Stonegates
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenville, Delaware.
- Location
- 4031 Kennett Pike, Greenville, Delaware 19807
- CMS Provider Number
- 085026
- Inspections on file
- 15
- Latest survey
- December 12, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Stonegates during CMS and state inspections, most recent first.
Two residents with Parkinson’s disease were ordered carbidopa-levodopa (Sinemet), but their MDS assessments inaccurately documented use of an anticonvulsant, despite no anticonvulsant orders in their records. Review of clinical records showed that carbidopa-levodopa was incorrectly coded as an anticonvulsant on multiple MDS assessments, and an RNAC reported having coded Sinemet this way for years based on prior instruction.
A resident’s care planning conferences were conducted without participation or documented input from the resident’s medical provider, despite multiple documented care conference dates. Sign-in sheets and a plan of care note showed attendance by an RN, LPN, RDN, and RNAC, while interviews with an LPN and the DON confirmed that medical providers do not attend or provide input for care plan/IDT meetings. This resulted in the comprehensive care plan not being developed and reviewed by the full required team of health professionals.
A resident with Parkinson’s disease, dementia, moderate cognitive impairment (BIMS 11), and a need for substantial/max assistance with bed mobility was observed on multiple occasions with bilateral quarter bed rails in the up position. Staff interviews indicated the resident required a hoyer lift for transfers, did not independently use the bed rails, and needed staff to guide her hands to hold the rails. Review of the clinical record showed no evidence that alternatives to bed rails were attempted, no bed rail assessment, no documented review of risks and benefits, no informed consent, and no bed rail care plan prior to installation and use of the bed rails.
A resident with Parkinson’s disease and anxiety disorder had multiple PRN lorazepam orders entered and renewed by a physician, who documented that the resident was experiencing positive benefit from the PRN Ativan and that it would be continued. However, review of the MARs and narcotic sheets for two consecutive months showed no recorded administrations of lorazepam, and the ADON confirmed that no doses had been given. This discrepancy showed that the medical record did not accurately or completely reflect the resident’s actual medication use.
A resident was observed in bed with bilateral quarter bed rails in the up position, and surveyors later determined that these bed rails had not been included in the facility’s routine, preventative maintenance program. During an interview with the NHA and DON, the facility could not provide evidence that the bed rails for this resident had undergone required preventative maintenance inspections, resulting in a deficiency related to bed safety equipment oversight.
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to all staff, as shown by the absence of QAPI training documentation for a housekeeping employee and a dietary employee hired earlier in the year. During a staff training record review, surveyors found no evidence that these two employees had completed QAPI training, and the Scheduling Coordinator confirmed that such documentation was not available. The deficiency was discussed with the NHA, DON, and ADON during the survey exit conference.
The facility failed to ensure proper food storage and handling, risking foodborne illness. Observations revealed opened food items without proper dating, improper organization of raw animal foods, and an ice machine scoop left outside its container. Additionally, juice containers were undated, and items were stored on the floor. These issues were confirmed by staff and reviewed with facility leadership.
The facility failed to maintain proper infection control in the laundry room by leaving the door between the washer and dryer rooms open and storing clean linen and emergency water supplies in the soiled room. Staff confirmed these practices, which could lead to cross-contamination.
During a dining observation, it was found that staff used gloves while serving and feeding residents, violating their dignity. Four residents, all dependent for eating and severely cognitively impaired, were involved. Staff confirmed that glove use had been a practice since the COVID pandemic. The findings were reviewed with facility leadership.
A facility failed to collaborate with a hospice provider in developing a comprehensive care plan for a resident with cerebrovascular disease. The facility's care plan did not include hospice interventions, lacked pain monitoring orders, and showed poor communication with hospice staff. Critical lab results were not shared with hospice, and there was no documentation of hospice staff education to facility staff. Missing hospice documentation and irregular communication were noted during observations and staff interviews.
The facility failed to provide required dementia training for two staff members, E13 and E14, who were hired in 2015 and 2018, respectively. This deficiency was confirmed by the HR Director and discussed during the exit conference with the NHA, DON, and ADON.
Inaccurate MDS Coding of Carbidopa-Levodopa as an Anticonvulsant
Penalty
Summary
The deficiency involves inaccurate assessment and documentation of medications on the MDS for two residents with Parkinson’s disease. One resident was admitted with Parkinson’s disease and had an MD order for carbidopa-levodopa to be given three times daily. Despite this, the resident’s annual and significant change MDS assessments documented that the resident was taking an anticonvulsant, while review of the medication orders showed no anticonvulsant medications were ordered at those times. The facility inaccurately coded carbidopa-levodopa as an anticonvulsant on both MDS assessments. A second resident, also admitted with Parkinson’s disease and ordered carbidopa-levodopa four times daily, had a quarterly MDS assessment that documented use of an anticonvulsant, even though review of the medication orders showed no anticonvulsant medications were ordered. During an interview, the RNAC stated that they had been coding Sinemet (carbidopa-levodopa) as an anticonvulsant for years, since CMS started tracking anticonvulsant medications, and that this was how they had been taught to code it. This practice resulted in inaccurate MDS documentation for the resident’s medication regimen.
Failure to Involve Medical Provider in Interdisciplinary Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to include the required members, specifically the resident’s medical provider, in the care planning process for one resident reviewed for unnecessary medications. Review of the resident’s record showed a care conference sign-in sheet with review dates of 5/27/25, 8/21/25, and 11/13/25, listing participants as an RN, LPN, RDN, and RNAC, but no medical provider. In an interview, an LPN confirmed that residents’ medical providers do not attend or participate in care plan meetings. In a separate interview, the DON stated that the DON, RNAC, dietary, and family attend the care plan/IDT meetings and confirmed that residents’ medical providers do not participate, either by attending or providing input. The DON also reviewed a 11/13/25 progress note titled “Plan of Care Note” and confirmed there was no documentation of participation or input from the resident’s medical provider. These findings were reviewed with the NHA, DON, and ADON during the exit conference. The deficiency is specifically related to the requirement that the comprehensive care plan be developed, reviewed, and revised by a team of health professionals, which includes the resident’s medical provider. The documentation and staff interviews demonstrated that, for this resident, the care planning conferences were conducted without involvement or documented input from the medical provider, despite multiple care conference dates and a formal plan of care note in the record.
Failure to Assess, Document Alternatives, and Obtain Consent Before Bed Rail Use
Penalty
Summary
The deficiency involves the facility’s failure to complete and document required assessments and consents before installing and using bilateral quarter bed rails for one resident reviewed for accidents. The resident had an annual MDS showing a BIMS score of 11, indicating moderate cognitive impairment, and active diagnoses of Parkinson’s disease and dementia. The MDS also documented that the resident required substantial to maximum staff assistance for rolling in bed and moving from lying to sitting at the side of the bed. On two separate observations, the resident was seen in bed with bilateral quarter side rails in the up position during a nap and later the same day. Record review showed no evidence that alternatives to bed rails were attempted, no bed rail safety assessment, no documentation that risks and benefits were reviewed with the resident or representative, no informed consent, and no bed rail care plan for the use of bilateral bed rails. During interviews, a CNA stated the resident required assistance to turn in bed and used a hoyer lift for transfers, and that the resident did not use the bed rails. An LPN stated the resident had Parkinson’s disease with hand tremors and needed staff to guide her hands to the bed rails and direct her to hold on, after which the resident would hold on. In a combined interview with the NHA and DON, no bed rail information dated prior to the surveyor’s inquiry was provided, confirming the lack of required documentation prior to installation and use of the bilateral bed rails.
Inaccurate Documentation of PRN Lorazepam Use
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records for a resident with diagnoses including Parkinson’s disease and anxiety disorder. The resident was admitted on 11/3/23, and on 11/18/25 a physician ordered lorazepam 0.5 mg PO every 6 hours PRN for anxiety, nausea/vomiting, or agitation; this order was discontinued on 11/24/25. On 11/24/25, the same lorazepam PRN order was re-entered for 14 days and then discontinued on 12/8/25. On 12/8/25 at 3:52 PM, the physician documented in a progress note that the resident was on PRN Ativan, that positive benefit had been seen, and that the medication would be continued for one month. A new lorazepam PRN order for 30 days was entered on 12/8/25. Review of the resident’s November and December 2025 MARs and the facility’s narcotic sheet for lorazepam showed that no doses of PRN lorazepam were administered during those months. During an interview on 12/11/25, the ADON confirmed that no lorazepam doses had been given in November or December and stated that the resident was not taking the medication. Despite this, the 12/8/25 physician note documented that the resident had experienced positive benefit from PRN Ativan, with no medication administration records to corroborate that any doses had been given. This discrepancy demonstrated that the resident’s clinical record did not accurately and completely reflect the care and treatment provided.
Failure to Include Bed Rails in Routine Preventative Maintenance Program
Penalty
Summary
The deficiency involves the facility’s failure to include a resident’s bed rails in a routine, preventative maintenance program as required by the facility’s bed safety procedures. On 12/10/25 at 1:48 PM and again at 3:38 PM, surveyors observed Resident 18 in bed with bilateral quarter bed rails in the up position. During a combined interview on 12/11/25 at 11:35 AM with the NHA (E1) and DON (E2), surveyors reviewed the requirement that bed rails be inspected as part of the facility’s maintenance program. At that time, the facility was unable to provide evidence that this resident’s bed rails had been included in any routine, preventative maintenance inspections prior to 12/10/25. On 12/12/25 at 12:30 PM, this finding regarding the lack of documented preventative maintenance for the resident’s bed rails was reviewed with facility leadership, including the NHA, DON, and ADON, during the exit conference.
Failure to Provide QAPI Training to All Staff
Penalty
Summary
The facility failed to ensure all staff received mandatory training on the facility’s Quality Assurance and Performance Improvement (QAPI) program, as evidenced by missing training documentation for two of ten employees reviewed. Employee E8, a housekeeping staff member who began working on 3/26/25, and Employee E7, a dietary staff member who began working on 8/7/25, had no evidence in their records of having completed QAPI training. During record review on 12/11/25 at 1:24 PM, surveyors identified the absence of QAPI training documentation for these two employees, and at the same time, the Scheduling Coordinator (E12) confirmed that there was no evidence that E7 and E8 had completed QAPI training. The finding was later reviewed with the NHA (E1), DON (E2), and ADON (E3) during the exit conference on 12/12/25 at 12:30 PM. No residents were mentioned in the report, and no additional clinical or medical details were provided related to the deficiency.
Improper Food Storage and Handling in Facility
Penalty
Summary
The facility failed to ensure proper food storage, preparation, and service, which could lead to foodborne illness among residents. During an observation in the kitchen, it was noted that the walk-in refrigerator contained opened food items such as tartar, mandarins, and cherries, which were labeled with dates but lacked information on when they should be consumed, sold, or discarded. Additionally, bread slices and sesame buns were not dated. In the dry storage area, a bag of tortilla chips, a bag of grits, and a pan of almonds were also found without dates indicating when they were opened or prepared. These findings were confirmed by a Food Service Assistant. Further observations revealed that raw animal foods were not properly organized in the walk-in refrigerator, with raw fish stored next to red beans and above tomato paste, and raw pork stored above precooked rice and mushrooms, increasing the risk of cross-contamination. The ice machine scoop was found lying on the counter outside its protective container, and a case of water and a large container of ice cream were stored on the floor of the walk-in refrigerator and freezer. Additionally, juice containers in a refrigerator next to the ice machine were not dated when opened, a fact confirmed by a Dietary Aide who subsequently removed them. These issues were reviewed during an exit conference with the Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing.
Infection Control Deficiency in Laundry Room
Penalty
Summary
The facility failed to handle, store, and process linens properly in the laundry room, leading to potential infection control issues. During observations, it was noted that the door between the washer room and the dryer (clean) room was open, which should remain closed to prevent cross-contamination. Additionally, the soiled room contained inappropriate items such as an office desk, a resident emergency water supply, and a cart with clean linen, which should not be stored in the soiled area. Interviews with staff confirmed these observations and acknowledged that the doors should remain closed and that clean items should not be stored in the soiled linen room.
Violation of Resident Dignity During Dining
Penalty
Summary
During a dining observation, it was found that food service employees and nursing staff were using gloves while serving and feeding residents, which violated the residents' dignity in their home environment. Four residents, identified as R13, R15, R17, and R19, were observed during this incident. All four residents were documented as dependent for eating and severely cognitively impaired, according to their respective MDS assessments. The use of gloves in the dining room was confirmed by staff members, who reported that this practice had been in place since the COVID pandemic. The findings were reviewed with the Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing during the exit conference.
Failure to Collaborate with Hospice Provider in Care Plan Development
Penalty
Summary
The facility failed to collaborate with the hospice provider in developing a comprehensive written plan of care for a resident admitted to hospice with a diagnosis of cerebrovascular disease. The facility's hospice care plan, initiated prior to the resident's admission to hospice, did not incorporate the hospice provider's care plan interventions. This included the absence of orders to monitor pain at scheduled intervals and a lack of communication with the hospice provider regarding critical lab results indicating potential heart failure. Additionally, there was only one documented instance of facility staff contacting hospice about the resident's change in condition. The facility also lacked evidence of communication between the hospice nurse and facility staff, as there were no records of the hospice nurse providing education to the staff as outlined in the hospice care plan. Observations revealed the absence of a sign-in sheet for hospice staff and missing comprehensive assessment and plan of care update reports in the resident's hospice binder. Interviews with facility staff indicated irregular communication and coordination with hospice staff, with no documentation of discussions about the resident's status. The hospice provider later furnished the missing reports upon request by the surveyor.
Lack of Dementia Training for Staff
Penalty
Summary
The facility failed to ensure that two out of five sampled employees received the required training on dementia management. Specifically, staff members E13 and E14 did not have evidence of completing dementia training. E13 was hired on August 19, 2015, and E14 was hired on March 28, 2018. This deficiency was confirmed during an interview with E15, the HR Director, who acknowledged the lack of dementia training for these employees. The findings were reviewed during the exit conference with the Nursing Home Administrator (E1), Director of Nursing (E2), and Assistant Director of Nursing (E3).
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
