Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westminster Village Health during CMS and state inspections, most recent first.
Surveyors identified that the facility’s call bell system was not functioning across multiple hallways, with call bells in numerous resident rooms failing to produce sound or activate corridor lights when pressed. An LPN, CNAs, and the Maintenance Director confirmed that call bells and associated personal pagers were inoperative throughout the building, and the Maintenance Director suggested a power surge as a possible cause. The NHA later provided call bell logs showing no call bell activations for several hours, indicating that residents had been without a working call system during that time.
Surveyors found that food was not stored and monitored according to professional standards. An undated, unlabeled sandwich and an expired pudding cup were discovered in a unit refrigerator, and review of food temperature logs showed that required temperature checks were not documented before several meals. A staff member confirmed both the presence of the undated/expired items and the missing temperature records, and these issues were later discussed with facility leadership including the NHA, DON, and ED.
A resident with a history of CVA and abnormal gait experienced an unwitnessed fall, resulting in multiple bruises and a fractured toe. The facility did not promptly notify the physician or state agency about the injuries as required, and the incident report was not completed in a timely manner.
A deficiency was found when a newly admitted resident's initial care plan and admission assessment were completed by an LPN rather than an RN, contrary to state nursing regulations. The LPN confirmed performing these tasks, and the DON stated this was in line with facility policy. The issue was reviewed with facility leadership.
A resident with cognitive impairment and a known risk for dehydration did not receive adequate fluids, as documented intake was consistently below the recommended amount. Despite being dependent on staff for eating and drinking, and family requests for IV fluids, the facility delayed interventions and did not monitor supplement or fluid intake as required. Staff and family interviews confirmed insufficient intake and lack of proper monitoring.
A resident with a history of CVA and abnormal gait experienced a fall and was sent to the hospital, then returned with documented purple bruising to the right fifth toe, right flank, and scattered bruising to the left lower leg, with additional notes of bruising to the right fifth toe. Several days later, a mobile X-ray of the right foot revealed a fracture at the base of the right fifth toe, and a physician’s order for the X-ray was documented. However, there was no evidence that the physician was notified of the significant bruising and injury of unknown source to the toe during the days between the fall and the X-ray, and the DON confirmed that no call was made to the physician despite facility expectations that such injuries be reported.
A resident with dementia and an impairment of the right middle finger had a physician’s order for a rolled washcloth to be placed in the right hand, and nurses documented completing this intervention on the TAR. Despite this, review of the clinical record showed no care plan addressing the resident’s limited ROM, contractures, or the rolled washcloth intervention. In an interview, the DON confirmed that no care plan had been developed for the contractures and explained that this was because the resident was on hospice, and these findings were later discussed with facility leadership.
A resident with COPD, CHF, and obstructive sleep apnea had a physician’s order for BiPap use at night with 3L O2, but the treatment administration record did not include instructions for storage of the respiratory equipment. During observations and interviews, an RN and the DON acknowledged that the resident’s BiPap mask and tubing were not stored in a protective plastic bag when not in use, despite the expectation that the equipment should be bagged, resulting in a failure to follow professional standards of respiratory care.
A deficiency was identified when a resident receiving quetiapine for multiple psychiatric conditions did not receive a repeat AIMS assessment as ordered to monitor for antipsychotic side effects. An initial AIMS at admission showed mild abnormal movements, and a consultant pharmacist later recommended a repeat AIMS, which the primary care provider ordered. Facility records, however, contained no completed repeat AIMS, and the DON acknowledged that staff performed a different psychiatric assessment instead of the ordered AIMS.
A resident had a physician order for a urinalysis culture and sensitivity, which was collected by the contracted lab and later phoned in to an LPN. The resident’s record did not show that the LPN notified the physician or NP when the results were received, and the NP did not review the results until two days after the facility had been informed. Facility nursing leadership later confirmed there was an unexplained delay in notifying the practitioner of the lab findings.
A resident on transmission-based precautions had a physician-ordered urinalysis culture and sensitivity collected by a contracted lab, but the test results were not filed in the clinical record as required by facility policy. During record review, surveyors found no lab report in the chart, and the ADON/IP later produced a copy of the results and acknowledged they had not yet been filed. These findings were discussed with facility leadership during the exit conference.
Surveyors found that two residents had no documentation of being offered or receiving a pneumococcal (PNA) vaccine, despite facility policy requiring that all residents be offered this immunization with education and documented consent or refusal. Review of immunization records showed no evidence of PNA vaccination or declination for these residents, and consents were only obtained on the same day they were requested by surveyors. The DON confirmed that the residents had not been offered the PNA immunization before the survey.
A resident with confusion and a history of wandering eloped from the facility by removing a window screen and disengaging the safety latch, exiting undetected due to the absence of window alarms. The resident crossed a parking lot and busy road before being located by staff and law enforcement. Staff interviews revealed that although a Wander guard device was in use, there was no order for regular checks, and the care plan required the device to be on at all times. The lack of window alarms and the resident's ability to exit through the window contributed to the incident.
The facility failed to ensure food safety in its kitchen operations, as observed during a survey. There were no sanitizing solutions for wiping cloths, incorrect chemical test strips were used, and compromised food cans were not separated. Additionally, the ice scoop was improperly stored, and food temperatures were not consistently recorded for several meals. These deficiencies were confirmed with the cook and reviewed with facility leadership.
The facility failed to ensure accurate MDS assessments for three residents, as their admission MDS documented the use of restraints, specifically bilateral bed rails, which were actually used as enabler bars for turning and repositioning. This miscoding was attributed to an RNAC in training and was discovered during a surveyor's request for the Matrix.
A facility failed to ensure required IDT members, specifically a physician or representative, participated in care plan meetings for a resident. Despite the presence of nursing, therapy, CNA, social worker, and dietary staff, the physician did not coordinate with care plan meetings, as confirmed by an RNAC. The issue was discussed with facility leadership during an exit conference.
The facility failed to follow physician orders for two residents, resulting in the administration of medications outside prescribed parameters. One resident received Lantus insulin despite a low blood sugar level, and another received midodrine HCL despite high blood pressure. Interviews and records confirmed these discrepancies, with no evidence of monitoring or addressing the irregularities.
The facility failed to provide adequate continence care for two residents, leading to frequent incontinence episodes. Despite having care plans with specific interventions, staff did not adhere to these plans, and there was no structured toileting program in place. Interviews revealed reliance on a two-hour check and change routine, which was insufficient to meet the residents' needs.
A resident's dietary preferences were not followed on two occasions, with breakfast trays missing specified items and including disliked foods. Staff confirmed the discrepancies, and it was noted that the staff responsible for plating was inexperienced.
The facility's MRR policy lacked necessary time frames for pharmacist responses to urgent medication recommendations. This deficiency was confirmed during an exit conference with the NHA, DON, and Executive Director, acknowledging that the policy did not meet expected requirements.
A resident with advanced dementia reported an allegation of sexual assault to nursing staff, but the facility failed to notify the attending physician and medical director as required by policy. The medical team only became aware of the incident more than twelve hours later, not through standard communication channels but via informal staff discussions. Review of communication logs confirmed no timely notification was made to the medical team.
The facility did not report allegations of sexual and emotional abuse involving two residents within the required 2-hour timeframe. In both cases, staff were aware of the allegations but delayed notifying the State Agency, with one report made over twelve hours later and another five days after the initial complaint. This failure occurred despite staff having access to reporting systems and knowledge of the incidents.
Facility-Wide Failure of Call Bell System Across Multiple Hallways
Penalty
Summary
The deficiency involves the facility’s failure to maintain a functioning call bell system throughout the building. During multiple observations on 12/9/25, the surveyor found that call bells in several resident rooms were not working; when the call bells were pressed, there was no audible sound and no corridor light activation. Staff present at the time, including LPNs and CNAs, confirmed that the call bells in these rooms were not functioning. Subsequent testing by staff and the surveyor revealed that call bells were not working on the 400 hallway, and then on the 200, 300, 500, and 100 hallways as well. On the 100 hallway, a CNA also confirmed that the personal pagers used to alert CNAs when a call bell is activated were not functioning. The Maintenance Director acknowledged the widespread failure of the call bell system and suggested that a power surge earlier that morning might be the cause. The Nursing Home Administrator confirmed being notified that the call bell system was not functioning and stated that he was reviewing the call bell logs. Review of those logs showed a lack of call bell activations starting at 7:31 AM, indicating that the system had been nonfunctional for several hours before the surveyor’s observations. During this period, residents across multiple hallways did not have access to a working call bell system in their rooms and related areas.
Failure to Maintain Proper Food Storage and Temperature Monitoring
Penalty
Summary
Surveyors identified a failure to store and serve food in accordance with professional standards. During a tour of the short-term unit refrigerator on 12/15/25 at 8:39 AM, they observed an undated, unlabeled sandwich and a pudding cup that was past its expiration date of 12/10/25. In addition, review of the facility’s food temperature logs at 9:00 AM on the same day showed missing documentation that food temperatures were taken prior to serving multiple meals, specifically breakfast, lunch, and dinner on 11/13/25; lunch on 11/20/25; dinner on 11/26/25; dinner on 11/28/25; and lunch on 12/4/25. During an interview at 9:52 AM on 12/15/25, staff member E21 (DDS) confirmed the presence of the undated and expired food items and acknowledged the missing food temperature recordings. These findings were later reviewed at the exit conference on 12/16/25 at 3:45 PM with the NHA (E1), DON (E2), and ED (E3).
Failure to Timely Report Injury of Unknown Source
Penalty
Summary
A deficiency occurred when the facility failed to timely report an injury of unknown source for one resident with a history of CVA and abnormal gait. The resident experienced an unwitnessed fall in the TV/dining room and was later found to have multiple bruises and a fractured right fifth toe. Documentation shows that the resident returned from the hospital with visible injuries, but the medical doctor on call was not notified upon return, and the incident was not reported to the state agency on the same day as required. Interviews with facility staff confirmed that the expected protocol was not followed, including timely notification of the physician, family, and state agency, as well as completion of the incident report.
Admission Assessment and Care Plan Not Completed by RN
Penalty
Summary
A deficiency was identified when the facility failed to ensure that the initial care plan and admission assessment for a newly admitted resident were completed by a Registered Nurse (RN), as required by the Delaware Board of Nursing Professional Regulations. Record review showed that both the baseline care plan and the admission assessment, which included documentation of vital signs, skin condition, care needs, and general condition upon arrival, were completed by an LPN. During interviews, the LPN confirmed she performed these tasks, with assistance from an aide for the skin assessment. The Director of Nursing stated that, according to facility policy, LPNs were permitted to complete admission assessments and care plans. These findings were discussed with facility leadership during the exit conference.
Failure to Provide Sufficient Hydration to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with mild cognitive impairment and a documented risk for hydration concerns was not provided with sufficient fluids to meet her assessed needs. The facility's policy required processes to ensure adequate hydration, but records showed the resident consistently received less than the recommended 1500 mL of fluids per day, with intake ranging from 140 mL to 540 mL on documented days. The resident was dependent on staff for assistance with eating and drinking, and her care plan reflected this need. Despite family concerns and requests for IV fluids due to poor oral intake, the facility delayed intervention pending lab results and did not initiate supplementation until after a nutrition assessment indicated malnourishment. The order for a nutritional supplement was not implemented until a day after it was recommended, and there was no evidence that the facility monitored the amount of supplement consumed or tracked total fluid intake as required. Interviews with staff and family confirmed that the resident required assistance with feeding and that her intake was inadequate. The registered dietitian and nursing staff acknowledged that the resident's fluid intake was below the minimum threshold for adequate hydration, and documentation practices did not ensure accurate monitoring of supplement or fluid consumption. The resident was ultimately sent to the hospital after a fall and did not return to the facility. The deficiency was reviewed with facility leadership during the exit conference.
Failure to Notify Physician of Significant Injury of Unknown Source
Penalty
Summary
The facility failed to notify the physician of a significant injury for one resident with a history of CVA and abnormal gait who was reviewed for accidents. The resident was admitted on 7/15/25 and experienced a fall on 8/1/25, after which a progress note at 4:00 PM documented transfer to the hospital. When the resident returned from the hospital at 11:40 PM the same day, documentation noted purple bruising to the right fifth toe and right flank, and scattered bruising to the left lower leg, with an additional note at 12:35 AM on 8/2/25 documenting bruising to the right fifth toe. On 8/4/25 at 2:58 PM, a mobile X-ray of the right foot was performed and revealed a fracture at the base of the right fifth toe, and at 3:00 PM a physician’s order for the X-ray was documented. There was no evidence in the clinical record that the physician was consulted or notified between 8/1/25 and 8/3/25 regarding the significant bruising and injury of unknown source to the resident’s right fifth toe. During interviews, a supervisor stated that the expectation for an unwitnessed fall with injuries was that the nurse would call the supervisor, and that the supervisor would notify the doctor and family, complete an incident report, and report to the state agency. The DON confirmed that no call was made to the physician when the injury of unknown source to the right fifth toe occurred, and these findings were reviewed with facility leadership during the exit conference.
Failure to Care Plan Contractures and ROM Interventions for Hospice Resident
Penalty
Summary
The facility failed to develop and implement a care plan addressing limited range of motion and contractures for one resident with an impairment to the right middle finger. The resident was admitted with multiple diagnoses including dementia and a right middle finger impairment, and later had a physician’s order dated 7/8/25 for placement of a rolled washcloth in the right hand, with task completion documented by nursing staff on the treatment administration record. However, review of the resident’s care plans on 12/11/25 at 10:05 AM showed no care plan addressing the resident’s contractures or the rolled washcloth intervention. During an interview at 10:21 AM, the DON confirmed the absence of a care plan for the contractures and stated there was no care plan because the resident was on hospice. These findings were subsequently reviewed with facility leadership at the exit conference on 12/16/25 at 3:45 PM.
Failure to Properly Store BiPap Equipment Between Uses
Penalty
Summary
The facility failed to follow professional standards of practice for respiratory care by not ensuring a resident’s BiPap equipment was stored in a protective plastic bag when not in use. The resident had been admitted with COPD, CHF, and obstructive sleep apnea and had a physician’s order for BiPap use at night with 3L oxygen. The resident’s treatment administration record did not contain any order regarding storage of the BiPap equipment. During surveyor interviews and observations, an RN and the DON both confirmed that the resident’s BiPap mask and tubing were not stored in a plastic bag when not in use, despite the expectation that the respiratory equipment should be bagged.
Failure to Complete Ordered AIMS Monitoring for Antipsychotic Therapy
Penalty
Summary
A deficiency occurred when the facility failed to complete ordered monitoring for side effects of psychotropic medication for one resident. The resident was admitted with multiple psychiatric diagnoses, including dementia with psychotic disturbance, psychotic disorder with delusions, and schizophrenia, and an AIMS assessment completed at admission showed a score of 3, indicating mild abnormal movements associated with antipsychotic use. The following day, a physician ordered quetiapine twice daily. During a subsequent consultant pharmacist medication regimen review, the pharmacist noted the baseline AIMS score of 3 and recommended obtaining an order to repeat the AIMS assessment due to the ongoing antipsychotic therapy. The primary care provider agreed with this recommendation and documented an order to repeat the AIMS assessment. However, review of the clinical record months later showed no evidence that a repeat AIMS assessment had been completed, and the DON confirmed that instead of performing the ordered repeat AIMS, another psychiatric assessment was done while the DON was on vacation. These findings were confirmed through record review and interviews and were discussed with facility leadership during the exit conference.
Delay in Practitioner Notification of Urine Culture Results
Penalty
Summary
The facility failed to promptly notify a practitioner of laboratory results for one resident on transmission-based precautions. The resident’s clinical record showed that a physician ordered a urinalysis culture and sensitivity test on 12/8/25, which was collected by the contracted laboratory on 12/11/25. On 12/13/25, the laboratory relayed the urinalysis culture and sensitivity results to the facility by phone to an LPN (E24), but the resident’s progress notes contained no evidence that this nurse informed the resident’s physician or nurse practitioner of the results at that time. The results were not reviewed by the nurse practitioner (E23) until 12/15/25, two days after the facility had been notified of the findings. During an interview on 12/16/25, the ADON/IP (E22) and DON (E2) confirmed there was a delay in practitioner notification without explanation, and these findings were later reviewed with facility leadership at the exit conference.
Failure to File Laboratory Test Results in Resident Clinical Record
Penalty
Summary
The facility failed to ensure that laboratory reports were filed in the clinical record for one resident on transmission-based precautions. The facility’s diagnostic services policy, last updated 12/24/24, stated that all test results would be maintained in the clinical record. For this resident, a physician ordered a urinalysis culture and sensitivity test on 12/8/25, and the contracted laboratory collected the specimen on 12/11/25. However, review of the resident’s clinical record on 12/16/25 at 1:00 PM showed no evidence that the urinalysis culture and sensitivity results were present in the record. At 2:00 PM on the same day, the ADON/IP provided the surveyor with a copy of the urinalysis culture and sensitivity results and confirmed that the report was not in the resident’s clinical record, stating that the results were waiting to be filed. These findings, including the absence of the laboratory report in the clinical record despite the completed test, were reviewed with the NHA, DON, and ED during the exit conference at 3:45 PM on 12/16/25.
Failure to Offer and Document Pneumococcal Vaccinations for Two Residents
Penalty
Summary
The facility failed to follow its immunization policy requiring that each resident be offered a pneumococcal vaccination and that the medical record contain documentation of education and either receipt or refusal of the vaccine. Record review for two residents admitted on 1/22/25 and 6/25/25 showed no evidence in their immunization records of pneumococcal vaccination or declination as of 12/15/25 at 12:35 PM. When the surveyor requested evidence of consent or declination, the DON and ADON/ICP later produced consents that were dated 12/15/25, the same day as the surveyor’s request, and the DON confirmed that these two residents had not been offered the pneumococcal immunization prior to that time. These findings were discussed with the NHA, DON, and ED during the exit conference on 12/16/25 at 3:45 PM, confirming that the required offer and documentation of pneumococcal vaccination had not occurred for the two residents reviewed for immunizations.
Resident Elopement Due to Inadequate Supervision and Window Security
Penalty
Summary
A deficiency occurred when a resident with a history of confusion, impaired safety awareness, and wandering behaviors was able to elope from the facility by climbing out of a window in their room. The resident had previously demonstrated goal-directed and aimless wandering, had been found attempting to leave the facility, and was identified as being at risk for elopement. Despite these behaviors, the resident was able to remove the window screen and disengage the safety latch without staff awareness, as the windows were not equipped with alarms to alert staff to unauthorized exits. On the day of the incident, the resident was noted to be fixated on leaving the facility to pay taxes and required repeated redirection by staff. The resident was last seen in their room after being assisted with bathing and toileting, and shortly thereafter, was observed outside the facility by staff and members of the public. The resident crossed a parking lot and a busy roadway, and was missing for approximately seven minutes before being located by staff and law enforcement. The resident was combative and refused to return to the facility, ultimately being transported to the hospital for evaluation. Interviews with staff confirmed that the resident had a Wander guard device, but there was no order for regular checks of its placement and function. The care plan indicated the need for the Wander guard to be on at all times, but the lack of window alarms and the resident's physical ability to exit through the window without detection contributed to the elopement. The facility's investigation identified the disengaged window safety latch as the means of exit and noted the absence of an alarm system on the windows as a critical factor in the incident.
Food Safety Deficiencies in Kitchen Operations
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, it was observed that there were no buckets containing sanitizing solution for storing wet wiping cloths used for sanitizing food preparation surfaces. Additionally, the cook tested the sanitizing solution in the three-compartment sink and found that the chemical concentration was insufficient for proper sanitization. It was later revealed that the facility had been using incorrect chemical test strips for testing sanitizer levels. Further observations revealed that there were three compromised food cans with dented sides that were not separated from the cans of food being served to residents. The ice scoop was improperly stored inside the ice machine, exposing the ice to potential contaminants. A review of the food temperature logs showed that food temperatures were not recorded for 23 out of 336 meals sampled, indicating a lack of consistent monitoring of food temperatures. These findings were confirmed with the cook and later reviewed with the Nursing Home Administrator, Director of Nursing, and Executive Director at the exit conference.
Inaccurate MDS Coding for Three Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for three residents, identified as R16, R32, and R217, out of an investigative sample of eighteen. Each of these residents was admitted to the facility in September or October 2024, and their admission MDS documented the use of restraints, specifically bilateral bed rails. However, observations conducted on October 21 and 22, 2024, revealed that these side rails were being used as enabler bars for turning and repositioning, not as restraints. This discrepancy was discovered when surveyors requested the Matrix, and it was revealed that the MDS had been miscoded. The miscoding of the MDS was attributed to E7, a Registered Nurse Assessment Coordinator (RNAC) who was still in training at the time. During an interview on October 25, 2024, with E6 (RNAC), E7 (RNAC), and E1 (Nursing Home Administrator), it was confirmed that the MDS for these residents was incorrectly coded. The issue was discussed further during an exit conference on October 31, 2024, with E1, E2 (Director of Nursing), and E4 (Executive Director).
Lack of Physician Participation in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that the required interdisciplinary team (IDT) members participated in the care plan meetings for one resident out of eighteen reviewed. The resident, identified as R37, was admitted to the facility on October 3, 2024. A care plan meeting was held on October 16, 2024, with attendees including the resident, a family member, nursing staff, therapy, a CNA, a social worker, and dietary staff. However, it was confirmed through an interview with E6, a Registered Nurse Assessment Coordinator (RNAC), that a physician or physician's representative did not participate in R37's care plan conferences. E6 stated that the physician reviews residents monthly but not in coordination with the care plan meetings. These findings were reviewed with the Nursing Home Administrator (E1), Director of Nursing (E2), and Executive Director (E4) during the exit conference on October 31, 2024.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders for two residents, leading to the administration of medications outside of prescribed parameters. For one resident, who was admitted with diabetes mellitus, a physician's order specified that Lantus insulin should be held if the blood sugar was less than 100. However, on February 17, 2024, the resident's glucose level was recorded at 78 ml/dl, yet the Lantus was administered by an LPN. Interviews with the involved LPNs confirmed the administration of the insulin despite the low blood sugar reading, which was contrary to the physician's order. In another case, a resident had a physician's order for midodrine HCL to be held if the systolic blood pressure exceeded 130. On November 5, 2023, the resident's blood pressure was documented at 152/81, yet the medication was administered. A consultant pharmacist's review noted the discrepancy, and an LPN confirmed the administration despite the blood pressure exceeding the specified parameter. The facility lacked documentation of monitoring or addressing the irregularity of administering medication outside the prescribed parameters.
Failure to Implement Effective Continence Care Programs
Penalty
Summary
The facility failed to provide adequate services to restore bowel and bladder continence for two residents, R21 and R37, as observed through their clinical records and interviews. R21 was admitted with an indwelling catheter and was frequently incontinent of bowel. Despite having a care plan with specific interventions to assist with continence, such as scheduled toileting and the use of a voiding diary, the CNA task flow sheets for August, September, and October 2024 showed a lack of adherence to these interventions. Interviews with staff revealed that R21 was not on a structured toileting program, and there was no evidence of attempts to restore bowel function. R37 was admitted with a care plan to remain continent of bowel and bladder, but the CNA task flow sheets indicated frequent incontinence of urine. The care plan included interventions like using incontinence products and assisting with toileting upon request. However, the flow sheets lacked evidence of following these individualized interventions. Interviews with R37 and staff indicated that R37 was not on a structured toileting program, and the resident reported incontinence due to delays in staff assistance. Interviews with facility staff, including an LPN and a CNA, confirmed the absence of a set toileting program, with reliance on a two-hour check and change routine. This routine was not sufficient to meet the individualized needs of the residents, as evidenced by the frequent incontinence episodes and lack of adherence to care plans. The findings were discussed with the Nursing Home Administrator, Director of Nursing, and Executive Director during the exit conference.
Failure to Follow Resident Dietary Preferences
Penalty
Summary
The facility failed to adhere to the dietary preferences and nutritional needs of a resident, identified as R47, during meal service. On two separate occasions, the resident received breakfast trays that did not match the meal ticket specifications. On the first occasion, the tray was missing apple juice and a fresh whole apple, and included items that the resident disliked, such as eggs and milk. The resident expressed dissatisfaction with receiving food she did not like. A CNA confirmed the discrepancies and noted that there was no apple juice available, offering cranberry juice as a substitute instead. On the following day, the resident's breakfast tray again did not match the meal ticket, missing a fresh whole orange and scrambled eggs with onions, and included bacon and sausage, which the resident could not eat due to a dislike of pork. An RN confirmed these discrepancies and offered sliced oranges as a substitute. The dietary regional support staff revealed that the staff responsible for plating the tray was inexperienced in this task, having been temporarily assigned from another area. The dietician confirmed the need for nutritionally equivalent substitutes when items are unavailable.
Deficiency in MRR Policy for Urgent Medication Response Times
Penalty
Summary
The facility failed to develop comprehensive policies and procedures for the monthly Medication Regimen Review (MRR) process, specifically lacking time frames for pharmacist responses to urgent medication recommendations. During a review of the facility's policy titled 'Consultant Pharmacist Reports,' it was noted that the policy did not include necessary information regarding the time frames for a pharmacist's response to urgent medication recommendations. This deficiency was confirmed during an exit conference with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Executive Director, where it was acknowledged that the MRR policy did not meet the expected requirements for urgent medication response times.
Failure to Notify Physician and Medical Director of Abuse Allegation
Penalty
Summary
The facility failed to implement its written abuse policy by not notifying a resident's physician or the medical director of an abuse allegation in a timely manner. The policy requires immediate reporting of abuse allegations to the Department of Health and prompt notification of the resident's attending physician, medical director, and family. On the night of the incident, a resident with profound dementia reported to a nurse that she had been sexually assaulted. The nurse attempted to inform the nursing supervisor but was unable to reach them and left a message with another staff member. Documentation and interviews revealed that neither the attending physician nor the medical director was notified of the allegation until more than twelve hours after the initial report. The physician only learned of the incident indirectly through staff discussions and was not informed via the standard communication channels, such as the doctor communication book or the on-call service. The nurse practitioner, who was present in the facility on the day following the allegation, also reported not being informed about the incident. Further review of communication logs and interviews with medical staff confirmed that there were no entries or notifications regarding the abuse allegation in the designated communication systems. The medical director and nurse practitioner both stated they were not contacted by the facility regarding the incident, and the on-call log did not show any record of notification. This lack of timely communication with the medical team constituted a failure to follow the facility's abuse reporting policy.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse within the required 2-hour timeframe for two out of three residents reviewed. In the first case, a resident with profound dementia alleged sexual assault to a registered nurse (RN) at approximately 11 PM. The RN informed several staff members, including certified nursing assistants (CNAs) and another RN supervisor, but the allegation was not reported to the State Agency until over twelve hours later. Multiple staff members were aware of the allegation, and the term 'rape' was used in conversations among staff, but the required immediate reporting did not occur. In the second case, a resident's daughter reported that a certified nursing assistant (CNA) was disrespectful and rude to her mother, constituting an allegation of emotional abuse. The facility initiated an internal investigation and placed the CNA on administrative leave, but the incident was not reported to the State Agency until five days after the facility became aware of the allegation. Both incidents demonstrate a failure by the facility to adhere to mandated reporting timelines for suspected abuse. The delay in reporting was due to staff not immediately escalating the allegations to the appropriate authorities, despite being aware of the requirements and having access to the necessary reporting systems.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Dover
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cadia Rehabilitation Capitol | 0.5 mi | ★★★★★ | 6 | 1 |
| Complete Care At Silver Lake Llc | 0.8 mi | ★★★★★ | 13 | 0 |
| Center At Eden Hill, Llc | 1.8 mi | ★★★★★ | 3 | 0 |
| Bay Terrace Rehabilitation And Health Center | 3 mi | ★★★★★ | 6 | 1 |
| Evergreen Post Acute | 6.2 mi | ★★★★★ | 5 | 0 |
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