not communicated to residents. Both residents eventually received their funds, but only after significant delays that did not comply with the facility's stated policy.
Failure to Timely Report Alleged Misappropriation of Resident Funds
Penalty
Summary
A deficiency occurred when the facility failed to recognize and report an allegation of misappropriation of resident property/funds within the required 24-hour timeframe. A grievance was filed on behalf of a resident who reported unauthorized charges on his credit card and a loan taken out in his name. The grievance was documented and assigned for investigation, but the incident was not identified as a potential misappropriation of resident funds and was not reported to the State Agency as required by federal regulations. Multiple staff members, including the Business Office Manager, Social Worker, and former Nursing Home Administrator, were aware of the grievance but did not recognize it as an allegation that required mandatory reporting. Interviews with facility staff confirmed that the grievance related to missing money was not reported to the State Agency because it was not recognized as an allegation of misappropriation. The Director of Nursing was unaware of the grievance, and the former Nursing Home Administrator stated he thought the allegation was related to an old incident and did not recall the details. The failure to recognize and report the allegation resulted in non-compliance with the facility's abuse policy and federal requirements for timely reporting of suspected misappropriation of resident property.
Failure to Investigate Allegation of Misappropriation of Resident Property
Penalty
Summary
For one of two residents reviewed for allegations of misappropriation of resident property, the facility failed to provide evidence that an allegation was thoroughly investigated. The facility's abuse policy requires investigation and reporting of any allegations of abuse, neglect, or misappropriation within federally required timeframes. An incident report was submitted to the State Agency after a resident alleged that a previous employee was stealing money, and the police were contacted. However, upon request, the facility was unable to provide documentation of an internal investigation, including interviews or statements related to the allegation. The Director of Nursing confirmed that no investigation was conducted beyond contacting the police.
Resident Denied Readmission After Hospitalization Due to Outstanding Bill
Penalty
Summary
A resident with a history of major depressive disorder, severe psychotic symptoms, anxiety, and suicidal ideation was admitted to the facility and was documented as cognitively intact with a goal to remain in the facility. The resident was transferred to the hospital for suicidal ideation, and the facility provided a transfer/discharge notice and bed hold policy notification, both signed by the resident. Following the transfer, facility staff initiated a referral to another nursing home and completed a discharge return not anticipated MDS assessment without documenting a discharge plan or referrals. When the inpatient psychiatric facility later requested information on transferring the resident back, the facility provided the necessary information but did not facilitate the resident's return. Multiple staff interviews confirmed that the resident was denied readmission to the facility after discharge from the inpatient psychiatric facility. The admissions staff, unit manager, and controller all stated that the denial was due to the resident owing a large outstanding bill, and corporate leadership would not allow readmission until Medicaid approval, which was ultimately denied. The facility's transfer list indicated the resident was transferred out for medical leave, but the resident was not permitted to return, and the facility did not comply with discharge requirements.
Failure to Provide Adequate Supervision During Care Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with multiple sclerosis, paraplegia, and generalized weakness was left unsupervised during care, resulting in a fall from bed and a head injury. The resident was dependent for bed mobility and unable to perform activities of daily living without assistance, as documented in the care plan and MDS assessment. The care plan included interventions such as keeping the bed in the lowest position when not providing care and providing extensive assistance with bed mobility. During the incident, a CNA rolled the resident onto her side to change her but left her unattended on her side while stepping into the bathroom to wet additional washcloths, leaving the bed in a raised position. The resident, who lacked the strength to remain on her side without support, rolled off the bed and sustained a laceration to the back of the head, requiring hospital evaluation and treatment. Interviews with staff confirmed that the resident could not maintain her position on her side independently and that the CNA left her unsupervised for a brief period. The incident report and clinical documentation corroborated that the resident was found on the floor after the fall, and the care plan was subsequently updated to increase rounding as a result of the event.
Failure to Ensure Physician Supervision for Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when a resident with a right heel wound was not adequately supervised by a physician for the care of pressure ulcers. The resident was admitted with a wound and subsequently seen by a practitioner for follow-up visits related to the wound and for antibiotic management. However, the progress notes from these visits lacked documentation of a physical assessment of the wound's characteristics by the provider. The practitioner confirmed during an interview that she did not follow wound care, stating that the wound nurse practitioner was responsible for that aspect, and her role was limited to ordering medications related to wound care. Further review of the clinical record showed that the wound was documented as a deep tissue injury, unstageable, with necrotic tissue and suspected infection. Despite ongoing treatment and diagnostic orders, there was no evidence in the provider's notes that a physical wound assessment was performed. This lack of documentation and direct assessment by the provider constituted a failure to ensure the resident's medical care was properly supervised by a physician for the pressure ulcer.
Failure to Promptly Notify Provider of Abnormal Lab Results
Penalty
Summary
A deficiency was identified when the facility failed to promptly notify the ordering medical practitioner of abnormal laboratory results for one resident. The resident was admitted and had a physician's order for a complete blood count (CBC) and comprehensive metabolic panel (CMP), with subsequent lab results indicating an elevated white blood cell count. Despite these abnormal findings, there was no documented evidence in the progress notes that the provider was notified of the lab results in a timely manner. This lack of prompt communication was confirmed during an interview with the RN Unit Manager, and the findings were reviewed with facility leadership.
Failure to Provide Prescribed Thickened Liquids Due to Communication Breakdown
Penalty
Summary
A deficiency occurred when a resident who had a physician's order for thickened liquids was served thin liquids, including water, coffee, and juice, during a meal. The resident was observed actively drinking the thin liquids, which resulted in coughing. The clinical record showed that the resident was admitted to the facility and was initially independent with eating, but a new order for thickened liquids was entered the day before the incident. Interviews with staff revealed that the certified nursing assistant (CNA) was not informed of the thickened liquid order during shift report, and the thin liquids were only replaced after the deficiency was noticed. Further investigation found that the new diet order was not entered as a dietary order in the electronic medical record (EMR), so the dietary department was not notified electronically. Additionally, no dietary communication slip was completed or delivered to the dietary department, and the dietician was unaware of the new order. This series of communication failures led to the resident not receiving fluids in the prescribed form.
Incomplete Documentation of Neurological Assessments After Resident Fall
Penalty
Summary
A deficiency was identified when a resident with baseline confusion experienced an unwitnessed fall. The facility's policy required that documentation in the medical record be objective, complete, and accurate. Following the fall, a neurological assessment form was initiated to monitor the resident, but the clinical record lacked specific information regarding the neurological checks performed. Progress notes written by the RN referenced that neuro checks were in progress but did not provide detailed documentation of the assessments. Upon review, the neurological assessment form was found to be incomplete, with missing entries for several hours following the incident. During interviews, the Director of Nursing confirmed the incompleteness of the neurological assessment form. The RN involved later produced handwritten notes from a personal notepad, stating that the intention was to transfer the information to the official form but was interrupted and unable to do so before the form was taken by another nurse. The handwritten notes were subsequently scanned into the resident's clinical record, but the original required documentation on the neurological assessment form was not completed as per facility policy.
Unsanitary Conditions in Nourishment Refrigerators
Penalty
Summary
The facility failed to maintain nourishment refrigerators in a sanitary condition and ensure safe food storage, which could lead to food-borne illness. On April 7, 2024, at 8:45 AM, the Reserve Unit nourishment refrigerator contained several improperly stored items, including a Boost drink dated October 17, 2023, a sandwich in a green and white wrapper dated February 21, an unmarked brown paper bag, a partially eaten pretzel salad without a date, opened and unlabeled cheese doodles, and salad dressing dated September 8, 2023. These items were confirmed and removed by a supervisor at 9:47 AM. On April 8, 2024, the nourishment refrigerator adjacent to the small dining room in the Riverside unit was found with a large semi-dried spill of orange liquid on the middle and bottom shelves of the door. Additionally, the full-sized refrigerator in the same dining room contained an undated and unlabeled small plastic food storage bowl of leftover food. These findings were reviewed during the exit conference on April 11, 2024, with the Director of Nursing.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to maintain the dignity and respect of three residents during care. For one resident, two CNAs provided care with the door open, exposing the resident's unclothed lower body to the hallway. This incident was confirmed by the CNAs involved. Similarly, another resident was observed receiving care with the door open, leaving their lower body exposed to the hallway, which was also confirmed by the CNA providing the care. In a separate incident, a resident with an intact cognitive state and dependent on staff for toilet use experienced inappropriate behavior from a former CNA. The CNA was argumentative and spoke in a loud and aggressive manner to the resident during care, which was corroborated by an agency RN present at the time. The resident reported feeling upset and crying after the incident, although they had not experienced issues with other staff members.
Failure to Notify Resident's Contact Person of Diet Change
Penalty
Summary
The facility failed to notify a resident's contact person about a change in the resident's diet texture, which constitutes a deficiency in communication regarding the resident's care. The resident, admitted with diagnoses including hypertension, stroke, left side weakness, and depression, had their diet downgraded from a regular textured diet to a dysphagia mechanical soft texture for safety reasons. This change was documented by a physician and a registered dietitian. However, the registered dietitian assumed that the nursing staff would notify the resident's contact person, which did not occur. An interview with a licensed practical nurse confirmed that nursing was responsible for notifying the contact person, but the clinical record lacked evidence of such notification. This oversight was identified during a review of the resident's clinical record and discussed in an exit conference with the nursing home administrator and director of nursing.
Failure to Provide Accessible Call Bell Systems for Quadriplegic Residents
Penalty
Summary
The facility failed to ensure that two residents, both with quadriplegia, had accessible and usable call bell systems. One resident, admitted with a spinal injury and quadriplegia, was provided with a standard push button call bell and a metal bell, both of which were out of reach and unusable due to his condition. Despite the resident's repeated communication of his inability to use the provided call bells, the facility did not provide an alternative solution until after the surveyor's observation. The unit manager was unaware of the availability of a suitable call bell system and only took action after the issue was highlighted during the survey. Another resident, also with quadriplegia and additional complex medical needs, was observed with a sip and puff call bell positioned out of reach, rendering it unusable. Despite being totally dependent, the resident was left without a functional means to call for assistance. The issue was confirmed by a respiratory therapist, who noted that the resident could call out for help, but this did not address the lack of a functional call bell system. These deficiencies were discussed with the facility's nursing home administrator and director of nursing during the exit conference.
Failure to Provide NOMIC Form Before Service Termination
Penalty
Summary
The facility failed to provide a resident with the Notice to Medicare Provider Non-Coverage (NOMIC) form before terminating services. This deficiency was identified during a review of the resident's clinical record, which showed that the resident was discharged to home on March 20, 2024. During an interview on April 11, 2024, the Nursing Home Administrator (E1) confirmed that the NOMIC form was not given to the resident. The NOMIC form is essential as it informs the beneficiary of their right to an expedited review of the service termination. These findings were discussed during the exit conference on April 11, 2024, with the Nursing Home Administrator and the Director of Nursing.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to recognize and immediately report an allegation of abuse involving two residents. On March 21, 2024, a disagreement occurred between two roommates, leading to a recommendation for a room change by the on-call nurse. However, an earlier incident on March 12, 2024, was documented by an LPN, indicating that one resident admitted to throwing soda cans and using derogatory language towards the other resident. Despite this, the incident was not recognized as an allegation of abuse and was not reported immediately. Interviews conducted on April 11, 2024, revealed that the RN supervisor was unaware of the soda can being thrown, and the DON confirmed that the incident was not recognized as abuse because the soda can did not physically hit the resident. The affected resident later stated that the soda can was thrown at him and his wife, causing them to get wet and prompting them to scream for assistance. The failure to report this incident as abuse was acknowledged during the exit conference with the Nursing Home Administrator and the DON.
Failure to Ensure Accurate MDS Assessment
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident, identified as R42, out of five residents reviewed for medication review. R42 was admitted to the facility on May 9, 2023. However, the admission MDS assessment conducted on May 15, 2023, did not include assessments for cognitive function, behaviors, mood, and pain levels. This omission was confirmed during an interview on April 9, 2024, with the Director of Reimbursement Services, who acknowledged that the assessment was missed and that R42 should have been interviewed. These findings were discussed during the exit conference on April 11, 2024, with the Nursing Home Administrator and the Director of Nursing.
Failure to Conduct Timely PASARR Screening for Resident with Mental Health Disability
Penalty
Summary
The facility failed to ensure timely coordination of the PASARR screening process for a resident with a mental health disability. The resident, identified as R68, was admitted with diagnoses including bipolar disorder, anxiety disorder, and major depressive disorder. Initially, a PASARR Level I screen was conducted, granting a 60-day approval period. However, the facility did not complete a new PASARR Level I and II screening by or before the 60th day, as required. This oversight resulted in the resident remaining in the facility beyond the authorized timeframe without the necessary updated screening. Interviews and record reviews confirmed that the PASARR Level I screen was not conducted within the required timeframe, and the PASARR Level II approval ended without appropriate follow-up. Despite the short-term approval without specialized services, the resident was not discharged as planned. These findings were discussed during the exit conference with the Nursing Home Administrator and the Director of Nursing, highlighting the facility's failure to adhere to the PASARR process for residents with mental health disabilities.
Failure to Develop Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop a care plan for a resident, identified as R42, who was prescribed an anticoagulant medication. R42 was admitted to the facility on May 9, 2023, and on the same day, a physician's order was written for the resident to receive an anticoagulant medication twice daily for blood clot prevention. The admission Minimum Data Set (MDS) assessment on May 15, 2023, and a quarterly MDS assessment on February 15, 2024, both documented that R42 received anticoagulant medication. However, a review of R42's care plans revealed a lack of evidence that a care plan was created to address the resident's use of the anticoagulant medication. This deficiency was confirmed during an interview with the Director of Reimbursement Services on April 9, 2024, and was discussed during the exit conference on April 11, 2024, with the Nursing Home Administrator and the Director of Nursing.
Lack of Interdisciplinary Team Input in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that all required interdisciplinary team (IDT) members participated in the care plan meetings for four residents. For one resident, the quarterly care plan meetings lacked input from the physician and the CNA. Another resident's care plan meetings also missed contributions from the physician and CNA. A third resident's care plan meeting was missing input from the physician, nurse, and CNA, and subsequent meetings continued to lack input from the physician and CNA. Interviews with CNAs revealed that they were generally not involved in care plan meetings unless specifically requested by the resident, and there was no formal process to document their input. Additionally, a fourth resident's care plan meeting lacked input from the CNA, dietary, activities, and the medical director. The Nursing Home Administrator (NHA) confirmed the absence of necessary team members in the care plan meetings. These deficiencies were discussed during the exit conference with the NHA and the Director of Nursing (DON). The report highlights a systemic issue in the facility's care planning process, where essential team members' input is not consistently documented or included.
Failure to Reposition Residents at High Risk for Skin Breakdown
Penalty
Summary
The facility failed to adhere to professional standards of practice for turning and repositioning two residents, R24 and R57, who were at high risk for skin breakdown. R24, who was readmitted with conditions including hypoxic ischemic encephalopathy and anoxic brain damage, was documented as totally dependent on staff for turning and repositioning. Despite a care plan indicating the need for repositioning every two hours, observations on 4/8/24 showed R24 lying on her back for four hours without being turned. Interviews with CNAs revealed inconsistencies in the repositioning practices, with one CNA stating R24 was turned every two hours, while observations contradicted this claim. Similarly, R57, who was readmitted with quadriplegia and other conditions, was also documented as totally dependent on staff for repositioning. Despite a care plan requiring repositioning every two hours, observations on 4/8/24 showed R57 lying on her back for four hours without being turned. Interviews with CNAs and R57 confirmed that repositioning was not occurring as required, with one CNA stating R57 was always on her back and R57 herself confirming the lack of repositioning. These failures were discussed with the Nursing Home Administrator and Director of Nursing during the exit conference.
Failure to Provide Continence Care
Penalty
Summary
The facility failed to provide appropriate care and services to restore bladder continence for a resident, identified as R75, who was admitted on March 8, 2024. Upon admission, R75 was documented as incontinent, and a subsequent evaluation indicated that R75 was a candidate for scheduled prompted voiding. However, the facility did not attempt a toileting program, as confirmed by an admission MDS on March 14, 2024. Observations and interviews revealed that staff did not assist R75 with toileting when the call light was activated, and the resident was not offered a urinal or bedpan, despite being able to verbalize the need to use the bathroom. The CNA task flow sheet also lacked documentation of a two-hour continence check, which was supposed to be part of the facility's toileting program. Interviews with various staff members, including CNAs, a COTA, and the Rehab Director, highlighted a lack of communication and implementation of recommended continence care for R75. The COTA confirmed that R75 could voice the need to use the toilet and had initiated the use of a bedpan and urinal during therapy sessions. However, direct care staff did not follow these recommendations, and the resident's care plan was not updated to reflect changes in R75's alertness and continence capabilities. The facility's failure to provide care and services that promoted maintaining and/or restoring continence was confirmed during an exit conference with the Nursing Home Administrator and Director of Nursing.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, R3 and R66, as per professional standards of practice. For R66, who was admitted with chronic obstructive pulmonary disorder (COPD) and hypoxic respiratory failure, the facility did not change or label the oxygen tubing and humidifier bottle weekly as required by the facility's policy. Observations on multiple occasions revealed that the oxygen equipment was not dated, and this was confirmed by a registered nurse during an interview. For R3, who was admitted with acute respiratory failure and other conditions, the facility did not change the tracheal suction machine equipment as per the physician's order. The suction canister, which contained thick secretions, had not been changed since 1/26/24, despite the order to change it weekly and as needed. This was confirmed by an LPN during an interview, who acknowledged the oversight. These deficiencies were discussed with the nursing home administrator and director of nursing during the exit conference.
Failure to Review Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that pharmacist recommendations were reviewed by the attending physician for one resident out of five reviewed for medication review. According to the facility's policy for Medication Regimen Reviews (MRR), the attending physician is required to document in the medical record that any irregularities have been reviewed and to note any actions taken. On February 5, 2024, a Pharmacist Consultant Note indicated that recommendations were made to evaluate and consider discontinuing the use of vitamin C and to consider switching the timeframe of a laxative for the resident. However, a review of the resident's MRR from that date revealed a lack of physician response to these recommendations. During an interview on April 10, 2024, the Nursing Home Administrator (E1) confirmed that the facility was unable to locate a physician response to the February 2024 MRR. These findings were discussed during the exit conference on April 11, 2024, with the Nursing Home Administrator (E1) and the Director of Nursing (E2).
Failure to Conduct Timely AIMS Testing for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to adhere to its policy on psychotropic medication use by not completing the Abnormal Involuntary Movement Scale (AIMS) testing every six months for a resident on antipsychotic medications. The policy, last updated in July 2022, mandates that psychotropic medications be monitored with AIMS testing as required. A review of the clinical record for a resident revealed that a physician's order was written for the resident to receive an antipsychotic medication daily, and an AIMS test assessment was conducted in July 2023. However, by April 2024, it was found that AIMS testing had not been completed for nine months, contrary to the facility's protocol. This deficiency was confirmed during an interview with the Assistant Director of Nursing (ADON) and discussed during the exit conference with the Nursing Home Administrator (NHA) and Director of Nursing (DON).
Failure to Maintain Cleanliness in Resident Room
Penalty
Summary
The facility failed to maintain cleanliness in one of the resident rooms, specifically room [ROOM NUMBER]. During multiple observations over several days, a large brown circular stain was noted on the floor of the room. Initially, the stain was accompanied by three large brown stains on the fitted sheet of an occupied bed and balled paper napkins on the floor. Although the fitted sheet was later cleaned and the napkins removed, the stain on the floor persisted for several days. A housekeeper confirmed the presence of the stain and explained that the facility employs three housekeepers daily, along with a floor technician responsible for floors, trash, and common areas. Despite daily sweeping and mopping, the stain remained until it was finally removed by the last observation date.
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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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