Regency Healthcare & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, Delaware.
- Location
- 801 N. Broom Street, Wilmington, Delaware 19806
- CMS Provider Number
- 085012
- Inspections on file
- 29
- Latest survey
- July 2, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Regency Healthcare & Rehab Center during CMS and state inspections, most recent first.
Two residents experienced deficiencies in care: one had a soiled and wet wound dressing left unchanged despite a physician's order and visible need, while another's ER discharge orders for PEG site cellulitis were not properly reviewed with the on-call provider or accurately transcribed by an LPN, resulting in staff being unaware of the new treatment order.
A resident with dementia did not receive timely follow-up dental services after refusing an initial exam and treatment, despite a provider's recommendation and a physician's order for dental evaluation. Nursing staff did not schedule the necessary follow-up, and the resident's family was not notified of any dental consults, resulting in a significant delay in dental care.
The facility failed to implement person-centered care plans for three residents, including a Spanish-speaking resident without a communication plan, a resident with an inadequate activity plan, and a resident with multiple falls due to unmet toileting needs. These deficiencies highlight the facility's inability to meet individual resident needs effectively.
A resident with dementia and bipolar disorder did not receive quetiapine fumarate as ordered due to the medication being unavailable and delayed delivery from the pharmacy. The facility failed to notify the physician promptly about the unavailability, resulting in missed doses. The issue was confirmed through staff interviews and discussed with facility leadership.
The facility did not ensure a certified food protection manager was present during all hours of operation in the food and nutrition service. Only one staff member with the necessary certification was scheduled to work part-time, while two other certified staff members were not scheduled at all. This absence of coverage increases the risk of foodborne outbreaks for vulnerable populations.
Two residents with cognitive impairments engaged in repeated aggressive interactions, including throwing water and hitting with a toilet seat cover, due to the facility's failure to effectively implement its abuse prevention program.
The facility failed to ensure accurate MDS assessments for three residents, resulting in discrepancies in their documented status. A resident's preferred language was incorrectly recorded, another resident's medication usage was not accurately reflected, and a third resident's physical limitations were inaccurately documented. These issues were confirmed during interviews and discussed with facility leadership.
A facility failed to coordinate with the PASRR program for a resident admitted without a known mental health diagnosis. After admission, the resident was found to have a history of depression, anxiety, and paranoia, and was prescribed medications for these conditions. Despite worsening anxiety and recommendations for further psychiatric evaluation, the facility did not submit a referral to the PASRR office, indicating a lapse in care coordination.
A resident with dementia experienced a decline in urinary continence and multiple falls related to toileting needs. Despite being a high fall risk, the facility did not implement a toileting program, leading to continued falls and incontinence issues. Observations and staff interviews confirmed the resident's need for supervision, which was not adequately provided.
A resident who spoke only Spanish and required an interpreter was not provided with translation services during two post-fall assessments. Documentation showed the resident was unable to communicate what happened due to language barriers, and there was no evidence that translation services were used during these incidents, despite facility policy requiring meaningful access for individuals with limited English proficiency.
A resident who was completely dependent on staff and required two-person assistance for all activities, including showering, was left in the care of a single aide during a shower. This led to the dislodgement of the resident's nephrostomy tube and multiple abrasions and bruises, requiring two emergency room visits for evaluation and treatment. Staff interviews and documentation confirmed that the care plan for two-person assistance was not followed, resulting in harm.
A resident admitted with seizure and anxiety diagnoses did not receive multiple doses of three ordered medications because staff failed to complete and send required C2 prescription forms to the pharmacy. As a result, the pharmacy did not deliver the medications, and staff documented missed doses over several days while attempting to resolve the issue.
A resident admitted with seizure and anxiety diagnoses did not receive prescribed controlled medications because the required C2 forms were not completed by the admitting MD or on-call NP. Despite repeated notifications from nursing staff, the necessary documentation was not provided to the pharmacy, resulting in the resident missing multiple doses of seizure and anxiety medications over a period of more than sixty hours.
A resident with normal cognitive function alleged inappropriate sexual contact by a CNA during care. Although the allegation was disclosed to multiple staff members and led to informal assignment changes, the incident was not reported to the Administrator or State Agency within the required timeframe. The delay in reporting occurred because staff assumed others had already reported the incident, resulting in a three-day lapse before authorities were notified.
A resident with a care plan for aggression was verbally abused by a staff member in the dining room after feeling ignored. The resident expressed frustration, leading to a verbal altercation with the staff member, who used derogatory language. Witnesses confirmed the exchange, highlighting the facility's failure to protect the resident from verbal abuse.
A facility failed to ensure an accurate MDS assessment for a resident's hearing status. The resident was admitted with a hearing aid, but the MDS incorrectly noted no hearing appliance use. This error was confirmed by the RNAC and discussed with the NHA and DON.
Failure to Follow Physician Orders and Properly Transcribe Readmission Orders
Penalty
Summary
For one resident, a failure to follow the physician's order for wound care was observed. The resident, who had intact cognition and required assistance with personal care, had a physician's order to have a right wrist skin tear cleansed and dressed daily and as needed. Despite the dressing being visibly soiled and wet after a shower, the nurse on duty did not change it, stating that the dressing was scheduled to be changed later in the day. The resident expressed an expectation that the dressing would be changed immediately due to its condition, but the nurse walked away without addressing the issue. The Director of Nursing confirmed that the dressing should have been changed when it was found to be soiled or wet, not just according to the scheduled time. For another resident, the facility failed to ensure that re-admission orders from the emergency room were properly reviewed and transcribed. Upon return from the ER with a diagnosis of cellulitis at the PEG tube site, the resident was to receive Bacitracin ointment twice daily for ten days. The LPN entered the order into the electronic medical record without reviewing the ER discharge order with the facility's on-call provider, as required by facility protocol. Additionally, the night shift nursing staff was unaware of the new order, and the RN/House Supervisor confirmed that the standard process of reviewing discharge orders with the provider was not followed.
Failure to Provide Timely Follow-Up Dental Services
Penalty
Summary
A resident with dementia was admitted to the facility and later refused a dental exam and treatment, with the dental provider recommending pre-sedation for any further dental care. The dental consultation report included a handwritten note instructing nursing staff to check the oral cavity for follow-up needs and to make a follow-up dental appointment. Despite a physician's order for a dental consult and documentation of the resident's moderate cognitive impairment, there was no evidence that a follow-up dental appointment was scheduled or completed until much later. The resident's family member reported not being notified of any dental consults and observed that the resident's teeth had not been cleaned by a dentist for about a year. Facility leadership confirmed that the follow-up dental appointment had not occurred until the day of the surveyor's inquiry.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for three residents, leading to deficiencies in meeting their individual needs. For one resident, who was admitted with a preferred language of Spanish, the facility did not create a communication care plan addressing the language barrier until two months after admission. This oversight occurred despite the resident's admission evaluation indicating a need for translation services. The resident was discharged before the care plan was implemented. Another resident's care plan for activities lacked measurable objectives and timeframes, failing to address the resident's medical, mental, and psychosocial needs. Additionally, a third resident, who had multiple falls related to toileting needs, did not have a person-centered care plan to address incontinence and prevent further falls. The facility did not develop an appropriate care plan until after the survey findings were reviewed with the nursing home administrator.
Failure to Administer Quetiapine Fumarate as Ordered
Penalty
Summary
The facility failed to ensure the administration of quetiapine fumarate (Seroquel) as ordered by the physician for a resident diagnosed with dementia and bipolar disorder. The resident was admitted with a care plan that included the use of antipsychotic medication to manage aggressive behaviors. On November 7, 2024, a physician's order was documented for quetiapine fumarate 50 mg to be administered twice daily. However, on December 3, 2024, a nurse noted that the medication was not available and reordered it from the pharmacy. Despite this, the medication was not delivered, resulting in missed doses on December 3 and December 4, 2024. The issue was compounded by the failure to notify the physician immediately when the medication was unavailable. Interviews with facility staff confirmed that the resident missed three doses of the medication due to the pharmacy's delay in delivery. The facility's Nursing Home Administrator (NHA) acknowledged that the physician was not informed promptly about the medication's unavailability. These findings were discussed with the facility's administrative and clinical leadership during the exit conference.
Lack of Certified Food Protection Manager Coverage
Penalty
Summary
The facility failed to ensure that a qualified person in charge was present during all hours of operation in the food and nutrition service. This deficiency was identified through observation and interview, revealing that only one staff member, the Food Service Manager, possessed a valid Food Protection Manager certificate from an Accredited Food Safety Program. This individual was scheduled to work only seventeen days out of twenty-eight in December 2024 and eight days out of fourteen in January 2025. The other two staff members with the necessary certification were not scheduled to work at all during this period. The absence of a certified food protection manager during all hours of operation increases the risk of a foodborne outbreak, particularly for vulnerable populations in the facility.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents, R42 and R43, from physical abuse by each other. R43, who was admitted with diagnoses including dementia and bipolar disorder, exhibited aggressive behaviors such as throwing water and hitting another resident with a toilet seat cover. Despite being care planned for these behaviors, R43 continued to engage in aggressive acts against R42 on multiple occasions, including throwing water on R42 and hitting R42 with a toilet cover. R42, admitted with diagnoses including depression, anxiety disorder, and dementia, was also involved in aggressive incidents. R42's care plan included interventions for impaired cognition and physical aggression. On one occasion, R42 hit R43 over the head with a toilet seat cover without provocation. The facility's failure to effectively manage and prevent these aggressive interactions between R42 and R43 resulted in repeated incidents of physical abuse. The facility's abuse prevention program, which was supposed to protect residents from abuse by anyone, including other residents, was not effectively implemented. The repeated incidents of aggression between R42 and R43 indicate a failure to ensure the safety and well-being of these residents, as evidenced by the multiple documented incidents of physical abuse.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in their documented status. One resident, admitted with Spanish as their preferred language, was incorrectly documented as preferring English in their admission MDS assessment. Another resident, who had an active physician's order for the anticonvulsant medication Depakote, was not accurately reflected as taking the medication in their quarterly MDS assessment. A third resident, admitted with a stroke diagnosis and impaired range of motion in both lower extremities, was inaccurately documented as having no functional limitations in their admission MDS assessment. These inaccuracies were confirmed during interviews with the RNAC and discussed during the exit conference with facility leadership.
Failure to Coordinate with PASRR Program for Resident with Mental Health History
Penalty
Summary
The facility failed to coordinate with the Pre-Admission Screening and Resident Review (PASRR) program for a resident who was admitted without a known or suspected mental health diagnosis. Initially, a PASRR Level 1 Screen completed by the hospital indicated no mental health issues for the resident. However, after admission, a psychiatric evaluation revealed a history of depression, anxiety, and paranoia, with previous treatment using Olanzapine, an antipsychotic medication. Despite these findings, the facility did not submit a referral to the PASRR office for a Level 1 screen. The resident was prescribed mirtazapine for depression and Xanax for anxiety shortly after admission. The care plan was updated to address these conditions, but the facility staff requested a psychiatric consultation due to worsening anxiety. The psychiatric note recommended continuing the current medications and suggested contacting the outpatient psychiatric provider for additional history, with a consideration to resume antipsychotic treatment. Despite these developments, the facility's Social Services Director confirmed that no referral to the PASRR office was made, indicating a lapse in the coordination of care for the resident.
Failure to Address Resident's Decline in Continence and Associated Falls
Penalty
Summary
The facility failed to evaluate and address a resident's decline in urinary continence, which was associated with multiple falls related to the resident's need for toileting assistance. The resident, who was admitted with dementia and had severely impaired cognition, was initially continent of urine and bowel. However, over time, the resident began exhibiting behaviors such as urinating on the floor and defecating on the air conditioning unit, indicating a decline in continence. Despite these changes, the facility did not initiate a toileting program or trial to address the resident's incontinence. The resident experienced several falls while attempting to use the bathroom independently, despite being care planned for falls related to poor safety awareness. The facility's records show that the resident was frequently incontinent of urine and bowel, yet no toileting program was implemented. The resident's care plan was updated to include offering a commode and providing incontinent care after each episode, but these measures were insufficient to prevent further falls. Observations revealed that the resident continued to attempt to use the bathroom without assistance, despite being a high fall risk and having impulsive and aggressive behaviors. Staff interviews confirmed that the resident required supervision when using the toilet, but the facility did not adequately address the resident's toileting needs. The facility's failure to evaluate the resident's toileting decline and implement a personalized toileting program contributed to the resident's continued falls and incontinence issues.
Failure to Provide Translation Services During Nursing Care
Penalty
Summary
A deficiency was identified when the facility failed to provide Spanish-speaking translation or interpretation services during nursing care for a resident with limited English proficiency. The facility's policy required meaningful access to information and services for individuals with limited English proficiency, including competent oral translation of vital information. Upon admission, the resident indicated Spanish as their preferred language and requested an interpreter for communication with healthcare staff. However, during two separate post-fall assessments, documentation showed that the resident was unable to explain what happened due to language barriers, and there was no evidence that translation services were utilized during these critical assessments. Record review and interviews confirmed that while the facility maintained a list of translation service transactions, there was no documentation of translation services being provided on the dates of the incidents in question. The absence of translation services during these events was further corroborated by the lack of relevant entries in the resident's clinical record and the facility's own transaction logs. The deficiency was discussed with facility leadership during the exit conference.
Failure to Provide Required Two-Person Assistance During Shower Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan requiring two-person assistance during showering. The resident, who had a history of traumatic brain injury, tracheostomy, enteral tube feeding, and required a nephrostomy tube for bladder drainage, was completely dependent on staff for all activities of daily living, including repositioning and showering. Despite clear documentation in the care plan and clinical records specifying the need for two-person assistance, only one staff member provided care during the shower. During the shower, the resident's nephrostomy tube became dislodged while being repositioned, and the resident sustained multiple abrasions and bruises to the face, torso, and lower extremities. The incident resulted in the resident being sent to the emergency room twice for evaluation and treatment, including replacement of the nephrostomy tube. Interviews with staff confirmed that only one aide was present in the shower room, and other aides did not assist, despite the resident's total dependence and documented need for two-person assistance. Further documentation and interviews revealed that the resident's family expressed concerns about the number of staff present during the shower and the condition of the shower bed. The facility's investigation found that the aide attempted to turn the resident alone, with the shower bed rails down, leading to the resident nearly sliding off and sustaining injuries. The failure to implement the resident's care plan for two-person assistance directly resulted in harm to the resident.
Failure to Obtain and Administer Ordered Medications Due to Incomplete C2 Forms
Penalty
Summary
A deficiency occurred when a resident was admitted with diagnoses including seizures and anxiety disorder, and physician orders were written for three medications: lacosamide, perampanel (Fycomba), and clonazepam. Despite these orders, the facility failed to obtain and administer these medications for several days following admission. Review of the Medication Administration Record (MAR) showed that multiple doses of each medication were missed over a three-day period, with staff documenting codes indicating either 'other/see nurse notes' or 'out of the facility' instead of actual administration. The clinical record and staff interviews confirmed that the required C2 prescription forms for these controlled medications were not completed and sent to the pharmacy at the time of admission, resulting in the pharmacy not delivering the medications. Further documentation revealed that staff were aware of the missing medications and communicated with the pharmacy and providers, but the necessary C2 forms were not completed and sent until several days after admission. The pharmacy confirmed receipt of the forms only after the missed doses had already occurred. The facility lacked evidence that the required forms were completed upon admission, directly leading to the resident missing multiple doses of essential seizure and anxiety medications.
Failure to Complete Required Controlled Substance Prescription Forms on Admission
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician or provider completed the required C2 forms for controlled prescription medications upon the admission of a resident with diagnoses including seizures and anxiety. The admitting physician, who also served as the Medical Director, entered orders for three controlled medications—clonazepam, lacosamide, and perampanel—into the electronic medical record, but did not complete the necessary C2 forms required by the pharmacy to dispense these medications. Nursing staff documented that only the C2 form for oxycodone was sent to the pharmacy, and the pharmacy reported not receiving prescriptions for the resident's seizure control medications. Despite being contacted multiple times by nursing staff, the nurse practitioner on call was unable to complete and return the required forms, stating that the forms would be filled out the following morning. As a result, the resident went over sixty hours without access to prescribed controlled medications, missing multiple doses of clonazepam, lacosamide, and perampanel. There was no documented explanation for the provider's inability to complete the forms, and the facility did not have a physician or provider available on weekends with the capability to fulfill this requirement. The deficiency was identified during record review and discussed with facility leadership during the exit conference.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident within the required two-hour timeframe as outlined in its own policy and state law. The resident, who had a history of stroke with left-sided weakness and demonstrated normal cognitive function, reported that a certified nursing assistant (CNA) had inappropriately touched him during care. The resident stated he had informed the former Social Work Director about the incident shortly after it occurred, and the CNA reported that he had told a nurse about the allegation. Despite these disclosures, the information was not escalated to the Administrator or the State Agency until three days after a nursing supervisor became aware of the allegation. Interviews and record reviews revealed that staff were aware of the allegation and had been informally adjusting assignments to prevent the CNA from caring for the resident, but no formal report was made. The nursing supervisor who learned of the allegation assumed that management was already aware and did not report it. The Director of Nursing and the Administrator confirmed they were unaware of the situation until notified by a state investigator, at which point the allegation was reported to the State Agency. The facility's failure to follow its policy and promptly report the abuse allegation resulted in a delay in notifying the appropriate authorities.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R95, from verbal abuse by a staff member, E6. R95, who had a care plan for physical and verbal aggression, was involved in an incident in the dining room where he felt ignored by E6 and expressed his frustration by yelling. In response, E6 engaged in a verbal altercation with R95, using curse words and derogatory language. This incident was witnessed by other staff members, who provided written statements confirming the exchange of insults between R95 and E6. The incident report and witness statements indicate that R95 was frustrated due to a missing meal ticket and felt ignored by E6, leading to the verbal confrontation. Despite R95's care plan interventions, which included listening to the resident and trying to calm him, E6's response escalated the situation. The facility's failure to manage the situation appropriately and protect R95 from verbal abuse resulted in a deficiency finding during the survey.
Inaccurate MDS Assessment for Resident's Hearing Status
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident regarding their hearing status. The resident was admitted to the facility with a hearing aid and charger, as documented in their inventory list. However, during an annual MDS assessment, it was incorrectly recorded that the resident did not use a hearing aid or other hearing appliance. This discrepancy was identified during a review of the resident's care plan, which noted that the resident was at risk for impaired communication and was very hard of hearing. The error in the MDS was confirmed during an interview with the Registered Nurse Assessment Coordinator (RNAC). The findings were discussed with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) during the exit conference.
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Multiple cognitively impaired residents with known behavioral issues, including wandering, agitation, and physical aggression, were not adequately protected from resident‑to‑resident abuse. In one case, a resident with dementia and PTSD was pushed to the floor by another resident who had a history of combative behavior, resulting in multiple fractures and facial lacerations after staff initially documented the event as an unwitnessed fall. In another case, two residents with dementia and psychotic features engaged in a physical altercation in a dayroom after one placed his hand on the other’s chest, leading to mutual punching. A separate incident occurred when a resident with dementia and behavioral disturbances entered another resident’s room, pulled at the bedcovers, yelled that the room was his house, and allegedly struck the other resident, who was later noted with puffiness around one eye. In all incidents, the involved residents had documented behavioral care plans and significant cognitive impairment, yet physical confrontations still occurred.
A resident with dementia, spinal stenosis, and total dependence for transfers, care-planned for Hoyer lift use with two-person assist, was being transferred from a shower bed to a Geri-chair when the Hoyer lift tipped sideways. Staff reported the lift’s legs had been widened and that one CNA manually pushed the feet apart instead of using the control, and straps may have been unevenly positioned. The resident was lowered to the floor while still in the sling and sustained a small skin tear to the elbow; imaging later showed no fractures. The DON stated that three CNAs were involved, including one on light duty who was not supposed to be using the lift, and that no mechanical defect was found with the lift.
The facility failed to thoroughly investigate several allegations of verbal and potential physical abuse involving four cognitively intact residents with conditions including hemiplegia, rheumatoid arthritis, type 2 DM, epilepsy, and heart disease. In each case, the facility’s investigations were limited, often including only the directly involved resident and omitting interviews with other potentially knowledgeable residents or staff. One resident reported a verbal altercation with a CNA after a fall to the floor, another reported being verbally abused by a roommate’s family member, a third reported a male CNA was too rough and upset while changing linens, and a fourth reported a staff member insulted her and refused brief care. Investigation files lacked broader resident and staff interviews, timely physical and psychosocial assessments, and review of the accused staff member’s employee record, contrary to the facility’s abuse policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
A resident with rectal cancer and intact cognition reported that an RN on night shift confronted him when he returned from smoking off campus, spoke to him loudly about his smoking, used profanity, and threatened to have staff refuse to buzz him back into the building. A CNA corroborated that the RN was upset about being called in to work and used curse words toward the resident, but did not report the incident at the time because the RN was the night supervisor. The resident reported the event to the Social Services Director the next day, yet the facility initially treated it as a grievance rather than abuse and delayed submitting a report to the State Survey Agency until weeks later, after determining it was a reportable abuse incident.
Two residents did not receive required ADL and hygiene care as care planned. One resident with dementia and osteoarthritis, dependent for toileting and personal hygiene, was not toileted during an evening shift, with CNA documentation showing no toileting and the oncoming CNA finding the resident’s clothing, linens, and mattress saturated with urine; the assigned CNA reported care resistance but did not notify an RN or LPN. Another resident with dementia and stroke, requiring assistance with dressing and personal hygiene, remained in bed in pajamas into the afternoon without having received morning care, despite CNA documentation indicating dressing was completed; the CNA later confirmed that care was only provided after being questioned by an RN supervisor following a family complaint.
A resident with left-sided weakness after a stroke, high fall risk, and total dependence for ADLs and bed mobility was being turned onto their side for peri care by an aide when they fell from the bed to the floor, sustaining head trauma and a scalp laceration while on blood thinners. The care plan required extensive to total assistance with two-person support for bed mobility, but the fall occurred during care without documentation of the required level of assistance, indicating the facility did not provide adequate supervision and assistance to prevent accidents as outlined in its own fall prevention practices.
A resident with significant upper extremity weakness and recent surgery was discharged home to a multi-story residence without confirmed DME delivery, home health services, or caregiver support. Although referrals for home health, skilled nursing, and DME were made and family attended a discharge care plan meeting, staff did not verify that services were active, did not set or confirm a start-of-care date with the agency, and did not confirm delivery of a hospital bed. The resident, who lived alone and could not manage fine motor tasks, arrived home without in-home assistance, reported difficulty with eating and self-care, and was later found by an HHA RN in unsafe conditions, unable to access food or medications, leading to emergency transport back to the hospital.
A resident with dementia, Parkinson’s disease, CHF, and a history of AKI had documented fluid goals and was identified as at risk for dehydration and malnutrition, yet daily intake records repeatedly showed fluid consumption well below the recommended amounts. Despite severely impaired cognition, poor oral intake, and documented changes in mentation, lethargy, falls, and restlessness, the facility did not consistently implement or document enhanced monitoring, assistive feeding measures, or timely provider consultation focused on hydration. The resident was hospitalized twice with AKI, dehydration, hypotension, and anemia, and staff interviews confirmed that while expectations existed to encourage fluids and notify providers when goals were not met, there was no clear evidence that these expectations were carried out for this resident.
A resident with cardiac conditions was discharged home with a documented post-discharge plan for home health aide, home health RN/LPN, and PT/OT, but the facility did not complete the home health referral before discharge. The resident went home with a family member and, according to a complaint, did not receive PT, OT, or a nursing wellness check for about a week. The SW later confirmed the referral for home health and therapy services was not requested until several days after discharge, and services did not begin until even later, despite therapy recommendations that are typically communicated to social services to arrange home care.
The facility failed to consistently revise care plans to reflect residents’ current needs and behaviors and did not ensure a cognitively intact resident was involved in ongoing care planning. One resident participated in an initial care conference but was not included in later care plan updates. Another resident with an order for a palm protector was frequently observed without it and often refused it, yet the care plan did not address refusals. Two cognitively impaired residents whose MDS assessments showed dependence for bathing had care plans that still listed only setup or one‑person assist. A cognitively impaired resident with combative behaviors and an incident of striking another resident had a behavior care plan that was not updated to include attempts to hit other residents or the risk of resident‑to‑resident altercations.
Failure to Prevent Resident‑to‑Resident Physical Abuse Among Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from resident‑to‑resident physical abuse. One resident with dementia, agitation, depression, anxiety, and PTSD, and a BIMS score indicating moderate cognitive impairment, was pushed to the floor by another resident after that resident entered his room and followed him into the hallway. Staff initially documented the event as an unwitnessed fall after hearing loud screaming and finding the resident on the floor with complaints of right shoulder and left wrist pain, active bleeding from facial lacerations, and clamminess. Subsequent review of surveillance footage showed that another resident walked into the victim’s room, then followed him out and pushed him, causing the fall that resulted in multiple fractures, including a closed left distal radius fracture, a closed, displaced comminuted right proximal humerus fracture, and a closed, displaced distal clavicle fracture. The resident who pushed him had dementia with mood disturbances, bipolar disorder with psychotic features, PTSD, insomnia, and depression, and a BIMS score indicating severe cognitive impairment. His care plan identified a behavior problem related to bipolar disorder and dementia, including wandering, refusal of care, and physical aggression toward staff and others, such as biting a CNA and swinging a walker at a CNA. The care plan directed staff to anticipate and meet his needs, divert him with alternative objects or activities, intervene to protect the rights and safety of others, and conduct safety checks. Despite these identified risks and interventions, he was able to enter another resident’s room and subsequently push that resident in the hallway, resulting in serious injury. Another incident involved two residents with significant cognitive impairment and behavioral symptoms, including delusions, physical behaviors toward others, agitation, and a tendency to invade others’ personal space. One resident, who was described as aggressive toward others, easily agitated, and prone to getting into others’ personal space, walked next to another resident sitting in a dayroom chair and placed his hand on that resident’s chest. The seated resident responded by punching him in the face with the back of his fist, and the first resident then punched back. Staff and psychiatric documentation noted this altercation and ongoing behavioral concerns such as combativeness with care, agitation, and wandering, but the record contained no additional progress notes describing the incident itself beyond the brief psychiatric follow‑up entry. A further incident occurred when a resident with anxiety, major depressive disorder, dementia with behavioral disturbances, agitation, and severe cognitive impairment entered another resident’s room on the memory care unit. The resident in the room, who had depression, anxiety, dementia without behavioral disturbances, PTSD, insomnia, hallucinations, verbal behaviors toward others, other behavioral symptoms, and wandering, reported that he was hit in the face. Staff heard yelling and found the intruding resident pulling covers at the foot of the bed and yelling that the room was his house, while the other resident sat on the side of the bed and stated that he had been hit and told staff to get a gun and shoot the other resident. Slight puffiness was noted around the reporting resident’s left eye. The intruding resident’s care plan documented compulsiveness, invading others’ personal space, yelling, restlessness, physical aggression, and attempts to assist other residents he believed needed help, with interventions to divert him, familiarize him with his surroundings, and intervene to protect the rights and safety of others. Despite these identified behaviors and interventions, he was able to enter another resident’s room, engage in a confrontation, and allegedly strike the resident.
Resident Injury from Improper Hoyer Lift Operation During Transfer
Penalty
Summary
The deficiency involves the facility’s failure to prevent an accident during a Hoyer lift transfer, resulting in a fall and skin tear injury to a resident. The resident had diagnoses including spinal stenosis, Alzheimer’s disease, vascular dementia with behavioral disturbance, bipolar disorder, and pain, and was documented on the MDS as dependent on staff for transfers from bed to chair. The care plan and physician orders specified that the resident required a Hoyer lift with assistance of two staff for transfers. On the day of the incident, the resident was being transferred via Hoyer lift after a shower, from a shower bed back to a Geri-chair. Progress notes and the post-fall evaluation documented that the fall occurred in the bathroom during a Hoyer transfer with staff assistance of two, and that the Hoyer lift tipped sideways. The resident was found on the floor in the sling, with staff reporting that the Hoyer lift’s legs were widened and that as the resident was being positioned over the chair, the lift tipped to the side. Staff held the sling on each side of the resident’s head and lowered the resident to the floor, after which a skin tear measuring 1.0 cm x 0.1 cm was noted on the elbow. The facility’s investigation determined that the Hoyer tipped because one CNA pushed the lift’s feet apart manually instead of using the designated button to open the legs. Interviews indicated that the manual mechanical lift used at the time was considered less steady and required manual operation of a foot pedal to open the legs, and that the straps may have been more to one side than the other. The DON reported that three CNAs were involved with operating the lift at the time of the incident, including one CNA on light duty who was not supposed to be using the Hoyer lift, and that the lift itself was later found to have no mechanical problems. As a result of the tipping incident, the resident sustained a skin tear to the elbow and required diagnostic imaging to rule out fractures.
Incomplete Investigations of Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of verbal or potential physical abuse as required by its abuse, neglect, and exploitation policy. One cognitively intact resident with hemiplegia following a stroke reported a verbal altercation with a CNA after sliding to the floor while being assisted back to bed. The resident requested use of a Hoyer lift, the CNA told him he could get himself up, and an argument ensued in which the CNA told the resident it was not his room and did not leave until directed by an LPN. The facility’s investigation file for this incident contained only the resident’s interview and no interviews with other residents on the unit who might have had knowledge of similar verbal abuse by the CNA. Another cognitively intact resident with rheumatoid arthritis, hypertension, and peripheral vascular disease reported that her roommate’s daughter came into her room and verbally abused her after the roommate had been relocated due to aggression. The daughter allegedly cursed at the resident, calling her an offensive name and telling her she was going to hell. The investigation file for this incident contained no interviews with other residents on the unit to determine whether they had experienced verbal abuse by this family member or had knowledge of the event. The DON acknowledged that no such interviews were conducted. A third cognitively intact resident with type 2 diabetes and epilepsy reported, through her daughter, that a male CNA wearing a red shirt was too rough with her and appeared upset about having to change her linens. The facility’s investigation into this potential staff-to-resident abuse included an interview with the resident but did not include interviews with other interviewable residents in the same area who might have had knowledge of the incident. A fourth cognitively intact resident with type 2 diabetes and heart disease, later discharged, reported that a staff member entered her room, called her a poor excuse for a human being, and refused to assist with changing her brief. The investigation documentation for this allegation lacked interviews with additional residents or staff, did not show that the resident was promptly assessed physically and psychosocially in relation to the allegation, and did not include a review of the accused staff member’s employee record, resulting in an incomplete investigation contrary to facility policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
Failure to Protect Resident From Verbal Abuse and Delay in Reporting Incident
Penalty
Summary
The facility failed to protect a cognitively intact resident from verbal abuse by a staff member. The resident, admitted with rectal cancer and independently ambulatory with a rolling walker, reported that during an overnight shift he left the campus to smoke and, upon returning and walking toward the nursing station, was confronted by an RN. According to the resident’s report, the RN told him that when she was on the night shift he was not allowed to go outside, using profanity toward him, and further stated that if he went out the door she would instruct staff not to buzz him back into the building. A CNA later confirmed that the RN had been upset about being called in to work, spoke loudly to the resident about his smoking, and used curse words when he responded to her. The incident was not promptly reported to facility administration despite occurring during the night shift, with the CNA stating that the RN involved was the supervisor at the time. The resident reported the incident the following day to the Social Services Director, but the facility did not immediately recognize or treat the allegation as reportable abuse. Instead, the administration initially considered it a grievance and investigated it in that manner. The incident report was not submitted to the State Survey Agency until several weeks after the resident’s report, and only after the facility later determined that the event constituted a reportable abuse incident.
Failure to Provide Required ADL and Hygiene Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL assistance to maintain grooming and personal hygiene for two dependent residents. One resident with dementia, osteoarthritis, and moderately impaired cognition was care planned to receive partial to substantial assistance with personal and oral care, scheduled toileting every two hours, and assistance with toilet transfers. CNA documentation for an evening shift showed “N/A” for all scheduled toileting times, and a facility incident report stated that the CNA assigned to this resident failed to provide incontinence care during that shift. The oncoming night-shift CNA later found the resident’s clothing, linens, and mattress saturated and soaked with urine and provided the needed care, with the prior-shift LPN confirming the condition when notified. The assigned CNA reported the resident was resistant to care but did not notify the LPN or RN for assistance or document the issue. The second resident, with dementia, stroke, weakness, and moderately impaired cognition, was care planned for an ADL self-care deficit requiring setup or cleanup assistance with eating, partial to substantial assistance with personal hygiene and oral care, and substantial assistance with toileting, showering/bathing, and lower body dressing. On a morning shift, the resident’s daughter-in-law reported to the LSW that she did not believe the resident had received morning care because he was still in bed wearing pajamas and had not yet received his lunch tray. A CNA statement indicated the resident had eaten breakfast and was later found asleep in bed, and CNA documentation for that shift showed the dressing task as completed. However, the facility’s follow-up summary documented that the CNA confirmed care had not been provided to the resident prior to being questioned by the RN supervisor, and the LSW confirmed that the CNA changed the resident only after the family reported the concern and nursing was notified.
Failure to Provide Adequate Supervision and Assistance During Bed Mobility for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for a resident with significant functional and cognitive impairments. The resident was admitted with left-sided weakness after a stroke and was care planned as extensively to totally dependent for bed mobility, requiring the support of two persons. A fall risk evaluation documented a score of 10, indicating high fall risk, and a quarterly MDS assessment showed the resident was unable to participate in a cognitive assessment and was completely dependent on staff for all ADLs. Despite these identified needs and risks, the resident was being turned onto their side for peri care by an aide when they fell from the bed to the floor. During this incident, the resident sustained head trauma and a small scalp laceration, and was on blood thinners at the time of the fall. The fall occurred while the aide was providing peri care and turning the resident, but the report does not document the presence of a second staff member, despite the care plan indicating the need for two-person assistance for bed mobility. The facility’s own policy on falls emphasized instituting individualized practices to minimize fall risk and maximize safety for residents identified as high risk, but the resident’s documented high fall risk and total dependence were not adequately addressed in the supervision and assistance provided at the time of the fall.
Failure to Ensure Safe Discharge with Confirmed Home Services and Support
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s discharge home included confirmed durable medical equipment (DME), home health services, and adequate caregiver support. The resident was admitted with spinal stenosis, cervical disc disorder, muscle weakness, carpal tunnel syndrome, and a recent post-fasciotomy to the right arm, and was documented as cognitively intact with a BIMS score of 14/15. Despite these physical limitations, the facility discharged the resident home in the evening via medical transport to a three-story residence, where no caregiver support was present. The facility’s own policy required a post-discharge plan of care developed with the resident and representative, and orientation to ensure a safe and orderly transfer or discharge, but the record lacked evidence that services were confirmed as in place prior to discharge. Prior to discharge, the social worker documented that the resident would have a safe discharge home with services and supports in place, and that referrals for home health care, skilled nursing services, and DME had been made, with family members in attendance at the discharge care plan. However, the clinical record did not contain confirmation that these services were actually arranged and active before the resident left the facility. The resident was discharged with medications called to the pharmacy for home delivery, but there was no documentation that the hospital bed had been delivered or that home health nursing, therapy, or home health aide services were scheduled to start at the time of discharge. The social worker later acknowledged not informing the agency of a specific start-of-care date, assuming the agency and VA would contact the resident, and confirmed not calling to verify delivery of the hospital bed. After discharge, it was discovered that the hospital bed ordered days earlier was not delivered until the morning after the resident arrived home, and that therapy, RN, and HHA services had not yet begun or contacted the resident by the time the facility followed up. The resident reported living alone, being unable to use their hands, needing a caretaker, and having to rely on a sister-in-law for limited assistance with hygiene, meals, and rearranging furniture for the bed that arrived later. The significant other confirmed that no one lived with the resident, that they had their own health issues, and that neither they nor their son stayed with the resident after discharge. When a home health RN eventually visited, the resident was found sitting on a couch in minimal clothing, reporting not having eaten adequately for two days, having little or no accessible food, and being unable to open medications or bottles due to impaired fine motor skills. The RN observed the resident’s inability to grip or perform fine motor tasks, assisted with toileting, and then contacted the agency director and emergency services due to the unsafe conditions in which the resident had been left. These events led surveyors to determine that the facility failed to ensure services and caregiver support were in place prior to discharge, resulting in an immediate jeopardy situation.
Removal Plan
- Audited discharge documentation related to home health services, appropriate caregiver/family support, and any necessary services to meet residents' care needs to determine if any residents were affected.
- Reviewed planned discharges by the Administrator, DON, Director of Social Services, and Director of Rehabilitation to ensure home health services, appropriate caregiver/family support, and necessary services to meet the resident's care needs are in place before discharge.
- Completed a root cause analysis identifying failure to have a robust discharge care plan meeting with the interdisciplinary team (IDT), resident, and resident representative.
- Reviewed the procedure for safe and effective discharge planning with the IDT.
- Re-educated the discharge planning IDT on the discharge policy and procedure to ensure sufficient preparation and orientation for a safe discharge.
- Implemented review of residents scheduled to be discharged to ensure appropriate discharge planning is in place.
- Implemented review of residents scheduled for discharge to ensure ADL support is in place, durable medical equipment is available prior to or on the discharge date, medications are available upon discharge, and identified needs/support are available.
- Implemented review of residents scheduled for discharge to ensure safe discharge planning is in place and to address any issues identified.
- Implemented oversight during utilization review by the NHA/designee to ensure discharge planning preparation and services are in place prior to discharge.
- Initiated audits and educational in-services to the IDT team and conducted staff interviews to confirm education received regarding discharge to the community and/or transfers to other facilities.
Failure to Maintain Adequate Hydration Resulting in Recurrent AKI and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate hydration for a resident with significant medical conditions, including acute kidney injury (AKI), congestive heart failure (CHF), dementia, and Parkinson’s disease. Upon admission, the resident’s care plan identified potential for altered nutrition and included interventions such as assisting at meals, encouraging oral fluids, and monitoring for additional nutrition interventions. A nutrition assessment established an initial fluid goal of 1943–2098 mL/day and documented that the resident was at risk for dehydration and malnutrition, with early labs showing a BUN of 29, creatinine of 1.4, and eGFR of 53. The admission MDS documented that the resident was severely cognitively impaired and required setup assistance for feeding and hydration. Daily fluid intake records from CNA task flow sheets and the MAR showed that the resident’s intake frequently fell below the recommended fluid goals, with multiple days of intake under 1200 mL and some days as low as 360–720 mL. A malnutrition risk assessment identified the resident as at risk for malnutrition due to severe dementia and tremors. A subsequent nutrition note on 5/12/25 documented that the resident’s average fluid intake was 330 mL/day, recommended discontinuing a prescribed hydration pass due to CHF, and set a new fluid goal of 1635–1766 mL/day, while continuing to recommend encouraging oral fluids. Despite these documented risks and low intakes, there is no evidence in the record of intensified monitoring or additional interventions to ensure the resident met the revised fluid goals. The resident experienced multiple clinical deteriorations associated with poor intake and changes in condition. On 6/1/25, after a day with only 360 mL of recorded intake, the resident was transferred to the hospital following falls, hypotension, and confusion, and was admitted with AKI and dehydration. After readmission to the facility, nursing documentation noted low oral intake and a plan to discuss adding the resident to an assist-to-feeding list, but the record lacked evidence that this occurred. Subsequent notes documented lethargy, increased confusion, agitation, restlessness, and continued poor intake, yet a physician progress note following two unwitnessed falls did not include an assessment of hydration status or interventions to improve hydration. On 6/19/25, labs showed a BUN of 62 mg/dL and creatinine of 1.7 mg/dL, and the resident was again sent to the hospital and admitted with AKI, hypotension, and anemia, requiring IV fluid resuscitation. Staff interviews confirmed expectations to monitor intake, encourage fluids, and notify providers when fluid goals were not met, but there was no documentation that the provider was consistently notified or that appropriate interventions were implemented in response to the resident’s ongoing inadequate fluid intake and changes in condition.
Failure to Arrange Timely Home Health Services Prior to Discharge
Penalty
Summary
The facility failed to ensure a timely referral for home health care services prior to discharge for one resident. Facility policy dated 5/1/25 required sufficient preparation and orientation to residents to ensure an orderly transfer or discharge. The resident was admitted on 7/28/25 with diagnoses including aortic valve replacement, aortic regurgitation, and congestive heart failure. A discharge summary dated 8/11/25 documented a post-discharge plan for home health aide, home health RN/LPN, and occupational and physical therapy. The resident was discharged home with a family member on 8/12/25. A complaint received by the Division on 9/30/25 stated that the resident was discharged to a family member's home without a home health care agency referral and that, after one week at home, the resident had not received any physical or occupational therapy or a wellness check from a nurse. During an interview on 2/16/26, the social worker reported needing to check if a referral was made and later confirmed that the referral for home health and therapy services was not requested until 8/15/25, with services opened on 8/20/25. The director of therapy confirmed that physical and occupational therapy were recommended for the resident and stated that such recommendations are typically communicated to social services to set up home care. Findings were reviewed with facility leadership during the exit conference.
Failure to Revise Care Plans and Involve Resident in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise person‑centered care plans and to involve a cognitively intact resident and/or representative in the care planning process. One resident with an intact BIMS score of 15 was admitted and had a documented care conference shortly after admission, but there was no evidence of any subsequent care conferences during the following year despite multiple care plan updates. The resident reported not recalling quarterly care plan meetings, and staff confirmed that no care conferences occurred after the initial one, with no documentation that the resident or representative participated in the later care plan revisions. Additional residents’ care plans were not revised to reflect current, individualized needs and behaviors. One resident had a physician’s order for a right palm protector or substitute, was repeatedly observed without it in place, and routinely refused it according to nursing and CNA interviews, yet the care plan did not address potential refusals. Two cognitively impaired residents whose MDS assessments documented dependence for bathing had care plans that continued to list only setup assistance or one‑person assist, without updating to reflect full dependence. Another cognitively impaired resident with documented combative behaviors toward staff and a reported incident of striking another resident with a remote had a behavior care plan that was not revised to include the new behavior of attempting to hit other residents or the potential for resident‑to‑resident altercations.
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