Seaford Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Seaford, Delaware.
- Location
- 1100 Norman Eskridge Highway, Seaford, Delaware 19973
- CMS Provider Number
- 085015
- Inspections on file
- 29
- Latest survey
- September 9, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Seaford Center during CMS and state inspections, most recent first.
A resident with a history of refusing care, including turning, repositioning, and wound treatment, was repeatedly documented by various staff as non-compliant and resistant to interventions. Despite these ongoing refusals, the facility did not develop an individualized care plan with measurable objectives or timeframes to address the resident's needs.
Two cognitively intact residents reported multiple missing clothing items, including sweatpants, shirts, underwear, and a sports jersey. One resident’s inventory form had no clothing documented, and staff acknowledged that a property loss form was never completed, relying only on checking the unit’s lost and found, where a single labeled item was located. Another resident’s room was observed to lack the reported missing items, with only a few clothing pieces present. These findings show the facility did not follow its own policy to inventory belongings on admission and update the list for new items, nor did it consistently document and report losses as required.
A resident who was cognitively intact reported missing underwear, shirts, pants, and a sports jersey, and a grievance was logged indicating the items might have been misplaced by laundry. The Housekeeping Director checked the laundry area and did not find the clothing, and the resident continued to report the items as missing months later. Interviews with staff, including the Quality Manager, confirmed there was no documented prompt response or resolution of the grievance, despite an established process for completing grievance logs, obtaining staff statements, and submitting documentation to the NHA.
Surveyors found that the facility failed to initiate required Level II PASRR referrals for three residents after new mental health diagnoses, including major depressive disorder and bipolar disorder, were documented in their records. Each resident had prior PASRR Level I screenings and later developed new or additional psychiatric diagnoses that were reflected in admission records, care plans, active diagnoses, and MDS assessments. Facility staff, including the Quality Manager and social work leadership, acknowledged that Level II PASRR referrals were required but not completed, and one social worker reported lacking system access needed to submit the referral.
A resident’s medications were not administered in accordance with professional standards when an LPN left six pills on the bedside table without confirming they were ingested, despite facility policy requiring observation to ensure completion of each dose. The resident later told a surveyor they did not know what the pills were, and the LPN acknowledged leaving the medications without verifying ingestion. These findings were subsequently reviewed with facility leadership during the survey exit conference.
A resident with stroke, dementia, muscle weakness, adult failure to thrive, and an existing stage 3 sacral pressure ulcer was care planned for Q2H turning/repositioning and skin checks based on a Braden score of 9 indicating very high risk. Despite this, surveyors observed the resident lying on his back in bed with the head elevated and without positioning pillows or wedges for a four-hour period, with no evidence of turning or repositioning. A wound NP confirmed that Q2H turning is expected even with an air mattress and that wedges or pillows were available, and a CNA stated that repositioning the resident off his back was not a problem, indicating that the ordered repositioning interventions were not carried out.
A resident with a history of stroke, dementia, dysphagia, adult failure to thrive, and severe protein-calorie malnutrition was receiving Jevity 1.2 cal via feeding pump, but the feeding container was not labeled with the required date, time, or staff initials as mandated by the facility’s enteral feeding policy. An RN reported that the night shift is responsible for hanging and labeling the feeding and confirmed that the required labeling was not present, demonstrating failure to follow established standards for tube feeding administration.
A resident with COPD who received respiratory therapy and had PRN orders for ipratropium-albuterol nebulizer treatments was found with an oxygen mask and nebulizer unit sitting on a bedside table instead of being stored in a protective, labeled treatment bag as required by facility policy. An RN confirmed that the equipment was not in a protective bag and reported that the respiratory therapist usually places such equipment in a labeled bag.
A resident with Medicaid coverage and documented broken, loose, and carious teeth had a care plan calling for dental referrals as needed, but staff failed to ensure assistance with obtaining dental services. Although the resident reported having asked the unit manager for help seeing a dentist, the SSD was unaware of the request, and the resident was not included on the contracted dentist’s appointment list. The unit manager acknowledged knowing of the resident’s need but had only recently contacted the SSD, resulting in the resident not being scheduled for dental care at the time of review.
Staff failed to follow infection prevention and control practices during wound care for a resident on Enhanced Barrier Precautions (EBP) for infected Hidradenitis Suppurativa wounds. During a dressing change, the IP entered the room without a face covering, placed wound care supplies and a visibly soiled personal cell phone on a clean drape, poured wound cleansing solution from an open medicine cup onto gauze held by another nurse, and directly handled gauze with gloved hands before it was used to dry and treat the wounds. The IP also used the same gloved hands to handle the cell phone and take close-up photos of the draining wounds, then again handled gauze and applied topical antibiotic before covering the wounds, and later acknowledged not wearing a face covering and touching the phone during the procedure.
A resident with multiple medical conditions was allegedly asked by an activity aide to expose himself in the activity room. The incident was reported by the resident's spouse and relayed to the activities director, who did not act on the information, considering it typical behavior. The nursing home administrator was not informed until several days later, resulting in a delayed report to authorities and a failure to meet required abuse reporting timelines.
A resident admitted with obstructive sleep apnea, emphysema, and chronic respiratory failure required nightly BiPAP therapy with specific settings. Although hospital discharge documents and orders specifying these settings were available, the facility did not enter the BiPAP settings into the EMR at admission, resulting in a lack of necessary respiratory therapy orders for the resident's immediate care.
The facility did not have a process to obtain and document official lab reports from dialysis providers for residents receiving hemodialysis. Instead, communication was limited to handwritten notes, binders, or phone calls for abnormal results, leaving the residents' EMRs without up-to-date lab information and hindering care coordination.
Physicians did not adequately review or document the care of three residents receiving hemodialysis, including failure to address non-compliance with supplemental oxygen and lack of review of lab results, as official lab reports from dialysis centers were not consistently available in the EMR. Communication from dialysis centers was limited to handwritten or verbal reports, resulting in incomplete oversight and documentation for residents with complex medical needs.
Two residents undergoing hemodialysis did not have official, dated laboratory reports with the testing laboratory's name and address filed in their EMR. Instead, the facility relied on handwritten or typed summaries from the dialysis centers, which were not official lab reports and were not consistently uploaded into the EMR.
Three residents receiving hemodialysis did not have their laboratory results from outside dialysis centers entered into the facility's EMR. Although lab work was performed regularly at the dialysis centers, the facility did not obtain or document these results, leaving the residents' medical records incomplete and not readily accessible.
The facility failed to prevent pressure ulcers in two residents, leading to avoidable injuries. One resident developed Stage 3 and Stage 4 pressure ulcers due to inadequate repositioning and lack of pressure offloading. Another resident developed a deep tissue injury on the heel, with observations showing heels resting directly on the mattress. Staff interviews confirmed the expectation to float heels, but documentation lacked evidence of consistent implementation.
The facility failed to ensure interdisciplinary team participation in care plan meetings and did not conduct these meetings every three months for several residents. Additionally, a resident's care plan was not updated to address behaviors related to nebulizer equipment use, despite the resident being severely cognitively impaired.
The facility failed to manage continence for three residents, who were frequently incontinent and not on a toileting program. Despite the facility's policy requiring quarterly reviews, there was no evidence of assessments or services to restore continence. Staff confirmed the lack of toileting programs and suitable bedpans for these residents.
The facility failed to complete annual evaluations for five CNAs due to a system failure caused by staff turnover. The CNAs had various hire dates, and the issue was identified during a survey. The NHA acknowledged the oversight, and the facility was working on completing the evaluations at the time of the survey.
The facility failed to properly store, prepare, and serve food, risking foodborne illness. Observations included deteriorating lettuce and celery in the refrigerator, standing water under the ice machine, and insufficient sanitizer levels in sanitizing buckets. These issues were discussed with the NHA, DON, and a corporate representative.
A facility failed to honor a resident's preference to get out of bed daily, despite the resident being cognitively intact and dependent on a sit-to-stand lift for transfers. Observations over several days showed the resident remained in bed, and staff confirmed they were aware of the resident's preference but cited being too busy to assist.
The facility did not provide a completed Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) for two residents who transitioned from Medicare Part A to another payer source. One resident began skilled services and ended coverage, remaining as a long-term care resident without receiving the SNFABN. Similarly, another resident transitioned without the SNFABN being provided. The Nursing Home Administrator acknowledged the oversight, stating staff did not realize the form was necessary.
A facility failed to conduct a PASARR Level II evaluation for a resident with a new diagnosis of schizophrenia. Initially, the resident's PASARR Level I screen showed no need for further evaluation. However, the annual MDS later documented schizophrenia, and the social worker could not find evidence of a new PASARR application. The facility lacked documentation for the required referral to the state agency.
The facility failed to provide adequate ADL care for two residents who were dependent on staff. One resident had overgrown fingernails with debris, indicating a lack of personal hygiene care, while another appeared disheveled and had unclean sheets, leading to a family complaint. Staff interviews confirmed that time constraints and inadequate care contributed to these deficiencies.
A facility failed to store a resident's nebulizer equipment in a protective plastic bag, as observed on two occasions. The resident, with chronic obstructive pulmonary disease and a stroke history, had a physician's order for Albuterol Sulfate Nebulization Solution. An LPN confirmed the equipment was not properly stored, and the issue was acknowledged by the DON during an exit conference.
The facility failed to adequately monitor psychoactive medications for two residents. One resident did not receive a required AIMS assessment while on Zyprexa, and another resident on Quetiapine was not monitored for symptoms of psychosis. Staff interviews revealed confusion and lack of documentation regarding these monitoring processes.
Failure to Develop Care Plan for Resident Refusals of Care
Penalty
Summary
A deficiency was identified when the facility failed to develop a care plan addressing a resident's repeated refusals of care, specifically related to turning, repositioning, and wound management. The resident was admitted to the facility and subsequently documented by multiple staff, including a wound nurse practitioner, nurse practitioner, wound nurse, CNA, and RN, as being non-compliant and resistant to care, often refusing to be turned, repositioned, or to have wounds treated. Despite these ongoing refusals and behavioral challenges, a review of the resident's care plan revealed no evidence of individualized objectives, goals, or timeframes to address the refusals of care. Staff interviews confirmed that a care plan for refusals should have been completed but was not present.
Failure to Protect and Document Residents’ Personal Belongings
Penalty
Summary
The deficiency involves the facility’s failure to reasonably protect residents’ personal belongings from loss, as required by its personal property policy. The policy, last updated 8/15/23, states that staff will identify and record residents’ belongings upon admission on an Inventory of Personal Effects form, keep this in the clinical chart, and add any additional items brought in after admission. Any loss is to be documented on a property loss form and referred to the Administrator. For one resident (R26), who was documented as mentally intact on a quarterly MDS dated 6/4/25, an interview on 9/2/25 revealed that he reported several missing clothing items, including five sweatpants, one hoodie, two sweatshirts, and four T‑shirts. Review of his undated inventory list showed that all areas for documenting clothing were blank, with no record of his clothing. On 9/4/25, a CNA (E8) confirmed that the resident had reported missing clothing a few weeks earlier and that no property loss form had been created; instead, staff only checked the lost and found, where one pair of sweatpants labeled with the resident’s name was located. A second resident (R50), admitted on 3/7/19 and documented as cognitively intact with a BIMS of 15 on a quarterly MDS dated 7/24/25, also reported missing personal clothing. During an interview on 9/2/25, this resident stated that a shirt, pants, underwear, and a cowboy jersey were missing. An observation of the resident’s room shortly thereafter found no underwear and no cowboy jersey, and only one shirt, two pairs of pants, and a sweatshirt present. On 9/4/25, the Housekeeping Director (E4) confirmed he was going to buy the resident some clothes. The findings related to both residents’ missing belongings and the lack of proper documentation and protection of their property were reviewed with the Nursing Home Administrator (E1) and the Quality Manager (E3) during the exit conference on 9/9/25.
Failure to Promptly Resolve Resident Grievance About Missing Clothing
Penalty
Summary
The deficiency involves the facility’s failure to promptly resolve a cognitively intact resident’s grievance regarding missing personal clothing items. The resident was admitted on 3/7/19 and later reported on 5/4/24 that underwear, shirts, pants, and a cowboy jersey were missing, stating he was unsure where the clothing went and that it was possible the laundry had misplaced it. The grievance/concern log documented that on 5/7/24 the Housekeeping Director checked the laundry room and did not find any missing clothing, but there was no further documented action demonstrating timely resolution of the concern. A quarterly MDS dated 7/24/25 recorded a BIMS score of 15, indicating the resident was cognitively intact. During an interview on 9/2/25, the resident continued to report that his underwear, shirts, pants, and cowboy jersey were missing, and on 9/4/24 the Housekeeping Director stated in an interview that he was going that day to buy the resident some clothes. In a separate interview on 9/4/24, the Quality Manager confirmed that the facility lacked evidence of a prompt response or resolution to the resident’s grievance about the missing clothing items originally reported on 5/4/24, despite the established process described by the NPE for documenting and submitting grievances to the NHA.
Failure to Initiate Required Level II PASRR Referrals After New Mental Health Diagnoses
Penalty
Summary
The deficiency involves the facility’s failure to initiate required referrals for Level II PASRR screenings after new mental health diagnoses were identified for three residents. One resident had a PASRR Level I outcome listing major depression and suspected anxiety disorder, and was later admitted with bipolar disorder, anxiety disorder, and depression. The resident’s care plan and psychiatric evaluation documented depressed mood and multiple psychotropic medications for depression, and the active diagnoses and MDS assessments reflected bipolar disorder and depression. The Quality Manager and Social Worker Director both confirmed that this resident required a Level II PASRR referral due to the new onset of depression and bipolar disorder, and acknowledged that the referral was not completed. Another resident was admitted with generalized anxiety disorder and had a PASRR Level I outcome listing anxiety disorder, but later had a new diagnosis of major depressive disorder documented in the admission record, care plan revisions addressing mood, and a significant change MDS reflecting active major depressive disorder. The Quality Manager and Social Worker Director confirmed that a Level II PASRR referral was required for this new diagnosis and that it was not done. A third resident, admitted several years earlier, had a new diagnosis of depression entered in the electronic chart and reflected on a quarterly MDS. The social worker reported she did not have access to the electronic system to place a PASRR Level II referral and confirmed that no Level II PASRR was completed. The Quality Manager also confirmed that no Level II PASRR had been completed in response to this new diagnosis of depression, and these findings were reviewed with the Nursing Home Administrator and Quality Manager at exit.
Medications Left at Bedside Without Ensuring Ingestion
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications were administered in accordance with professional standards and the facility’s own medication guidelines for one resident (R79) out of ninety-one residents screened. The facility’s policy, last updated January 2025, required that residents be observed after administration to ensure that the dose was completely ingested. On 9/2/25 at 9:16 AM, a surveyor entered R79’s room and observed six pills left on top of the bedside table. When asked, R79 stated, “I don't know what these are do you?” The surveyor left the room and immediately returned with E13 (LPN), who confirmed that they had left R79’s medications without ensuring that the medications were ingested, contrary to the facility’s policy and professional standards. On 9/9/25 at 2:00 PM, these findings were reviewed with the Nursing Home Administrator (E1) and the Quality Manager (E3) during the exit conference.
Failure to Reposition High-Risk Resident With Stage 3 Pressure Ulcer
Penalty
Summary
Surveyors identified that the facility failed to provide pressure ulcer care and preventive repositioning for a resident with a high risk for skin breakdown. The resident was admitted with a stroke, dementia, muscle weakness, adult failure to thrive, and a stage 3 sacral pressure ulcer, and an admission MDS documented total dependence for turning and repositioning with impairments in both upper and lower extremities. A Braden Scale assessment showed a score of 9, indicating very high risk for pressure ulcer development, and the care plan called for turning and repositioning and skin checks every 2 hours. Despite this, on multiple observations on the same day, the resident was seen lying in bed on his back with the head of the bed elevated approximately 45–60 degrees, without positioning pillows or wedges, and remained on his back for four hours without being turned. The wound NP stated that turning and repositioning is expected every 2 hours even with an air mattress and that wedges or pillows were available, and a CNA confirmed that pillows or wedges could be used and that it was not a problem to get the resident off his back, demonstrating that the facility did not implement the ordered repositioning regimen.
Failure to Label Enteral Feeding per Facility Policy
Penalty
Summary
Surveyors found that the facility failed to follow its own policy and current professional standards for enteral feeding administration for one resident with a feeding tube. The facility’s policy, revised 2/24/25, required staff to fill in the container’s label with the patient’s name, room number, date, start time, and flow rate, and to label the administration set with the start date and time. The resident, admitted on 6/20/25 with stroke, dementia, dysphagia, adult failure to thrive, and severe protein-calorie malnutrition, had an admission MDS on 6/27/25 documenting use of a mechanically altered diet with a feeding tube, and a care plan dated 8/20/25 noting an enteral feeding tube to meet nutritional needs. On 9/2/25 at 10:57 AM, direct observation showed that Jevity 1.2 cal tube feeding was infusing via pump for this resident, but the Jevity bottle was not labeled with the date, time, or initials of the staff who started the infusion, contrary to facility policy. During an interview at 12:54 PM the same day, an RN stated that the overnight shift hangs the feeding and is supposed to date, time, and initial it, and confirmed that this information was missing from the resident’s tube feeding container. These findings were later reviewed with the nursing home administrator and quality manager during the exit conference on 9/9/25.
Improper Storage of Nebulizer and Oxygen Mask Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of respiratory care when a resident’s oxygen mask and nebulizer equipment were not stored in a protective plastic bag as required by facility policy. The facility’s nebulizer policy, revised 11/1/23, directed staff to place nebulizer equipment in a treatment bag labeled with the patient’s name and date. The resident, admitted on 4/10/24, had a history of COPD and a physician order dated 4/8/25 for PRN ipratropium-albuterol nebulizer treatments every six hours as needed for shortness of breath or wheezing, and a care plan dated 8/20/25 documented that the resident received respiratory treatments as ordered. A significant change MDS dated 8/29/25 documented that the resident received respiratory therapy. On 9/2/25 at 10:39 AM, surveyors observed the resident’s oxygen mask with nebulizer unit attached sitting on top of the bedside table with no protective bag available. During an interview at 10:42 AM, an RN confirmed the equipment was on the bedside table and not in a protective bag, and stated that the respiratory therapist usually places such equipment in a labeled bag. These findings were later reviewed with the NHA and Quality Manager during the exit conference.
Failure to Assist Resident in Obtaining Needed Dental Services
Penalty
Summary
The facility failed to provide or obtain needed dental services for one resident. The facility’s dental services policy stated that the center would provide or obtain routine and emergency dental services to meet each patient’s needs. The resident was admitted with Medicaid coverage, and an admission MDS documented that the resident was cognitively intact and had broken natural teeth. A care plan was created for the resident’s dental problems, including broken, loose, and carious teeth, with an intervention specifying dental referrals as needed. Despite this, the resident reported having spoken with the unit manager about seeing a dentist and stated that nothing had happened for a couple of weeks. The social services designee reported being unaware of any request for dental services from this resident and provided a list of residents scheduled to be seen by the contracted dentist, which did not include the resident. The unit manager confirmed knowledge of the resident’s need for assistance to see a dentist and stated that they had only recently reached out to the social services designee to request the resident be added to the list. This sequence of events showed that the resident’s identified dental needs and request for assistance were not timely communicated or acted upon, resulting in the resident not being scheduled for dental services as of the time of the surveyor’s review.
Failure to Follow Infection Control Practices During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when staff failed to follow infection prevention and control practices, including CDC-referenced Enhanced Barrier Precautions (EBP), during wound care for one resident. The resident had been admitted with multiple conditions including Hidradenitis Suppurativa and was being treated for wound infections, with orders for EBP and topical Clindamycin to infected groin wounds. During an initial pool screening, the resident’s bed sheets were observed with moderately sized circular pale pink stains, and the resident reported having open wounds that sometimes drained. The CDC guidance cited in the report specifies that wound care for any skin opening requiring a dressing is a high-contact activity requiring gown and glove use, and that face protection may be needed if there is a risk of splash or spray. During an observed dressing change, the Infection Preventionist (IP) entered the resident’s room without a face covering and placed a clean drape on the bedside table along with dressing change supplies and a personal cell phone. The cell phone’s face appeared opaque with visible fingerprints and smears, and there was no observation of the phone being cleaned prior to the procedure. The IP poured wound cleaning agent from a medicine cup onto gauze held by another nurse, with the open mouth of the cup creating a potential for splashing. The IP directly handled sterile gauze with gloved hands before handing it to the nurse to pat the wounds dry, then used the same gloved hands to handle the cell phone and take close-up pictures of the draining and abscess-prone wounds. The IP again directly handled gauze with gloved hands, applied antibiotic ointment to it, and used it on the wounds. In a subsequent interview, the IP acknowledged not wearing a face covering and touching the cell phone during the dressing change, and stated disagreement with the need for a face covering because the wound was not being irrigated, while asserting the phone had been cleaned despite no prior cleaning being observed.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident within the required time constraints. The incident involved a resident with diagnoses including hypertension, low back pain, and nervous system disorders, who was reportedly asked by an activity aide to expose his private parts while in the activity room. The resident's spouse reported the incident, and another resident relayed the information to the activities director. Despite these reports, the activities director did not act on the information, dismissing it as typical behavior from the residents involved. The nursing home administrator was not made aware of the alleged abuse until several days after the initial report. The delay in reporting was due to a lack of communication and failure to recognize the seriousness of the allegation by staff members who received the information. The incident was not reported to the Division of Healthcare & Quality until several days after it was first brought to the attention of staff. Interviews confirmed that staff did not immediately recognize or act upon the allegation, resulting in a failure to meet the required reporting timeframe for suspected abuse.
Failure to Obtain and Enter BiPAP Orders at Admission
Penalty
Summary
A deficiency occurred when the facility failed to obtain and enter physician orders for BiPAP respiratory settings into the electronic medical record (EMR) for a resident admitted with diagnoses including obstructive sleep apnea, emphysema, and chronic respiratory failure with hypoxia. Upon admission, the resident required nightly BiPAP therapy, and the hospital discharge summary as well as uploaded hospital orders specified the need for BiPAP with particular settings. Despite this, there was no evidence in the EMR of BiPAP settings orders from the time of admission until two days later. The facility's policy required verification and application of ordered BiPAP settings at initial setup, but this was not followed, resulting in the absence of necessary respiratory therapy orders for the resident's immediate care.
Failure to Obtain and Document Dialysis Lab Reports
Penalty
Summary
The facility failed to establish and implement a process to obtain and document complete laboratory reports from dialysis providers for residents receiving hemodialysis. For three residents with end stage renal disease and dependence on hemodialysis, their clinical records lacked up-to-date laboratory results from their respective dialysis centers. Although the dialysis centers performed regular lab work, the official lab reports were not consistently sent to or filed in the facility's electronic medical records (EMR), and only select lab values or handwritten notes were communicated, often via binders or phone calls for abnormal results. For one resident admitted with multiple diagnoses including diabetes, anemia, and end stage renal disease, the last documented lab result in the facility's EMR was several months old, despite monthly labs being performed at the dialysis center. The dialysis center communicated some lab results through a report card or binder, but did not provide official lab reports to the facility. Similar issues were found for another resident with hyperlipidemia, end stage renal disease, and stroke, whose weekly dialysis labs were not documented in the facility's EMR, with communication limited to phone calls for abnormal results or handwritten notes in a communication sheet. A third resident, also dependent on hemodialysis, had only a single set of labs documented in the facility's EMR since admission, despite regular labs being performed at the dialysis center. The facility relied on handwritten communication sheets and phone calls for abnormal results, and did not have a process to ensure that official lab reports from the dialysis centers were obtained and made available to facility providers. This lack of a formal process impeded the coordination of care for residents receiving dialysis.
Failure to Ensure Physician Review of Care and Lab Results for Dialysis Residents
Penalty
Summary
The facility failed to ensure that physicians reviewed the total program of care for three residents who were receiving hemodialysis and supplemental oxygen therapy. For one resident with a history of coronary artery disease, end stage renal disease, and stroke, the physician did not document or address the resident's non-compliance with supplemental oxygen therapy, despite multiple recorded instances of low oxygen saturation and missed oxygen use. Additionally, there was no evidence of a documented plan of care regarding the frequency of lab draws or review of lab results, even though the resident was newly initiated on hemodialysis due to acute kidney injury. The physician's progress notes repeatedly referenced reviewing labs that were not present in the resident's electronic medical record (EMR), and the facility could not provide evidence that these labs were reviewed as required. For two other residents with end stage renal disease and dependence on hemodialysis, the facility did not have official laboratory reports from the hemodialysis centers uploaded into their EMRs. Communication from the dialysis centers was limited to handwritten notes or verbal reports of abnormal labs, rather than comprehensive lab reports. Provider progress notes for these residents also referenced reviewing labs that were not available in the EMR, and there was no documentation of lab review or plans of care based on these results. Interviews with dialysis center staff confirmed that official lab reports were not routinely sent to the facility, and only abnormal results were communicated, often verbally. The lack of official lab reports and incomplete documentation in the residents' EMRs meant that physicians could not adequately review or address the residents' ongoing care needs, including lab monitoring and compliance with prescribed therapies. This failure to ensure proper physician oversight and documentation affected residents with complex medical conditions, including those with recent hospitalizations for complications related to their kidney disease.
Failure to Maintain Complete Laboratory Records for Dialysis Residents
Penalty
Summary
For two residents receiving hemodialysis, the facility failed to maintain complete, dated laboratory records in the residents' electronic medical records (EMR) that included the name and address of the testing laboratory. One resident, admitted with diagnoses such as diabetes, anemia, seizure disorder, and end stage renal disease, had monthly lab work performed at an outside hemodialysis center. However, the official laboratory reports were not sent to the facility, and only handwritten communication sheets with lab results were present in the resident's dialysis binder. These handwritten results were not on the official laboratory report and were not uploaded into the EMR. Similarly, another resident with multiple diagnoses including diabetes, anemia, hyperlipidemia, hypomagnesemia, and end stage renal disease had lab results documented on a quarterly report card generated by the hemodialysis center. This report did not include the name and address of the testing laboratory and was not uploaded into the EMR. Interviews with facility and dialysis center staff confirmed that the standard practice was to provide handwritten or typed summaries of lab results, rather than official lab reports, and that these were not consistently shared with or filed by the facility.
Failure to Maintain Complete and Accessible Medical Records for Dialysis Residents
Penalty
Summary
The facility failed to maintain complete and readily accessible medical records for three residents who were receiving hemodialysis. For each of these residents, laboratory results from their dialysis treatments, which were performed at outside hemodialysis centers, were not obtained and entered into the facility's electronic medical record (EMR). Specifically, one resident had no laboratory blood work documented in the EMR since July, despite monthly labs being drawn at the dialysis center. Another resident, who required weekly labs due to acute kidney injury, had no evidence of these results in the EMR, including a STAT lab ordered and drawn at the facility. A third resident's EMR lacked recent lab results, and only a partial set of lab values was found in a dialysis binder, not uploaded into the EMR. Interviews with staff from both the facility and the dialysis centers confirmed that lab work was being performed regularly at the dialysis centers, but the official lab reports were not being sent to or entered by the facility. Facility staff acknowledged the absence of these results in the EMR and indicated a lack of process for obtaining and documenting the lab results from the dialysis units. The deficiency was identified through record review and staff interviews, which revealed the incomplete and inaccessible medical records for residents dependent on hemodialysis.
Failure to Prevent Pressure Ulcers in Residents
Penalty
Summary
The facility failed to provide adequate care and services to prevent pressure ulcers and promote healing for two residents, R20 and R45. For R20, the facility did not ensure that the resident was turned and repositioned regularly, which resulted in the development of avoidable Stage 3 and Stage 4 pressure ulcers on the heels. Despite being identified as at risk for pressure ulcers, the care plan for R20 lacked specific interventions to offload pressure from the heels until after the ulcers had developed. Observations revealed that the pillows used to float R20's heels were not positioned correctly, allowing the heels to rest directly on the mattress. For R45, the facility also failed to prevent an avoidable deep tissue injury from developing on the right heel. The care plan for R45 did not include measures to offload pressure from the heels, despite the resident's dependence on staff for mobility and being at risk for pressure ulcers. Observations showed that R45's heels were frequently resting directly on the mattress without proper support to float them, contributing to the development of a deep tissue injury. Interviews with staff members confirmed that the purpose of floating heels is to prevent skin breakdown and that staff should be adjusting pillows every two hours. However, the facility's documentation lacked evidence of consistent implementation of these measures, and the staff did not report or address reddened areas on the residents' skin that did not go away. The facility's failure to implement and monitor appropriate interventions led to the development and worsening of pressure ulcers for both residents.
Deficiencies in Care Plan Meetings and Behavioral Management
Penalty
Summary
The facility failed to ensure that the required interdisciplinary team (IDT) members participated in care plan meetings and that these meetings occurred every three months for four out of twenty sampled residents. For one resident, the initial care plan meeting lacked input from the physician, and there was no evidence of a quarterly care plan meeting. Another resident's care plan meetings lacked input from the nurse and physician, and there was a significant gap in meetings despite a change in status assessment. A third resident's care plan meetings lacked input from a certified nursing assistant, and there were gaps in meetings despite quarterly assessments. Additionally, the facility did not review and revise a resident's care plan to reflect a behavior of frequently removing nebulizer equipment from its protective bag. This resident, who was severely cognitively impaired, was observed to turn the nebulizer machine on and off and remove the equipment from the bag without a care plan addressing these behaviors. The Director of Nursing was unaware of these behaviors, and the care plan was not updated to reflect them until after the surveyor's findings were shared.
Deficiency in Continence Management for Residents
Penalty
Summary
The facility failed to provide appropriate continence management for three residents, resulting in a deficiency in maintaining or restoring bladder continence. The facility's policy, revised on 6/15/22, required quarterly reviews of continence status as part of the care planning process. However, for three residents, the facility did not respond to decreased continence or provide services to restore continence. Resident R20 was admitted on 5/12/22 and was frequently incontinent of bowel and bladder, yet was not placed on a toileting program. Interviews with staff confirmed that R20 was dependent on care and not offered a bedpan, and there was no evidence of a quarterly bowel and bladder assessment. Similarly, Resident R38, admitted on 5/10/23, required extensive assistance for toileting and was frequently incontinent of urine and always incontinent of bowel. Despite this, R38 was not on a toileting program, and staff confirmed the lack of a suitable bedpan. Resident R45, admitted on 7/13/19, was frequently incontinent and not on a toileting program, with staff confirming the absence of a bedpan offer. The facility lacked evidence of responding to decreased continence and failed to provide services to restore continence for these residents, as well as lacking evidence of quarterly bowel and bladder assessments.
Failure to Complete Annual CNA Evaluations
Penalty
Summary
The facility failed to complete annual evaluations for five certified nursing assistants (CNAs), identified as E7, E8, E9, E10, and E11. This deficiency was discovered during a record review and interview process. The CNAs had varying dates of hire, ranging from November 20, 2017, to March 7, 2023. The Nursing Home Administrator (NHA), identified as E1, provided documentation regarding the evaluations and acknowledged a system failure due to staff turnover, which resulted in the overdue performance evaluations. At the time of the survey, the facility was in the process of completing these evaluations. The findings were discussed with the NHA, the Director of Nursing (DON), and a corporate representative during the exit conference.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in a manner that prevents foodborne illness to the residents. During an initial tour of the kitchen, an open plastic bag containing lettuce and celery with browned edges and negative changes in quality and texture was observed in the walk-in refrigerator. Additionally, a puddle of standing water was found under the ice machine and the water line that supplies it. Furthermore, the Dietary Services Manager tested the sanitizer level of the solution in two red sanitizing buckets, and the test strips indicated that the chemical concentration was insufficient for proper sanitization. These findings were reviewed with the Nursing Home Administrator, Director of Nursing, and a corporate representative during the exit conference.
Failure to Facilitate Resident's Preference for Daily Activity
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not facilitating their preference to get out of bed daily. The resident, who was admitted to the facility on January 31, 2024, was documented as being dependent on a sit-to-stand lift for transfers and was cognitively intact with a BIMS score of 13. Despite this, observations from September 16 to September 20, 2024, consistently noted the resident lying in bed watching television. On September 23, 2024, the resident expressed during an interview that they preferred to get out of bed daily but were told by staff that they were too busy to assist. A CNA confirmed the resident's preference and the staff's awareness of it. The facility lacked evidence of accommodating the resident's daily preference to get out of bed.
Failure to Provide SNFABN for Medicare Part A Discharges
Penalty
Summary
The facility failed to provide a completed Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) for two out of three Medicare Part A discharges reviewed. Resident R10 began receiving Medicare Part A skilled services on February 15, 2024, with the last day of covered services on April 2, 2024. The resident remained at the facility as a long-term care resident, but there was no evidence that the SNFABN was provided when Medicare Part A services ended and the resident switched to another payer source. Similarly, Resident R48 started Medicare Part A skilled services on April 29, 2024, with the last day of covered services on July 2, 2024. This resident also stayed at the facility as a long-term care resident, and there was no evidence of the SNFABN being provided upon the transition to another payer source. During an interview, the Nursing Home Administrator (E1) stated that the SNFABN form was not provided because the staff did not realize it was still necessary when the resident switched to another payer source. These findings were reviewed with the Nursing Home Administrator, Director of Nursing, and a corporate representative during the exit conference.
Failure to Conduct PASARR Level II Evaluation for New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure a referral for a PASARR Level II evaluation was conducted for a resident, identified as R64, who had a new mental health diagnosis. R64 was admitted with diagnoses including atrial fibrillation, hypertension, and major depressive disorder. Initially, a PASARR Level I screen indicated no need for a Level II evaluation. However, the resident's annual MDS later documented a new diagnosis of schizophrenia. During an interview, the social worker, E6, was unable to find evidence of a new PASARR application for R64 and acknowledged that it was not completed, although it was due. The facility lacked documentation to show that the resident was referred to the state agency for the necessary PASARR Level II evaluation and determination.
Failure to Provide Adequate ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, R39 and R89, who were dependent on staff for their care. R39, admitted to the facility in April 2021, was documented as dependent for bathing and personal hygiene. Despite having a scheduled shower routine and a preference for bed baths, observations on multiple occasions revealed that R39 had overgrown fingernails with debris underneath. Interviews with staff confirmed that nail trimming, which was expected to be done weekly, was not completed due to time constraints, indicating a lack of proper ADL care. R89, who required substantial assistance for various ADLs, was admitted back to the facility in June 2024 and later to hospice care. Despite documentation indicating that bathing and toileting were provided, a family complaint highlighted that R89 appeared disheveled and had unclean sheets during a visit. The facility's incident report and interviews confirmed that R89 had not received adequate care, as evidenced by his appearance and the family's concerns. The CNA responsible for R89's care was educated on ADL care and suspended pending investigation, underscoring the facility's failure to ensure proper ADL support for dependent residents.
Failure to Properly Store Nebulizer Equipment
Penalty
Summary
The facility failed to adhere to professional standards of practice by not ensuring that a resident's nebulizer equipment was stored in a protective plastic bag. The resident, who was admitted with chronic obstructive pulmonary disease and a history of stroke, had a physician's order for Albuterol Sulfate Nebulization Solution to be used as needed for shortness of breath. Despite this, observations on two consecutive days revealed that the resident's nebulizer tubing and mask were left on the nightstand table without being enclosed in a protective plastic bag. This was confirmed by an LPN and later acknowledged by the Director of Nursing during an exit conference.
Deficiencies in Monitoring Psychoactive Medications
Penalty
Summary
The facility was found to have deficiencies in monitoring psychoactive medications for two residents, R22 and R57. For R22, the facility failed to conduct an Abnormal Involuntary Movement Scale (AIMS) assessment in February 2024, despite the resident being on Zyprexa (olanzapine) and having a history of hospitalization during that period. The AIMS assessment is crucial for monitoring potential side effects of antipsychotic medications. Interviews with staff revealed confusion about the responsibility for entering orders for AIMS assessments, and it was confirmed that the assessment was not completed as required. For R57, the facility did not adequately monitor for symptoms of psychosis despite the resident being prescribed Quetiapine Fumarate for psychosis. The physician's order included monitoring for side effects but lacked specific instructions to monitor for symptoms of psychosis. Interviews with staff indicated that there was no documentation of monitoring for psychosis symptoms, highlighting a gap in the facility's medication management and monitoring processes.
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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