Regal Heights Healthcare & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hockessin, Delaware.
- Location
- 6525 Lancaster Pike, Hockessin, Delaware 19707
- CMS Provider Number
- 085006
- Inspections on file
- 24
- Latest survey
- May 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Regal Heights Healthcare & Rehab Center during CMS and state inspections, most recent first.
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.
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.
Latest citations in Delaware
Multiple cognitively impaired residents with known behavioral issues, including wandering, agitation, and physical aggression, were not adequately protected from resident‑to‑resident abuse. In one case, a resident with dementia and PTSD was pushed to the floor by another resident who had a history of combative behavior, resulting in multiple fractures and facial lacerations after staff initially documented the event as an unwitnessed fall. In another case, two residents with dementia and psychotic features engaged in a physical altercation in a dayroom after one placed his hand on the other’s chest, leading to mutual punching. A separate incident occurred when a resident with dementia and behavioral disturbances entered another resident’s room, pulled at the bedcovers, yelled that the room was his house, and allegedly struck the other resident, who was later noted with puffiness around one eye. In all incidents, the involved residents had documented behavioral care plans and significant cognitive impairment, yet physical confrontations still occurred.
A resident with dementia, spinal stenosis, and total dependence for transfers, care-planned for Hoyer lift use with two-person assist, was being transferred from a shower bed to a Geri-chair when the Hoyer lift tipped sideways. Staff reported the lift’s legs had been widened and that one CNA manually pushed the feet apart instead of using the control, and straps may have been unevenly positioned. The resident was lowered to the floor while still in the sling and sustained a small skin tear to the elbow; imaging later showed no fractures. The DON stated that three CNAs were involved, including one on light duty who was not supposed to be using the lift, and that no mechanical defect was found with the lift.
The facility failed to thoroughly investigate several allegations of verbal and potential physical abuse involving four cognitively intact residents with conditions including hemiplegia, rheumatoid arthritis, type 2 DM, epilepsy, and heart disease. In each case, the facility’s investigations were limited, often including only the directly involved resident and omitting interviews with other potentially knowledgeable residents or staff. One resident reported a verbal altercation with a CNA after a fall to the floor, another reported being verbally abused by a roommate’s family member, a third reported a male CNA was too rough and upset while changing linens, and a fourth reported a staff member insulted her and refused brief care. Investigation files lacked broader resident and staff interviews, timely physical and psychosocial assessments, and review of the accused staff member’s employee record, contrary to the facility’s abuse policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
A resident with rectal cancer and intact cognition reported that an RN on night shift confronted him when he returned from smoking off campus, spoke to him loudly about his smoking, used profanity, and threatened to have staff refuse to buzz him back into the building. A CNA corroborated that the RN was upset about being called in to work and used curse words toward the resident, but did not report the incident at the time because the RN was the night supervisor. The resident reported the event to the Social Services Director the next day, yet the facility initially treated it as a grievance rather than abuse and delayed submitting a report to the State Survey Agency until weeks later, after determining it was a reportable abuse incident.
Two residents did not receive required ADL and hygiene care as care planned. One resident with dementia and osteoarthritis, dependent for toileting and personal hygiene, was not toileted during an evening shift, with CNA documentation showing no toileting and the oncoming CNA finding the resident’s clothing, linens, and mattress saturated with urine; the assigned CNA reported care resistance but did not notify an RN or LPN. Another resident with dementia and stroke, requiring assistance with dressing and personal hygiene, remained in bed in pajamas into the afternoon without having received morning care, despite CNA documentation indicating dressing was completed; the CNA later confirmed that care was only provided after being questioned by an RN supervisor following a family complaint.
A resident with left-sided weakness after a stroke, high fall risk, and total dependence for ADLs and bed mobility was being turned onto their side for peri care by an aide when they fell from the bed to the floor, sustaining head trauma and a scalp laceration while on blood thinners. The care plan required extensive to total assistance with two-person support for bed mobility, but the fall occurred during care without documentation of the required level of assistance, indicating the facility did not provide adequate supervision and assistance to prevent accidents as outlined in its own fall prevention practices.
A resident with significant upper extremity weakness and recent surgery was discharged home to a multi-story residence without confirmed DME delivery, home health services, or caregiver support. Although referrals for home health, skilled nursing, and DME were made and family attended a discharge care plan meeting, staff did not verify that services were active, did not set or confirm a start-of-care date with the agency, and did not confirm delivery of a hospital bed. The resident, who lived alone and could not manage fine motor tasks, arrived home without in-home assistance, reported difficulty with eating and self-care, and was later found by an HHA RN in unsafe conditions, unable to access food or medications, leading to emergency transport back to the hospital.
A resident with dementia, Parkinson’s disease, CHF, and a history of AKI had documented fluid goals and was identified as at risk for dehydration and malnutrition, yet daily intake records repeatedly showed fluid consumption well below the recommended amounts. Despite severely impaired cognition, poor oral intake, and documented changes in mentation, lethargy, falls, and restlessness, the facility did not consistently implement or document enhanced monitoring, assistive feeding measures, or timely provider consultation focused on hydration. The resident was hospitalized twice with AKI, dehydration, hypotension, and anemia, and staff interviews confirmed that while expectations existed to encourage fluids and notify providers when goals were not met, there was no clear evidence that these expectations were carried out for this resident.
A resident with cardiac conditions was discharged home with a documented post-discharge plan for home health aide, home health RN/LPN, and PT/OT, but the facility did not complete the home health referral before discharge. The resident went home with a family member and, according to a complaint, did not receive PT, OT, or a nursing wellness check for about a week. The SW later confirmed the referral for home health and therapy services was not requested until several days after discharge, and services did not begin until even later, despite therapy recommendations that are typically communicated to social services to arrange home care.
The facility failed to consistently revise care plans to reflect residents’ current needs and behaviors and did not ensure a cognitively intact resident was involved in ongoing care planning. One resident participated in an initial care conference but was not included in later care plan updates. Another resident with an order for a palm protector was frequently observed without it and often refused it, yet the care plan did not address refusals. Two cognitively impaired residents whose MDS assessments showed dependence for bathing had care plans that still listed only setup or one‑person assist. A cognitively impaired resident with combative behaviors and an incident of striking another resident had a behavior care plan that was not updated to include attempts to hit other residents or the risk of resident‑to‑resident altercations.
Failure to Prevent Resident‑to‑Resident Physical Abuse Among Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from resident‑to‑resident physical abuse. One resident with dementia, agitation, depression, anxiety, and PTSD, and a BIMS score indicating moderate cognitive impairment, was pushed to the floor by another resident after that resident entered his room and followed him into the hallway. Staff initially documented the event as an unwitnessed fall after hearing loud screaming and finding the resident on the floor with complaints of right shoulder and left wrist pain, active bleeding from facial lacerations, and clamminess. Subsequent review of surveillance footage showed that another resident walked into the victim’s room, then followed him out and pushed him, causing the fall that resulted in multiple fractures, including a closed left distal radius fracture, a closed, displaced comminuted right proximal humerus fracture, and a closed, displaced distal clavicle fracture. The resident who pushed him had dementia with mood disturbances, bipolar disorder with psychotic features, PTSD, insomnia, and depression, and a BIMS score indicating severe cognitive impairment. His care plan identified a behavior problem related to bipolar disorder and dementia, including wandering, refusal of care, and physical aggression toward staff and others, such as biting a CNA and swinging a walker at a CNA. The care plan directed staff to anticipate and meet his needs, divert him with alternative objects or activities, intervene to protect the rights and safety of others, and conduct safety checks. Despite these identified risks and interventions, he was able to enter another resident’s room and subsequently push that resident in the hallway, resulting in serious injury. Another incident involved two residents with significant cognitive impairment and behavioral symptoms, including delusions, physical behaviors toward others, agitation, and a tendency to invade others’ personal space. One resident, who was described as aggressive toward others, easily agitated, and prone to getting into others’ personal space, walked next to another resident sitting in a dayroom chair and placed his hand on that resident’s chest. The seated resident responded by punching him in the face with the back of his fist, and the first resident then punched back. Staff and psychiatric documentation noted this altercation and ongoing behavioral concerns such as combativeness with care, agitation, and wandering, but the record contained no additional progress notes describing the incident itself beyond the brief psychiatric follow‑up entry. A further incident occurred when a resident with anxiety, major depressive disorder, dementia with behavioral disturbances, agitation, and severe cognitive impairment entered another resident’s room on the memory care unit. The resident in the room, who had depression, anxiety, dementia without behavioral disturbances, PTSD, insomnia, hallucinations, verbal behaviors toward others, other behavioral symptoms, and wandering, reported that he was hit in the face. Staff heard yelling and found the intruding resident pulling covers at the foot of the bed and yelling that the room was his house, while the other resident sat on the side of the bed and stated that he had been hit and told staff to get a gun and shoot the other resident. Slight puffiness was noted around the reporting resident’s left eye. The intruding resident’s care plan documented compulsiveness, invading others’ personal space, yelling, restlessness, physical aggression, and attempts to assist other residents he believed needed help, with interventions to divert him, familiarize him with his surroundings, and intervene to protect the rights and safety of others. Despite these identified behaviors and interventions, he was able to enter another resident’s room, engage in a confrontation, and allegedly strike the resident.
Resident Injury from Improper Hoyer Lift Operation During Transfer
Penalty
Summary
The deficiency involves the facility’s failure to prevent an accident during a Hoyer lift transfer, resulting in a fall and skin tear injury to a resident. The resident had diagnoses including spinal stenosis, Alzheimer’s disease, vascular dementia with behavioral disturbance, bipolar disorder, and pain, and was documented on the MDS as dependent on staff for transfers from bed to chair. The care plan and physician orders specified that the resident required a Hoyer lift with assistance of two staff for transfers. On the day of the incident, the resident was being transferred via Hoyer lift after a shower, from a shower bed back to a Geri-chair. Progress notes and the post-fall evaluation documented that the fall occurred in the bathroom during a Hoyer transfer with staff assistance of two, and that the Hoyer lift tipped sideways. The resident was found on the floor in the sling, with staff reporting that the Hoyer lift’s legs were widened and that as the resident was being positioned over the chair, the lift tipped to the side. Staff held the sling on each side of the resident’s head and lowered the resident to the floor, after which a skin tear measuring 1.0 cm x 0.1 cm was noted on the elbow. The facility’s investigation determined that the Hoyer tipped because one CNA pushed the lift’s feet apart manually instead of using the designated button to open the legs. Interviews indicated that the manual mechanical lift used at the time was considered less steady and required manual operation of a foot pedal to open the legs, and that the straps may have been more to one side than the other. The DON reported that three CNAs were involved with operating the lift at the time of the incident, including one CNA on light duty who was not supposed to be using the Hoyer lift, and that the lift itself was later found to have no mechanical problems. As a result of the tipping incident, the resident sustained a skin tear to the elbow and required diagnostic imaging to rule out fractures.
Incomplete Investigations of Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of verbal or potential physical abuse as required by its abuse, neglect, and exploitation policy. One cognitively intact resident with hemiplegia following a stroke reported a verbal altercation with a CNA after sliding to the floor while being assisted back to bed. The resident requested use of a Hoyer lift, the CNA told him he could get himself up, and an argument ensued in which the CNA told the resident it was not his room and did not leave until directed by an LPN. The facility’s investigation file for this incident contained only the resident’s interview and no interviews with other residents on the unit who might have had knowledge of similar verbal abuse by the CNA. Another cognitively intact resident with rheumatoid arthritis, hypertension, and peripheral vascular disease reported that her roommate’s daughter came into her room and verbally abused her after the roommate had been relocated due to aggression. The daughter allegedly cursed at the resident, calling her an offensive name and telling her she was going to hell. The investigation file for this incident contained no interviews with other residents on the unit to determine whether they had experienced verbal abuse by this family member or had knowledge of the event. The DON acknowledged that no such interviews were conducted. A third cognitively intact resident with type 2 diabetes and epilepsy reported, through her daughter, that a male CNA wearing a red shirt was too rough with her and appeared upset about having to change her linens. The facility’s investigation into this potential staff-to-resident abuse included an interview with the resident but did not include interviews with other interviewable residents in the same area who might have had knowledge of the incident. A fourth cognitively intact resident with type 2 diabetes and heart disease, later discharged, reported that a staff member entered her room, called her a poor excuse for a human being, and refused to assist with changing her brief. The investigation documentation for this allegation lacked interviews with additional residents or staff, did not show that the resident was promptly assessed physically and psychosocially in relation to the allegation, and did not include a review of the accused staff member’s employee record, resulting in an incomplete investigation contrary to facility policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
Failure to Protect Resident From Verbal Abuse and Delay in Reporting Incident
Penalty
Summary
The facility failed to protect a cognitively intact resident from verbal abuse by a staff member. The resident, admitted with rectal cancer and independently ambulatory with a rolling walker, reported that during an overnight shift he left the campus to smoke and, upon returning and walking toward the nursing station, was confronted by an RN. According to the resident’s report, the RN told him that when she was on the night shift he was not allowed to go outside, using profanity toward him, and further stated that if he went out the door she would instruct staff not to buzz him back into the building. A CNA later confirmed that the RN had been upset about being called in to work, spoke loudly to the resident about his smoking, and used curse words when he responded to her. The incident was not promptly reported to facility administration despite occurring during the night shift, with the CNA stating that the RN involved was the supervisor at the time. The resident reported the incident the following day to the Social Services Director, but the facility did not immediately recognize or treat the allegation as reportable abuse. Instead, the administration initially considered it a grievance and investigated it in that manner. The incident report was not submitted to the State Survey Agency until several weeks after the resident’s report, and only after the facility later determined that the event constituted a reportable abuse incident.
Failure to Provide Required ADL and Hygiene Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL assistance to maintain grooming and personal hygiene for two dependent residents. One resident with dementia, osteoarthritis, and moderately impaired cognition was care planned to receive partial to substantial assistance with personal and oral care, scheduled toileting every two hours, and assistance with toilet transfers. CNA documentation for an evening shift showed “N/A” for all scheduled toileting times, and a facility incident report stated that the CNA assigned to this resident failed to provide incontinence care during that shift. The oncoming night-shift CNA later found the resident’s clothing, linens, and mattress saturated and soaked with urine and provided the needed care, with the prior-shift LPN confirming the condition when notified. The assigned CNA reported the resident was resistant to care but did not notify the LPN or RN for assistance or document the issue. The second resident, with dementia, stroke, weakness, and moderately impaired cognition, was care planned for an ADL self-care deficit requiring setup or cleanup assistance with eating, partial to substantial assistance with personal hygiene and oral care, and substantial assistance with toileting, showering/bathing, and lower body dressing. On a morning shift, the resident’s daughter-in-law reported to the LSW that she did not believe the resident had received morning care because he was still in bed wearing pajamas and had not yet received his lunch tray. A CNA statement indicated the resident had eaten breakfast and was later found asleep in bed, and CNA documentation for that shift showed the dressing task as completed. However, the facility’s follow-up summary documented that the CNA confirmed care had not been provided to the resident prior to being questioned by the RN supervisor, and the LSW confirmed that the CNA changed the resident only after the family reported the concern and nursing was notified.
Failure to Provide Adequate Supervision and Assistance During Bed Mobility for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for a resident with significant functional and cognitive impairments. The resident was admitted with left-sided weakness after a stroke and was care planned as extensively to totally dependent for bed mobility, requiring the support of two persons. A fall risk evaluation documented a score of 10, indicating high fall risk, and a quarterly MDS assessment showed the resident was unable to participate in a cognitive assessment and was completely dependent on staff for all ADLs. Despite these identified needs and risks, the resident was being turned onto their side for peri care by an aide when they fell from the bed to the floor. During this incident, the resident sustained head trauma and a small scalp laceration, and was on blood thinners at the time of the fall. The fall occurred while the aide was providing peri care and turning the resident, but the report does not document the presence of a second staff member, despite the care plan indicating the need for two-person assistance for bed mobility. The facility’s own policy on falls emphasized instituting individualized practices to minimize fall risk and maximize safety for residents identified as high risk, but the resident’s documented high fall risk and total dependence were not adequately addressed in the supervision and assistance provided at the time of the fall.
Failure to Ensure Safe Discharge with Confirmed Home Services and Support
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s discharge home included confirmed durable medical equipment (DME), home health services, and adequate caregiver support. The resident was admitted with spinal stenosis, cervical disc disorder, muscle weakness, carpal tunnel syndrome, and a recent post-fasciotomy to the right arm, and was documented as cognitively intact with a BIMS score of 14/15. Despite these physical limitations, the facility discharged the resident home in the evening via medical transport to a three-story residence, where no caregiver support was present. The facility’s own policy required a post-discharge plan of care developed with the resident and representative, and orientation to ensure a safe and orderly transfer or discharge, but the record lacked evidence that services were confirmed as in place prior to discharge. Prior to discharge, the social worker documented that the resident would have a safe discharge home with services and supports in place, and that referrals for home health care, skilled nursing services, and DME had been made, with family members in attendance at the discharge care plan. However, the clinical record did not contain confirmation that these services were actually arranged and active before the resident left the facility. The resident was discharged with medications called to the pharmacy for home delivery, but there was no documentation that the hospital bed had been delivered or that home health nursing, therapy, or home health aide services were scheduled to start at the time of discharge. The social worker later acknowledged not informing the agency of a specific start-of-care date, assuming the agency and VA would contact the resident, and confirmed not calling to verify delivery of the hospital bed. After discharge, it was discovered that the hospital bed ordered days earlier was not delivered until the morning after the resident arrived home, and that therapy, RN, and HHA services had not yet begun or contacted the resident by the time the facility followed up. The resident reported living alone, being unable to use their hands, needing a caretaker, and having to rely on a sister-in-law for limited assistance with hygiene, meals, and rearranging furniture for the bed that arrived later. The significant other confirmed that no one lived with the resident, that they had their own health issues, and that neither they nor their son stayed with the resident after discharge. When a home health RN eventually visited, the resident was found sitting on a couch in minimal clothing, reporting not having eaten adequately for two days, having little or no accessible food, and being unable to open medications or bottles due to impaired fine motor skills. The RN observed the resident’s inability to grip or perform fine motor tasks, assisted with toileting, and then contacted the agency director and emergency services due to the unsafe conditions in which the resident had been left. These events led surveyors to determine that the facility failed to ensure services and caregiver support were in place prior to discharge, resulting in an immediate jeopardy situation.
Removal Plan
- Audited discharge documentation related to home health services, appropriate caregiver/family support, and any necessary services to meet residents' care needs to determine if any residents were affected.
- Reviewed planned discharges by the Administrator, DON, Director of Social Services, and Director of Rehabilitation to ensure home health services, appropriate caregiver/family support, and necessary services to meet the resident's care needs are in place before discharge.
- Completed a root cause analysis identifying failure to have a robust discharge care plan meeting with the interdisciplinary team (IDT), resident, and resident representative.
- Reviewed the procedure for safe and effective discharge planning with the IDT.
- Re-educated the discharge planning IDT on the discharge policy and procedure to ensure sufficient preparation and orientation for a safe discharge.
- Implemented review of residents scheduled to be discharged to ensure appropriate discharge planning is in place.
- Implemented review of residents scheduled for discharge to ensure ADL support is in place, durable medical equipment is available prior to or on the discharge date, medications are available upon discharge, and identified needs/support are available.
- Implemented review of residents scheduled for discharge to ensure safe discharge planning is in place and to address any issues identified.
- Implemented oversight during utilization review by the NHA/designee to ensure discharge planning preparation and services are in place prior to discharge.
- Initiated audits and educational in-services to the IDT team and conducted staff interviews to confirm education received regarding discharge to the community and/or transfers to other facilities.
Failure to Maintain Adequate Hydration Resulting in Recurrent AKI and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate hydration for a resident with significant medical conditions, including acute kidney injury (AKI), congestive heart failure (CHF), dementia, and Parkinson’s disease. Upon admission, the resident’s care plan identified potential for altered nutrition and included interventions such as assisting at meals, encouraging oral fluids, and monitoring for additional nutrition interventions. A nutrition assessment established an initial fluid goal of 1943–2098 mL/day and documented that the resident was at risk for dehydration and malnutrition, with early labs showing a BUN of 29, creatinine of 1.4, and eGFR of 53. The admission MDS documented that the resident was severely cognitively impaired and required setup assistance for feeding and hydration. Daily fluid intake records from CNA task flow sheets and the MAR showed that the resident’s intake frequently fell below the recommended fluid goals, with multiple days of intake under 1200 mL and some days as low as 360–720 mL. A malnutrition risk assessment identified the resident as at risk for malnutrition due to severe dementia and tremors. A subsequent nutrition note on 5/12/25 documented that the resident’s average fluid intake was 330 mL/day, recommended discontinuing a prescribed hydration pass due to CHF, and set a new fluid goal of 1635–1766 mL/day, while continuing to recommend encouraging oral fluids. Despite these documented risks and low intakes, there is no evidence in the record of intensified monitoring or additional interventions to ensure the resident met the revised fluid goals. The resident experienced multiple clinical deteriorations associated with poor intake and changes in condition. On 6/1/25, after a day with only 360 mL of recorded intake, the resident was transferred to the hospital following falls, hypotension, and confusion, and was admitted with AKI and dehydration. After readmission to the facility, nursing documentation noted low oral intake and a plan to discuss adding the resident to an assist-to-feeding list, but the record lacked evidence that this occurred. Subsequent notes documented lethargy, increased confusion, agitation, restlessness, and continued poor intake, yet a physician progress note following two unwitnessed falls did not include an assessment of hydration status or interventions to improve hydration. On 6/19/25, labs showed a BUN of 62 mg/dL and creatinine of 1.7 mg/dL, and the resident was again sent to the hospital and admitted with AKI, hypotension, and anemia, requiring IV fluid resuscitation. Staff interviews confirmed expectations to monitor intake, encourage fluids, and notify providers when fluid goals were not met, but there was no documentation that the provider was consistently notified or that appropriate interventions were implemented in response to the resident’s ongoing inadequate fluid intake and changes in condition.
Failure to Arrange Timely Home Health Services Prior to Discharge
Penalty
Summary
The facility failed to ensure a timely referral for home health care services prior to discharge for one resident. Facility policy dated 5/1/25 required sufficient preparation and orientation to residents to ensure an orderly transfer or discharge. The resident was admitted on 7/28/25 with diagnoses including aortic valve replacement, aortic regurgitation, and congestive heart failure. A discharge summary dated 8/11/25 documented a post-discharge plan for home health aide, home health RN/LPN, and occupational and physical therapy. The resident was discharged home with a family member on 8/12/25. A complaint received by the Division on 9/30/25 stated that the resident was discharged to a family member's home without a home health care agency referral and that, after one week at home, the resident had not received any physical or occupational therapy or a wellness check from a nurse. During an interview on 2/16/26, the social worker reported needing to check if a referral was made and later confirmed that the referral for home health and therapy services was not requested until 8/15/25, with services opened on 8/20/25. The director of therapy confirmed that physical and occupational therapy were recommended for the resident and stated that such recommendations are typically communicated to social services to set up home care. Findings were reviewed with facility leadership during the exit conference.
Failure to Revise Care Plans and Involve Resident in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise person‑centered care plans and to involve a cognitively intact resident and/or representative in the care planning process. One resident with an intact BIMS score of 15 was admitted and had a documented care conference shortly after admission, but there was no evidence of any subsequent care conferences during the following year despite multiple care plan updates. The resident reported not recalling quarterly care plan meetings, and staff confirmed that no care conferences occurred after the initial one, with no documentation that the resident or representative participated in the later care plan revisions. Additional residents’ care plans were not revised to reflect current, individualized needs and behaviors. One resident had a physician’s order for a right palm protector or substitute, was repeatedly observed without it in place, and routinely refused it according to nursing and CNA interviews, yet the care plan did not address potential refusals. Two cognitively impaired residents whose MDS assessments documented dependence for bathing had care plans that continued to list only setup assistance or one‑person assist, without updating to reflect full dependence. Another cognitively impaired resident with documented combative behaviors toward staff and a reported incident of striking another resident with a remote had a behavior care plan that was not revised to include the new behavior of attempting to hit other residents or the potential for resident‑to‑resident altercations.
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