Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Regal Heights Healthcare & Rehab Center during CMS and state inspections, most recent first.
Failure to protect residents from abuse. A resident with severe cognitive impairment physically assaulted a roommate while the roommate was asleep, and staff observed the attack. Another resident with severe cognitive impairment sexually grabbed a female resident, while the care plan had not been updated for years despite prior sexually inappropriate behavior. A third resident with intact cognition reported verbal mistreatment and being forcefully grabbed by a CNA at the nurse’s station.
Failure to report resident abuse, sexual misconduct, and injuries of unknown origin: Staff documented multiple resident-to-resident physical abuse incidents involving a resident with dementia and repeated sexual inappropriate behaviors by another resident, but the incidents were not reported to the Administrator or reflected on the reportable log. Staff interviews showed some events were observed but not escalated. The facility also documented bruises and other injuries of unknown origin for a severely cognitively impaired resident, but the Administrator confirmed the injuries were not reported to the SSA.
Failure to Investigate Resident Abuse, Unknown Injury, and Possible Neglect: The facility did not investigate multiple resident-to-resident physical and sexual abuse incidents involving a resident with severe cognitive impairment, nor did it investigate sexual inappropriate behavior affecting another resident. The facility also did not thoroughly investigate an injury/possible neglect event involving a severely cognitively impaired resident found on the floor after care, as the investigation omitted staff names and did not review the care plan requiring 2-person assistance.
A resident with severe cognitive impairment was found with two gowns, one of which was tied tightly below the knees and behind the neck by a CNA to prevent repeated disrobing. This action restricted the resident's movement and access to care, and staff were unaware that this constituted a physical restraint. The intervention was not part of the care plan and was not used to treat a medical symptom, resulting in the resident being left in a semi-fetal position and soiled for an extended period.
A resident with multiple chronic conditions, who was cognitively intact and independent, was subjected to verbal abuse by a CNA after requesting that used towels be removed from the bathroom. The CNA responded dismissively and later engaged in a heated exchange of profanities with the resident, an incident witnessed by the resident's significant other via phone video. The facility failed to protect the resident from verbal abuse by staff.
Two residents experienced incidents involving unexplained bruising and allegations of abuse that were not reported to the appropriate authorities within the required two-hour timeframe. In both cases, facility staff either failed to recognize the need to report or assumed reporting by another entity was sufficient, resulting in noncompliance with mandatory abuse reporting requirements.
A resident with dementia, impaired cognition, and poor balance was left sitting unsupervised on the side of the bed during care, contrary to her care plan and documented need for substantial assistance. While a CNA retrieved clothing from the closet, the resident fell and sustained a large hematoma, requiring emergency evaluation. Staff interviews confirmed the resident's dependence and the lack of supervision at the time of the incident.
A resident with severe cognitive impairment was repeatedly denied proper representation in care planning conferences when the facility incorrectly identified a DPOA for financial matters as the resident representative, rather than the family member responsible for medical decisions. As a result, care conference invitations were sent to the wrong individual, preventing the appropriate representative from participating in decisions about the resident's medical care.
A resident with dementia was moved to a different wing at the facility's request, and the family was only verbally informed of the change by admissions staff and the DON, who cited behavioral reasons. No written notice or explanation was provided, and documentation in the resident's records was lacking.
Two residents who received insulin for diabetes did not have their use of hypoglycemic medications, including insulin, properly documented in the high-risk drug class section of their MDS assessments. This omission was confirmed by the nurse assessment coordinator after review of clinical and medication records.
A deficiency was found when a resident's care plan did not include required PASRR level II recommendations for accommodations related to visual impairment. Although the resident had a history of impaired vision and had declined cataract surgery, the care plan only included general vision care and did not address the specific supports outlined in the PASRR determination. Staff interviews and record review confirmed the omission.
A resident with a heart assist device and history of stroke was not care planned for subacute bacterial endocarditis (SBE) prophylaxis before dental procedures, despite clinical guidelines and a dental consult recommending dental cleaning and restorative work. The absence of an order for prophylactic antibiotics and lack of care plan addressing this need resulted in a failure to meet professional standards of quality.
A resident with moderate hearing loss was not consistently provided with or assisted in using a hearing aid, despite repeated requests and the device being present in the room. Staff were unaware of the resident's need for a hearing aid, and there was no physician order or care plan intervention addressing its use, resulting in the resident's hearing needs not being properly managed.
A resident with a PEG/feeding tube did not receive medications as ordered when an LPN administered multiple crushed medications together and failed to flush the tube with 5 ml of water between each medication, contrary to physician orders. Instead, the LPN flushed with 30 ml of water before and after administering all medications at once.
Two residents with obstructive sleep apnea had CPAP orders that did not specify the required machine settings. Although both residents brought their own CPAP devices and had orders for use at night and removal in the morning, the specific settings were not included in the physician orders, as confirmed by staff interviews.
A medication pass observation revealed that an LPN administered multiple oral medications to a resident with a PEG/feeding tube by crushing and mixing them together, then delivering them all at once, resulting in a medication error rate of 20.45%. The LPN confirmed the medications were not given one at a time as required.
Surveyors observed multiple failures in infection control practices, including an LPN not wearing a gown during medication administration via a feeding tube for a resident on enhanced barrier precautions, and another LPN not changing gloves or performing hand hygiene between wound care tasks for a resident with multiple wounds. Additionally, a CNA improperly donned a gown during incontinence care, resulting in the gown falling onto the resident. These lapses were confirmed by the staff involved and discussed with facility leadership.
Multiple residents did not have their influenza and pneumococcal vaccination status accurately documented, and several were not assessed or offered these vaccines as required. The facility was unable to provide evidence of vaccination or declination when requested, and leadership acknowledged a gap in infection prevention staffing during the period reviewed.
Three residents were not assessed or offered the COVID-19 vaccine after admission, and the facility could not provide documentation of vaccination or declination when requested. The DON reported that the facility was between full-time infection preventionists at the time.
The facility did not have a formalized or evaluated training program for staff responsible for the care of a resident with a left ventricular assist device (LVAD), despite identifying this as a special care need. While some staff demonstrated knowledge and the resident reported appropriate care, the absence of structured competency assessment and training for all relevant staff led to a deficiency.
Two residents were not treated with dignity and respect when an LPN administered medications via feeding tube without providing privacy, and another resident was repeatedly left sitting on a mechanical lift sling in her wheelchair throughout the day, contrary to facility protocol.
Two residents did not have individualized, person-centered care plans addressing their specific needs. One resident with diabetes and insulin use lacked a care plan for diabetes management, while another with peripheral vascular disease and a non-pressure ulcer did not have a care plan addressing non-compliance with wearing protective clothing. These deficiencies were confirmed through record review, staff interviews, and observation.
A resident with severe cognitive impairment and total dependence for ADLs did not receive required incontinence care during an overnight shift. CNA documentation for toileting was missing, and the assigned CNA confirmed she did not change the resident, believing the brief was dry. The resident was later found in a soiled and soaked brief.
A resident with severe cognitive impairment and total dependence on staff suffered significant burns over 15-20% of the body during a shower when two CNAs failed to detect dangerously hot water caused by a malfunctioning mixing valve. The resident, unable to communicate pain, was found with redness and peeling skin after the shower, and subsequent assessment confirmed multiple first- and second-degree burns. The facility's hot water system was later found to be delivering water above safe temperature limits.
Three residents who experienced falls did not have the required post-fall assessments documented by an RN in their EMRs. Instead, LPNs recorded the incidents and immediate assessments, but no RN documentation was present as required by state nursing standards. Facility staff confirmed the absence of RN post-fall assessment documentation in the residents' records.
A resident with COPD and no speech capability experienced respiratory distress, with low oxygen saturation and elevated heart rate. Although a physician's order for as-needed albuterol was in place for shortness of breath, staff did not administer the medication before the resident was sent to the hospital. Staff confirmed the omission during interview, and the medication administration record showed it was not given during the event.
A resident with advanced dementia and impaired communication was assessed for pain using a numerical scale, despite being unable to self-report due to cognitive and speech deficits. Staff did not utilize a non-verbal pain assessment tool as required by the care plan and professional standards, resulting in pain management decisions based on inappropriate assessments after the resident sustained an injury and fracture.
A resident with multiple medical conditions experienced a fall while removing wheelchair footrests. While the incident and a minor injury were noted, the facility did not document a comprehensive post-fall assessment, including vital signs or focused evaluation, as required by professional standards.
A resident was exposed to potential risk when the facility failed to consistently monitor and maintain safe water temperatures, as required by policy and manufacturer guidelines. Water temperature checks were not performed on each floor as required, and mixing valve maintenance was not conducted monthly, leading to a spike in temperature due to sediment buildup. This deficiency highlights lapses in equipment monitoring and adherence to safety protocols.
The facility failed to ensure that food items in unit refrigerators were properly dated and labeled, as required by their policy. Surveyors observed multiple instances of undated and unlabeled food items, including a garden salad, a bag of frozen food, a tea bag, a bowl of cold cereal, fresh strawberries, a Tupperware inside a Ziploc bag, and three frozen beverages. These findings were confirmed by staff and reviewed with the NHA, DON, and Ombudsman representatives.
The facility failed to ensure the residents' right to a dignified existence and privacy for two residents. An LPN referred to a resident as a 'feeder' and stood over the resident while assisting with a meal. In another instance, an RN left the privacy curtain open during a dressing change and signed bandages while they were already on the resident. Both staff members confirmed the findings.
The facility failed to offer a cognitively intact resident the opportunity to formulate an advanced directive, as confirmed by a review of her clinical record and an interview with the social worker.
The facility failed to ensure the accuracy of the MDS assessments for two residents. One resident's mechanical soft diet was not accurately reflected in the MDS assessment, and another resident's ongoing dialysis treatment was not properly coded. These discrepancies were confirmed during interviews with the RNAC and reviewed with facility leadership and Ombudsman representatives.
The facility failed to develop care plans for a resident's missing teeth and another resident's new diagnoses of depression and anxiety disorder. Despite observations and concerns, no care plans were created to address these issues, as confirmed by staff and reviewed with facility leadership.
The facility failed to provide appropriate services and equipment to maintain a resident's range of motion and mobility. Despite a treatment order for an adaptive left hand/wrist orthotic, observations revealed the resident was not wearing it, and staff confirmed it was not being applied as required. Interviews with staff and the Rehabilitation Director highlighted the oversight, contributing to the deficiency.
A facility failed to provide a cognitively intact resident with the admission agreement upon transfer from another skilled nursing facility. The agreement, which includes information on services, charges, consents, policies, advance directives, and resident rights, was not completed until the day of the surveyor's request. This was confirmed by the Assistant Director and discussed during the exit conference with facility leadership and Ombudsman representatives.
The facility failed to include mandatory appeal and ombudsman contact information in the transfer notices for four residents transferred to the hospital. This deficiency was confirmed through record reviews and staff interviews.
The facility failed to ensure resident records were complete and accurate for two residents. One resident's order for a protective eye shield was mistakenly resumed and documented as provided despite not being needed. Another resident's smoking status was inaccurately documented, despite being observed smoking and requiring supervision.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical, sexual, and verbal abuse involving three residents. One resident with unspecified dementia and depression, who had a BIMS score of 0 out of 15, was involved in a physical altercation with a roommate. Nursing documentation stated the resident was witnessed hitting the roommate while the roommate was lying in bed, and staff later found the resident standing over the roommate and hitting her. The roommate, who had a BIMS score of 15 out of 15, was struck while sleeping and had a small scratch on the top of the left hand. Interviews with nursing staff confirmed the incident and that the residents were separated after staff intervened. A second resident with unspecified dementia and major depressive disorder, who had a BIMS score of 6 out of 15, was involved in a sexual abuse incident with another resident. Staff interviews stated that this resident touched, grabbed, and violated women, and that there was an incident in which he grabbed another resident’s breasts. The care plan for this resident addressed making sexual comments or touching others, but the record showed it had not been updated with new interventions since 2017. The DON stated she was unaware of the resident sexually fondling the other resident, and the Administrator also stated she was unaware of current issues involving this resident. A third resident with anxiety and depression, who had a BIMS score of 15 out of 15, reported verbal and physical mistreatment by a CNA. The resident stated the CNA was rude, threw back his covers, and later came behind him at the nurse’s station, grabbed his wheelchair, and pulled him back so hard that he had to hold onto the desk. A written statement from an LPN described an escalated verbal exchange and noted the resident resisted being moved. The facility’s follow-up documentation stated a verbal exchange was witnessed by nursing staff and that the CNA was terminated after the incident.
Failure to Report Resident Abuse, Sexual Misconduct, and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report resident-to-resident physical and sexual abuse incidents to the Administrator within two hours for three sampled residents and failed to report injuries of unknown origin to the State Survey Agency for one sampled resident. The report states that incidents involving residents R153, R82, R136, and R55 were documented in nursing notes, but none of those incidents were found on the facility reportable log. The Administrator later confirmed that none of the resident-to-resident incidents of physical and sexual abuse had been reported. R153, who had diagnoses including unspecified dementia and depression and a quarterly MDS BIMS score of 0 out of 15, was involved in multiple altercations with roommates. One note described R153 hitting roommate R82 while the roommate was lying in bed, with staff intervening and room changes implemented. Another note described R136 reporting that R153 hit her on the arm after R136 tried to pull a privacy curtain. A third note described R153 hitting roommate R55 in the chest after R55 moved a phone cord, followed by R153 throwing items across the room. Staff interviews showed that incidents were observed and discussed, but reporting to management was inconsistent or not completed. The report also identified sexual inappropriate behavior by R48, who had diagnoses including unspecified dementia and major depressive disorder and a BIMS score of 6 out of 15, toward another resident, R140, who had severe cognitive impairment with a BIMS score of 4 out of 15. R48's MAR documented six incidents of sexual inappropriate behavior toward others between August 2025 and May 2026, but there was no documentation identifying which residents were affected. An LPN described observing R48 touching a female resident's breasts and separately grabbing R140's breasts, but stated she did not report the incident and assumed others had done so. The SSD, DON, and Administrator stated they were unaware of these incidents, and the Administrator confirmed they had not been reported. The facility also failed to report injuries of unknown origin for R34, who had dementia with behavioral disturbance, type 2 diabetes, repeated falls, and severe cognitive impairment with a BIMS score of 0 out of 15. R34 was found with a bruise of unknown origin to the right shin, and earlier had bruises of unknown origin to the right breast and left upper arm, along with a contusion to the left great toenail. Documentation stated R34 could not explain the bruises, and staff statements described the injuries as unknown origin. The Administrator stated the facility found no documented evidence that R34's injuries of unknown origin had been reported to the SSA.
Failure to Investigate Resident Abuse, Unknown Injury, and Possible Neglect
Penalty
Summary
The facility failed to investigate multiple resident-to-resident abuse incidents involving a resident with diagnoses of unspecified dementia and depression, whose quarterly MDS showed a BIMS score of 00 out of 15. On 06/14/25, the resident was witnessed hitting a roommate while the roommate was lying in bed, and staff documented that the resident had thrown water on the roommate while she slept. The resident was also documented on 12/31/25 as having hit her roommate on the arm after the roommate attempted to pull the privacy curtain between the beds because the light was too bright. On 3/17/26, the resident was documented as having hit another roommate in the chest after the roommate moved the phone cord. The Administrator confirmed that none of these resident-to-resident physical and sexual abuse incidents had been investigated. The facility also failed to investigate sexual inappropriate behavior involving a resident with diagnoses of unspecified dementia and major depressive disorder, whose quarterly MDS showed a BIMS score of 6 out of 15, and another resident with unspecified dementia and a BIMS score of 4 out of 15. The MAR for the resident with the behaviors documented six incidents of sexual inappropriate behavior toward others from August 2025 through May 2026, with the last documented incident on 05/07/26. The record did not identify which residents were affected. An LPN stated she remembered observing the resident grabbing another resident’s breasts and that the residents were separated, but the Administrator confirmed there was no investigation for the resident-to-resident sexual abuse incidents. The facility failed to thoroughly investigate an injury of unknown origin and a potential neglect incident involving a resident with severe cognitive impairment and a BIMS score of 0 out of 15. After the resident was found on the floor following care by staff, the record stated the CNA reported the resident fell off the bed while care was being provided, and the resident was sent to the hospital for evaluation. The facility’s investigative documentation concluded the resident rolled out of bed during care, but it did not include the names of the CNA and nurse involved and did not review the care plan, which identified the resident required two staff for bed mobility and toileting and had a low air loss mattress. The DON stated the investigation was not thorough and that the care plan should have been reviewed.
Improper Use of Physical Restraint with Tied Gown
Penalty
Summary
A resident with dementia, bipolar disorder, anxiety, and insomnia was found to have been placed in two gowns during the evening shift. The first gown was worn correctly, while the second, oversized gown was gathered and tied in a knot below the resident's knees and behind her neck. This was done by a CNA in response to the resident repeatedly lifting her gown and exposing herself in the hallway. The knotted gown restricted the resident's ability to reposition or straighten her legs, and she remained in this position throughout the evening and night shifts without opportunities for repositioning, incontinence care, or release of the restraint. The resident's care plans documented her severe cognitive impairment, dependence on staff for activities of daily living, and a history of removing clothes inappropriately. Despite these documented needs, the intervention used—tying the gown—was not part of her care plan and was not implemented to treat a medical symptom, but rather to prevent her from exposing herself. Staff involved were unaware that tying the gown in this manner constituted a physical restraint, and the resident was left in a semi-fetal position, unable to move freely or access her body for an extended period. Multiple staff interviews and documentation confirmed that the gown was tied tightly enough that significant effort was required to remove it, and the resident was found soiled and unable to straighten out her legs. The facility's policy clearly states that restraints are only to be used to treat medical symptoms and never for staff convenience or discipline. The use of the gown as a restraint in this case was not in accordance with policy, and the resident was deprived of necessary care and mobility as a result.
Failure to Protect Resident from Verbal Abuse by CNA
Penalty
Summary
A resident with end stage renal failure, heart failure, and morbid obesity, who was cognitively intact and independent with activities of daily living, was involved in a verbal altercation with a CNA. The incident began when the resident requested that used towels be removed from the bathroom before taking a shower. The CNA responded dismissively, suggesting the resident speak to a supervisor if dissatisfied. Later, upon overhearing the resident discussing the issue on the phone, the CNA confronted the resident, yelled profanities, and engaged in a heated exchange. The confrontation was witnessed by the resident's significant other via phone video. Facility records and interviews confirmed that the CNA and the resident exchanged profanities, with the CNA admitting to cursing at the resident after being provoked. The facility's investigation documented the incident as a verbal confrontation, and the CNA was suspended pending investigation. The report concludes that the facility failed to protect the resident from verbal abuse by a staff member.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to report allegations of abuse involving two residents within the required two-hour timeframe. For one resident, clinical records documented the presence of two significant bruises on the inner side of the left arm, with no clear explanation for their origin. The facility's incident report suggested the bruises may have resulted from a transfer, and it was noted that family members had difficulty moving the resident during transportation. Despite this, there was no evidence that the incident was reported to the state incident reporting center as required. In another case, a resident with a history of bipolar disorder and recent hospitalization for a urinary tract infection made an allegation of abuse to hospital staff, which was subsequently reported by the hospital to the state agency. Facility staff were aware of the allegation, and an internal investigation was conducted. However, the Director of Nursing stated that the facility did not report the incident to the state agency, believing it was unnecessary since the hospital had already done so. Interviews confirmed that the allegation was reported internally within two hours, but not to the appropriate authorities.
Failure to Provide Adequate Supervision During Bedside Care Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with dementia, major mood disorder, osteoporosis, and a completely impaired cognitive status was left unsupervised sitting on the side of her bed during care. The resident was documented as requiring substantial to maximal assistance for dressing and moving from lying to sitting, with care plans specifying that the bed should be in the lowest position when care was not being provided. Despite these interventions, a CNA left the resident sitting on the side of the bed while retrieving a top from the closet, during which time the resident fell to the floor. The CNA confirmed that the resident was not in her line of vision due to a pulled curtain and acknowledged that the resident needed significant help because of her weakness. Following the fall, the resident sustained a large hematoma on her forehead and was sent to the emergency room for evaluation. Clinical records and staff interviews confirmed the resident's ongoing need for total assistance due to poor balance and weakness. The facility failed to provide adequate supervision and assistance as required by the resident's care plan and documented needs, resulting in the resident's fall and injury.
Failure to Involve Correct Resident Representative in Care Planning
Penalty
Summary
The facility failed to ensure that the correct resident representative was invited to participate in care planning conferences for a resident with severe cognitive impairment. Record review showed that the resident had a durable power of attorney (DPOA) for financial matters only, appointing one individual (P6), while a family member (F3) was involved in medical care decisions. Despite this, the facility repeatedly listed the DPOA-financial (P6) as the resident representative and sent care conference invitations to this individual, who did not attend or respond. Documentation of care conferences consistently indicated that the DPOA-financial was invited, but there was no RSVP, and the agreement with the plan of care was marked as 'YES' without the appropriate representative's input. Interviews confirmed that the resident's profile incorrectly listed the DPOA-financial as the first point of contact, resulting in the family member responsible for medical decisions not being invited to participate in care planning. This error persisted over multiple care conferences, preventing the correct representative from exercising the resident's rights regarding medical care and treatment decisions.
Failure to Provide Written Notice and Explanation for Room Change
Penalty
Summary
A deficiency occurred when the facility failed to provide a written explanation to the family of a resident with dementia regarding a room change initiated by the facility. The resident had been living on the C wing since admission and was moved to the A wing at the facility's request. The resident's husband was verbally informed of the move by admissions staff and the DON, who cited the resident's behavior as the reason, but no written notice or documentation explaining the reason for the move was provided to the family. Additionally, there was no documentation in the resident's progress notes about the room change, and the Notice of Room Change document lacked the required written explanation for the move.
Failure to Accurately Document Insulin Use in Resident Assessments
Penalty
Summary
The facility failed to accurately document insulin usage for two out of four residents reviewed for assessments. One resident, admitted with diabetes and end stage kidney disease, had a physician order for Insulin Lispro to be administered before meals and at bedtime. However, the resident's quarterly Minimum Data Set (MDS) did not indicate the use of hypoglycemic medications, including insulin, in the section for high-risk drug classes, despite documentation of insulin administration in the electronic medical record. Similarly, another resident received insulin injections twice daily over a specified period, as recorded in the electronic medication administration record, and the MDS noted seven days of insulin injections. Nevertheless, the use of hypoglycemic medications was not documented in the high-risk drug class subsection of the MDS. These omissions were confirmed by the responsible nurse assessment coordinator during interviews.
Failure to Incorporate PASRR Level II Recommendations for Visually Impaired Resident
Penalty
Summary
A deficiency was identified when the facility failed to incorporate the recommendations from a PASRR level II determination into the care plan of a resident with visual impairment. The PASRR level II, completed after a level I referral, specified that the resident required services and accommodations for visual impairment, including support with activities of daily living, nursing care, activities, care plan conferences, and assistance with reviewing or signing medical or financial documents. However, the resident's care plan, last revised prior to the PASRR determination, only referenced general vision care approaches and did not reflect the specific PASRR recommendations. Record review showed that the resident had a history of impaired vision related to diabetes and dense cataracts, had declined cataract surgery, and had periodic eye consultations. During interviews, facility staff were unable to provide documentation that the PASRR level II recommendations had been incorporated into the care plan. The PASRR determination was not readily accessible in the electronic medical record, and staff only obtained it upon the surveyor's request. The deficiency was confirmed through record review and staff interviews.
Failure to Care Plan for SBE Prophylaxis Prior to Dental Procedures
Penalty
Summary
A deficiency was identified when a resident with a history of stroke and the presence of a heart assist device (LVAD) was not care planned for subacute bacterial endocarditis (SBE) prophylaxis prior to dental procedures. The resident was admitted with significant cardiac risk factors, including an artificial heart pump, which requires prophylactic antibiotics before any dental procedures that may invade the gums, as per standard practice and referenced clinical guidelines. Despite a dental consult recommending dental cleaning and restorative work, there was no evidence in the resident's medical record or care plan that SBE prophylaxis was considered or ordered prior to the scheduled dental appointment. The absence of a comprehensive care plan addressing the need for antibiotic prophylaxis for dental procedures in this high-risk resident constituted a failure to meet professional standards of quality. The findings were reviewed with facility leadership during the exit conference.
Failure to Ensure Proper Hearing Aid Use and Care Planning
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that a resident with hearing impairment received proper treatment and assistive devices to maintain hearing abilities. The resident was admitted with intact cognition and initially assessed as having adequate hearing, but subsequent assessments documented increasing difficulty with hearing, progressing to moderate difficulty. Despite the presence of a hearing aid on the resident's bedside table and the resident's repeated requests for assistance with hearing, there was no physician's order for the use of a hearing aid, and the care plan for impaired verbal communication did not include interventions related to hearing aid use. Multiple staff members, including an LPN, were unaware of the resident's use of a hearing aid, and the device was not consistently applied or documented in the resident's care plan or physician's orders. Observations showed the resident frequently without the hearing aid, struggling to hear during interactions, and requesting help to access the device. Interviews with staff and review of records confirmed the lack of documentation and care planning for the hearing aid, despite the resident's ongoing hearing difficulties and the device being available in the room. The deficiency was confirmed through interviews and record reviews, which demonstrated that the facility did not ensure the resident's hearing needs were properly addressed through care planning, staff awareness, or physician orders.
Failure to Follow Physician Orders for Feeding Tube Medication Administration
Penalty
Summary
A deficiency was identified when a resident with a PEG/feeding tube, admitted with a history of traumatic brain injury and NPO status, did not receive care in accordance with physician orders during medication administration. The resident's care plan included tube feeding and specific flushes as ordered by the physician, which required flushing the feeding tube with 5 ml of water between each medication and 30 ml of water before and after each medication. During a medication pass observation, an LPN crushed eight medications and mixed them together with water, administering them all at once through the feeding tube, followed by a single flush of 30 ml of water before and after the administration. The LPN confirmed in an interview that she did not flush 5 ml of water between each medication as ordered, instead administering all medications together and only flushing before and after. This failure to follow the physician's specific orders for medication administration via feeding tube constituted the deficiency.
Failure to Document CPAP Settings in Physician Orders
Penalty
Summary
For two out of three residents reviewed for respiratory care, the facility failed to include the required CPAP machine settings in the physician orders. One resident was admitted with a diagnosis of obstructive sleep apnea and had an order for CPAP use at bedtime and removal in the morning, but the specific machine settings were not documented in the order. Similarly, another resident with obstructive sleep apnea had an order for CPAP use at night and removal in the morning, but again, the settings were not specified. Interviews with facility staff, including the respiratory therapist and the Director of Nursing, confirmed that the CPAP orders for both residents lacked the necessary settings, despite the residents bringing their own machines from home.
Medication Error Rate Exceeds Acceptable Threshold During PEG Tube Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by 9 medication errors out of 44 opportunities during a medication pass observation, resulting in a 20.45% error rate. During the observed medication administration for one resident with a PEG/feeding tube, an LPN prepared and administered multiple oral medications by crushing them together and dissolving them in water, rather than administering each medication separately as required for PEG tube administration. The LPN also prepared and mixed Valproic Acid separately but ultimately administered all medications at the same time through the feeding tube. The LPN confirmed during an interview that all medications were administered simultaneously, not one at a time. The incident was discussed with the nursing home administrator and the director of nursing, and the findings were reviewed during the exit conference. The report does not mention any corrective actions or follow-up steps taken after the incident.
Failure to Implement and Maintain Infection Control Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in the use of personal protective equipment (PPE) and hand hygiene during direct resident care. Specifically, an LPN did not wear a gown while administering medications via a feeding tube to a resident who had a physician's order for enhanced barrier precautions. This omission was confirmed by the staff member involved. Additionally, during wound care for another resident with orders for enhanced barrier precautions, an LPN failed to change gloves and perform hand hygiene between removing soiled dressings and applying clean dressings to multiple wound sites, instead using the same contaminated gloves throughout the procedure. This was also acknowledged by the staff member after the observation. Further, a CNA was observed improperly donning a gown, failing to securely tie it, which resulted in the gown falling onto the resident during incontinence care. The CNA admitted to not knowing the requirement to wear a gown for the care provided and to being in a hurry, which led to improper use of PPE. These deficiencies were observed during direct care activities that required enhanced barrier precautions, as indicated by facility policy and CDC guidance posted in the facility. The findings were reviewed and confirmed with facility leadership.
Failure to Document and Offer Influenza and Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure accurate documentation and proper administration of influenza and pneumococcal vaccines for multiple residents. Specifically, five out of ten residents reviewed did not have their vaccination status accurately documented. Four residents were not offered the pneumococcal vaccine, and six residents were not assessed or documented for the influenza vaccine. In one case, the facility did not check the Delvax system, which showed that a resident had already received the influenza vaccine, and failed to offer the recommended PCV20 pneumococcal vaccine as per CDC guidelines. There was no evidence in the electronic medical records that these vaccines were assessed, offered, or declined for the affected residents. When documentation was requested, the facility was unable to provide evidence of vaccination or declination for the residents in question. During an interview, the DON stated that the facility was between infection preventionists, with a new IP scheduled to start at the end of May. These findings were reviewed with facility leadership during the exit conference.
Failure to Assess and Offer COVID-19 Vaccine to Newly Admitted Residents
Penalty
Summary
The facility failed to assess and offer the COVID-19 vaccine to three out of ten residents reviewed for vaccination. Specifically, for residents admitted on 4/14/25, 2/26/25, and 2/27/25, there was no evidence in their electronic medical records that the facility had assessed or offered the COVID-19 vaccine. Additionally, when documentation was requested, the facility was unable to provide evidence of vaccination or declination for these residents. During an interview, the Director of Nursing stated that the facility was between full-time infection preventionists, with a new infection preventionist scheduled to start at the end of May. These findings were reviewed with facility leadership during the exit conference.
Failure to Formalize and Evaluate Staff Competency for LVAD Care
Penalty
Summary
The facility failed to provide and evaluate staff for appropriate competencies and skill sets regarding the care of a resident with a left ventricular assist device (LVAD). The facility assessment identified the need for staff to have competencies in special care needs, including LVAD care. However, during interviews, the Nursing Home Administrator acknowledged that there were no formalized competencies or comprehensive training in place for LVAD care, despite some informal education efforts by the unit manager. Review of the resident's hospital discharge binder revealed extensive and detailed instructions for LVAD care, but the facility had not implemented a structured training or competency evaluation for staff prior to the survey. A resident with an LVAD reported that staff appeared knowledgeable and followed appropriate precautions during dressing changes, and a unit manager demonstrated understanding of LVAD care tasks. Despite this, the lack of a formalized and evaluated training program for all staff responsible for LVAD care constituted a deficiency, as the facility had not ensured that all staff were properly trained and assessed for competency in this specialized area as required by the facility's own assessment.
Failure to Ensure Resident Dignity and Privacy
Penalty
Summary
Two residents were not treated with dignity and respect as required. In the first instance, a nurse (LPN) administered medications via a PEG/feeding tube to a resident who was lying in bed with the bedroom door left open and the privacy curtain not drawn. This allowed the resident to be visible from the hallway to both visitors and staff during the procedure. The nurse later confirmed that privacy should have been provided during medication administration. In the second instance, a resident with dementia was repeatedly observed sitting in her wheelchair with a blue mechanical lift sling left under her throughout the day, including during meals and activities. Facility staff confirmed that the sling should not remain under the resident while she is seated in her wheelchair. These actions failed to ensure that both residents were treated with dignity and respect.
Failure to Develop Individualized Care Plans for Diabetes Management and Skin Protection
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for two residents with identified needs. One resident was admitted with a diagnosis of diabetes and required insulin, but the comprehensive care plan did not include specific approaches or interventions for managing diabetes or insulin administration. This omission was confirmed by a licensed practical nurse/unit manager during an interview and was discussed with facility leadership during the exit conference. Another resident was admitted with peripheral vascular disease and a non-pressure ulcer of the left ankle, requiring assistance with personal care and interventions to prevent skin breakdown. Although the care plan included encouraging the resident to wear long pants to prevent injury, observations showed the resident repeatedly wearing short pants, with long pants available but not worn. Staff interviews indicated the resident often did not comply with wearing long pants, but the care plan lacked individualized approaches to address this non-compliance. These findings were confirmed through record review, staff interviews, and direct observation.
Failure to Provide Incontinence Care to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for activities of daily living, including incontinence care, did not receive appropriate care during an overnight shift. The resident had a history of severe cognitive impairment, was always incontinent of urine and bowel, and required total assistance with toileting hygiene. The resident's care plan specified the need for a toileting schedule and regular assistance due to cognitive loss and incontinence. On the shift in question, documentation for bladder continence and toilet use was missing from the CNA flowsheet. A CNA assigned to the resident confirmed during an interview that she did not provide incontinence care, stating she checked the back of the resident's incontinence brief and felt it was dry, so she did not change it. However, another staff member later found the resident in a fetal position with her gown tied in a knot and her incontinence brief soaked and very soiled.
Failure to Prevent Resident Burns Due to Inadequate Supervision and Unsafe Water Temperature
Penalty
Summary
A resident with severe cognitive impairment, nonverbal status, and total dependence on staff for activities of daily living was admitted with diagnoses including Alzheimer's disease. The resident's care plan documented impaired verbal communication and required staff to assess non-verbal behaviors and provide close supervision. On the day of the incident, two CNAs were present to provide a shower, with one orienting the other. The CNAs reported checking the water temperature at the start of the shower using both a gloved hand and bare wrist, finding it acceptable. The resident was placed in a reclining shower chair, and the shower began with hair washing. The shower head was placed on the grab bar and wall while shampooing, and the water was not rechecked before rinsing. Redness and skin peeling were noticed only during drying, prompting the CNAs to call an LPN for a skin check. Upon assessment, the LPN observed redness and peeling on the resident's face, neck, forehead, chest, and upper left shoulder. The resident, who was unable to express pain due to his nonverbal status, was found to have sustained burns. Emergency services were called, and the EMT documented multiple first- and second-degree burns over 15-20% of the resident's body surface area, including the chest, abdomen, head, and back. The nurse was unable to explain how the burns occurred, only stating that the water must have been too hot during the shower. The resident was described as a full-care patient, unable to care for himself or follow commands, and was nonverbal at baseline. Subsequent investigation revealed that the facility's hot water temperature was above 120 degrees Fahrenheit due to a malfunctioning mixing valve, which was later found to have sediment affecting its function. The maintenance director confirmed the water temperature exceeded the safe range, but the exact temperature was unknown. The incident resulted in significant burns to the resident, as documented by hospital staff and photographic evidence. The failure to ensure safe water temperature and adequate supervision during the shower led to the resident sustaining serious burns.
Failure to Document RN Post-Fall Assessments
Penalty
Summary
Three residents with histories of conditions such as stroke, dementia, and difficulty walking experienced falls while in the facility. In each case, documentation in the electronic medical record (EMR) was completed by an LPN, who recorded the circumstances of the fall, the immediate assessment, and vital signs. However, there was no evidence in the EMR that a registered nurse (RN) completed or documented the required post-fall assessment as mandated by the Delaware State Board of Nursing Scope of Practice. Interviews with facility staff, including the Corporate Risk Manager and the Nursing Home Administrator, confirmed that RN post-fall assessments were not documented in the residents' progress notes or charts following the incidents. The facility's internal incident reports were not included in the residents' EMRs, and there was no RN documentation present for the falls involving the three residents.
Failure to Administer Ordered Respiratory Medication During Distress
Penalty
Summary
A resident with multiple diagnoses, including Chronic Obstructive Pulmonary Disease (COPD) and dysphonia, was admitted to the facility and documented as having no speech capability. On the day in question, the resident experienced respiratory distress, as noted by staff who recorded that the resident was having difficulty breathing, with oxygen saturation levels in the low 70s and an elevated heart rate. Staff attempted to calm the resident, which led to a slight improvement in oxygen levels, and contacted the nurse practitioner for further intervention, including a stat chest x-ray and oxygen. Despite having a physician's order for albuterol sulfate to be administered as needed for shortness of breath, the medication was not given to the resident during the episode of respiratory distress. Review of the medication administration record confirmed that albuterol was not administered prior to the resident being sent to the hospital for respiratory distress. This was further corroborated by staff interview, confirming the omission of the ordered medication during the critical event.
Failure to Use Appropriate Pain Assessment for Non-Verbal Resident
Penalty
Summary
A resident with dementia and significant communication deficits, as documented in the care plan and MDS, was admitted to hospice and later sustained an injury resulting in swelling, bruising, and a skin tear to the right knee. Staff assessed the resident's pain using a numerical pain scale, despite the resident's inability to communicate verbally or understand others, as indicated by unclear speech and rare comprehension. The care plan specified the need to assess for both verbal and non-verbal signs of pain, but staff failed to use an appropriate pain assessment tool for non-verbal individuals, such as the PAINAD scale. Following the injury, the resident's pain was repeatedly documented using the inappropriate numerical scale, and pain medication was administered based on these assessments. An x-ray later revealed a distal femur fracture, and the resident was transferred to a higher level of care. The DON confirmed that a full assessment, including a pain assessment suitable for residents with severe cognitive deficits, should have been performed. The facility did not follow the care plan or professional standards by failing to use a pain monitoring instrument aligned with the resident's communication abilities.
Incomplete Post-Fall Assessment Documentation
Penalty
Summary
A deficiency was identified when the facility failed to maintain complete and readily accessible medical records for a resident who experienced a fall. The resident, admitted with coronary artery disease, hypertension, peripheral vascular disease, and right-sided hemiplegia, was found on the floor after attempting to remove footrests from his wheelchair. Although progress notes documented the incident and a small skin tear, there was no comprehensive post-fall assessment recorded in the resident's chart, such as vital signs, focused assessment, or range of motion. This lack of documentation was confirmed by the Director of Nursing and reviewed with facility leadership during the exit conference.
Failure to Maintain Safe Water Temperatures Due to Inadequate Equipment Monitoring
Penalty
Summary
The facility failed to maintain the water supply and patient care equipment in safe operating condition for one resident out of twenty-eight reviewed. According to the facility's policy, domestic water temperatures should be maintained between 95-110 degrees Fahrenheit, with mixing valves set at 110 degrees and daily temperature checks required. However, interviews revealed that water temperature recordings on each floor were not being conducted prior to a specific date, and the mixing valve was only being checked every three months instead of monthly as recommended by the manufacturer's maintenance manual. Additionally, there was no evidence of monthly mixing valve cartridge inspections prior to the incident. A resident was showered in a different wing's shower room, not the one where the temperature was checked, raising concerns about the consistency of water temperature monitoring throughout the facility. Maintenance staff discovered a spike in water temperature due to sediment buildup in the mixing valve, which had not been regularly inspected or cleaned. The lack of adherence to both facility policy and manufacturer recommendations for maintenance contributed to the deficiency in ensuring safe water temperatures for residents.
Failure to Date and Label Food Items in Unit Refrigerators
Penalty
Summary
The facility failed to ensure that food items in unit refrigerators were properly dated and labeled, as required by their policy on food brought by family/visitors. During tours of the unit refrigerators, surveyors observed multiple instances of undated and unlabeled food items. Specifically, on the [NAME] unit, an undated and unlabeled garden salad was found. On the Eastburn unit, an undated and unlabeled bag of frozen food, a tea bag, and a bowl of cold cereal were discovered. Additionally, on the [NAME] unit, an undated and unlabeled pint of fresh strawberries and a Tupperware inside a Ziploc bag were found, along with three undated and unlabeled frozen beverages. These findings were immediately confirmed by various staff members, including unit clerks and RNs, and were later reviewed with the Nursing Home Administrator, Director of Nursing, and representatives from the Ombudsman's Office.
Failure to Ensure Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure the residents' right to a dignified existence and privacy for two out of 40 residents observed. During a lunch observation, an LPN referred to a resident as a 'feeder' while removing the resident's lunch tray and stood over the resident while assisting with the meal. In another instance, during a dressing change observation, the privacy curtain to a resident's room remained open, and an RN placed and signed bandages on the resident's foot and buttocks while they were already on the resident. Both staff members immediately confirmed the findings. The findings were reviewed during the exit conference with the Nursing Home Administrator, Director of Nursing, Clinical Resource Manager, and representatives from the Ombudsman's Office.
Failure to Offer Advanced Directive Opportunity
Penalty
Summary
The facility failed to offer a resident the opportunity to formulate an advanced directive. The resident's clinical record showed that she was cognitively intact with a BIMS score of 15, indicating full mental capacity. However, a review of her clinical record revealed no evidence that she was given the chance to create an advanced directive. During an interview, the social worker acknowledged this oversight and stated that she would immediately offer the resident the opportunity to formulate an advanced directive. This finding was discussed during the exit conference with the nursing home administrator, director of nursing, clinical records manager, and representatives from the Ombudsman's Office.
Inaccurate MDS Assessments for Dietary and Dialysis Needs
Penalty
Summary
The facility failed to ensure the accuracy of the MDS assessments for two residents. For one resident, the clinical record indicated a physician-ordered mechanical soft diet, but the quarterly MDS assessment did not accurately reflect this dietary requirement. This discrepancy was confirmed during an interview with the RNAC. For another resident, who was care planned for hemodialysis due to end-stage renal disorder, the quarterly MDS assessment failed to accurately code the ongoing dialysis treatment under the appropriate section. This finding was also confirmed during an interview with the RNAC and reviewed with the NHA, DON, CRM, and representatives from the Ombudsman's Office.
Failure to Develop Care Plans for Dental and Mental Health Needs
Penalty
Summary
The facility failed to develop a care plan to address a resident's missing teeth and another resident's new medical diagnoses of depression and anxiety disorder. For the first resident, an admission MDS assessment documented obvious cavity or broken natural teeth, and during an initial pool screening, the resident was observed to have missing teeth. Despite concerns raised by a family member about the resident losing teeth, a review of the clinical record revealed no care plan addressing the broken teeth. This was confirmed by a registered nurse and unit manager who acknowledged the absence of a care plan for the resident's missing teeth. For the second resident, who was readmitted to the facility with diagnoses of depression and anxiety disorder, the facility failed to develop a person-centered care plan to address these new medical conditions. The resident had physician's orders for lorazepam to manage anxiety, which were adjusted over time. However, a review of the resident's records showed no evidence of a care plan tailored to the resident's depression and anxiety disorder. These findings were reviewed with the nursing home administrator, director of nursing, clinical records manager, and representatives from the Ombudsman's Office.
Failure to Provide Appropriate Services and Equipment for Resident's Range of Motion
Penalty
Summary
The facility failed to provide appropriate services, equipment, and assistance to maintain function and mobility or prevent further decrease in range of motion for a resident's left wrist and hand. The resident, who was readmitted with diagnoses including stroke, left side weakness, and contractures, had a treatment order for an adaptive left hand/wrist orthotic to be worn for five hours as tolerated, with skin checks every shift. However, observations on multiple occasions revealed that the resident was not wearing the orthotic, and the resident confirmed that no one had offered to put it on until asked by the surveyor. Interviews with staff members, including an LPN and a CNA, confirmed that the orthotic was not being applied as required, and the CNA admitted to needing to check the care plan to know the duration for which the orthotic should be worn. Further interviews with the Rehabilitation Director confirmed the resident's condition and the purpose of the orthotic in preventing worsening of contractures. The findings were reviewed with the Nursing Home Administrator, Director of Nursing, and other representatives, including those from the Ombudsman's Office. The lack of adherence to the treatment order and failure to provide the necessary assistance and equipment contributed to the deficiency in maintaining the resident's range of motion and mobility.
Failure to Provide Admission Agreement
Penalty
Summary
The facility failed to provide a cognitively intact resident with the admission agreement upon their transfer from another skilled nursing facility. The resident's clinical record lacked evidence of a signed admission agreement, which should have included information on services, charges, consents, policies, advance directives, and resident rights. This deficiency was confirmed by the Assistant Director (E6) during an interview, who acknowledged that the admission agreement was not completed at the time of the resident's admission but was only finalized on the day of the surveyor's request. The issue was discussed during the exit conference with the Nursing Home Administrator, Director of Nursing, Case Resource Manager, and representatives from the Ombudsman's Office.
Deficiency in Transfer Notices
Penalty
Summary
The facility failed to ensure that all mandatory contents were included in the transfer notices for four residents (R12, R169, R176, R177) who were transferred to the hospital. Specifically, the notices lacked critical information such as the right to appeal the transfer or discharge to the State, the name, address, and telephone number of the State entity that receives appeal hearing requests, information on how to obtain an appeal form, assistance in completing and submitting the appeal hearing request, and the contact details of the Office of the State Long-term Care Ombudsman. This deficiency was confirmed through record reviews and interviews with facility staff, including the Admission Director and the Nursing Home Administrator (NHA), who acknowledged the omission of the required appeal information in the transfer notices. For instance, R12 was transferred to the hospital after hitting her head, and the transfer notice lacked the required appeal information. Similarly, R176 was transferred due to a change in mental status, R177 was sent to the hospital after a fall, and R169 had two hospital admissions, all without the necessary appeal and ombudsman contact information in their transfer notices. These omissions were confirmed during interviews with the Admission Director and the NHA, who admitted that the current transfer forms did not include the complete appeal and ombudsman contact information. The findings were reviewed with the NHA, Director of Nursing (DON), Clinical Resource Manager (CRM), and representatives from the Ombudsman's Office.
Incomplete and Inaccurate Resident Records
Penalty
Summary
The facility failed to ensure resident records were complete and accurate for two residents. For one resident who had cataract surgery, an order for a protective eye shield was mistakenly resumed upon readmission to the facility, despite the resident not needing it. Staff continued to document that the eye shield was provided, even though the resident did not wear it. Interviews with staff confirmed the error and the incorrect documentation, and the resident confirmed that the eye shield had not been needed or worn for months. For another resident with diagnoses including diabetes, hypertension, and chronic obstructive pulmonary disease, the facility's smoking screen evaluations inaccurately documented that the resident did not smoke. Despite this, the resident was observed smoking outside, and staff confirmed that the resident was indeed a smoker. The discrepancies in the smoking evaluations and the care plan, which indicated the resident required supervision while smoking, were confirmed by staff and reviewed with facility administration and representatives from the Ombudsman's Office.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 604 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hockessin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willowbrooke Court At Cokesbury Village | 0.8 mi | ★★★★★ | 0 | 0 |
| Coral Springs Rehab & Healthcare | 2.1 mi | ★★★★★ | 8 | 0 |
| Cadia Rehabilitation Pike Creek | 2.5 mi | ★★★★★ | 3 | 0 |
| Complete Care At Brackenville Llc | 2.7 mi | ★★★★★ | 4 | 0 |
| Pike Creek Nursing & Rehabilitation Center | 2.8 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.