Westminster Village Health
Inspection history, citations, penalties and survey trends for this long-term care facility in Dover, Delaware.
- Location
- 1175 Mckee Road, Dover, Delaware 19904
- CMS Provider Number
- 085032
- Inspections on file
- 20
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 13 (1 serious)
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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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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