Wilmington Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, Delaware.
- Location
- 700 Foulk Road, Wilmington, Delaware 19803
- CMS Provider Number
- 085028
- Inspections on file
- 21
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Wilmington Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not consistently implement proper infection control measures, including the use of appropriate disinfectants for C. difficile and Enhanced Barrier Precautions for residents with wounds or indwelling devices. Additionally, staff failed to replace a full sharps container in a resident bathroom in accordance with OSHA and FDA guidelines, as confirmed by observations and staff interviews.
The facility failed to uphold residents’ rights to dignity and self-determination by not effectively informing them of daily meal options. Several residents reported they did not receive menus and only learned what was being served when meals arrived, although alternate items could be requested. While the daily menu was posted at the entrance to the common dining area, CNAs, the Food Service Director, and the Director of Recreation confirmed that menus were not distributed and residents were generally not made aware of daily meals in advance, aside from a list of always-available options.
A resident with multiple medical conditions was readmitted with several wounds, but wound care orders were not entered into the record at the time of admission. Although wound care was performed by nursing staff, official orders were not documented until several days later, resulting in a lack of physician orders for immediate wound care.
A resident with a urostomy and pelvic drain did not have the output amounts documented as ordered, despite care plans and physician orders requiring this. Multiple entries in the TAR were left blank for both the urostomy and pelvic drains, and an LPN confirmed that CNAs may have emptied the devices without reporting the amounts, leading to incomplete documentation.
Two residents experienced deficiencies in nutrition and hydration management, including missed weight monitoring, inconsistent implementation of dietary orders, and lack of documentation showing that fluids were offered or consumed as required by care plans and facility policy. Staff interviews and record reviews confirmed these failures, resulting in inadequate support for the residents' nutritional and hydration needs.
A resident with a urostomy tube and a history of recurrent UTIs experienced a delay in the collection of a physician-ordered urinalysis with culture and sensitivity after blood was observed in the urine. Although the order was documented and scheduled for collection, the sample was not obtained until the following day, with no documentation explaining the delay. Nursing staff confirmed the labs were not collected in a timely manner.
Two residents were not treated with appropriate dignity and respect when an LPN/unit manager referred to them as "feeders" while explaining to a surveyor that staff needed to be present in their room to assist and feed them. This language, used in the context of a dining observation, constituted a failure to use respectful terminology when describing residents who required assistance with eating.
A resident’s oral/dental status was inaccurately coded on multiple MDS assessments when Section L documented no pain, chewing difficulty, cavities, broken teeth, or gum issues despite a dental consultation noting extensively decayed teeth, cavities, and root tips that might require extraction. The RN MDS coordinator reported she did not perform a physical oral assessment and was unaware of the dentist’s consult findings, and the dentist stated he had not personally examined the resident’s teeth at that time and had not been informed of dental concerns by nursing staff, resulting in inaccurate MDS coding over two review periods.
A resident had an initial PASARR Level I indicating no mental health diagnoses or psychotropic medications and no need for further screening. After admission, the resident was started on quetiapine for psychosis, later documented on the admission MDS as having a psychotic disorder, receiving antipsychotic and antidepressant medications, and receiving psychological therapy, and was subsequently prescribed PRN lorazepam for agitation, anxiety, and psychosis. Despite these changes in condition and qualifying psychotropic medication use, facility staff did not initiate a PASARR referral, as confirmed by the SSD and reviewed with the NHA, DON, and corporate nurse.
A resident with a diagnosis including malnutrition, documented by OT and nutrition assessments as dependent for eating and requiring full assistance with feeding, did not receive timely help during a lunch meal. One staff member placed the meal tray on an overbed table away from the resident and left without assisting, and a CNA who entered next stated she would feed the resident but left the room and did not return while the surveyor observed. During this time the resident expressed being very hungry, and only later did an LPN/UM enter, position the tray, uncover the food, and begin offering the meal, revealing a failure to provide necessary ADL assistance with eating.
A resident with dementia, bilateral hearing loss, and impaired vision, but cognitively intact, had documented preferences for pets, some reading, and music, and an activity assessment indicating a desire for center activities, 1:1 staff time, and self-directed activities. The care plan listed multiple self-directed and friendly visit options but only specified video calls with family and friendly visits as needed, and monthly documentation showed limited, nonspecific 1:1 visits without duration or staff identifiers. Observations found the resident in bed with no TV, music, or accessible personal items, and on a morning when the calendar listed meet & greet, snacks, and outdoor time, staff were only seen briefly delivering cookies and not engaging the resident in planned activities, despite records indicating attendance. The DOR confirmed that pet visits and weekly family calls were not reflected on the calendar, in documentation, or in the care plan, and that the plan was not person-centered with measurable objectives and timeframes.
A resident at risk for pressure ulcers, with fragile skin and an order for a low air loss mattress to be checked every shift, was repeatedly observed in bed with the device not turned on and later found unplugged from the wall. Despite this, the eTAR showed that LPNs on two shifts documented the treatment as completed, while one shift left it blank. This resulted in the resident not receiving the prescribed pressure ulcer preventative intervention as ordered.
A resident with ESRD and physician orders for thrice-weekly dialysis did not consistently have complete dialysis communication forms. During one month, multiple pre-dialysis forms lacked documentation of meals, medications, and changes in condition, and some were entirely blank. Several forms for scheduled dialysis visits were missing from the medical record. Staff interviews confirmed that assigned nurses were responsible for completing these forms and that the missing and incomplete documentation occurred as cited by surveyors.
A resident with dementia, anxiety, and major depressive disorder with psychotic symptoms was re-admitted on antipsychotic therapy, and an admission MDS and care plan identified the use of antipsychotics with an intervention to monitor behaviors. An MRR documented that the antipsychotic required monitoring, and the physician signed this recommendation, with an order in place for the antipsychotic to be given twice daily for psychosis. However, an LPN confirmed that there was no active monitoring intervention appearing on the record as would normally be expected each shift, suggesting it may have been lost when the resident was discharged and re-admitted, resulting in the facility not acting on and documenting the MRR recommendation as required by its policy.
A resident with intact cognition had a care plan for oral care and was evaluated by a dentist, who recommended follow-up to restore cavities and noted that extensively decayed teeth and root tips might require extraction if symptoms developed. Despite this, the resident was not scheduled for timely follow-up dental treatment and was instead placed on a routine six‑month list. The resident later reported loose, falling teeth that affected chewing and eating, and a surveyor observed chipped and decayed teeth. An LPN UM confirmed the lack of earlier dental follow-up, and leadership was informed of these findings.
The facility failed to post required information informing residents how to formally complain to the State Agency. During a resident council meeting, residents reported they did not know how to make a formal complaint to the state, and a subsequent tour showed that the main bulletin board for residents and visitors did not include instructions for filing a complaint with the state agency. The NHA later confirmed the absence of this required complaint information, which was reviewed with the NHA, DON, and a corporate nurse during the survey exit conference.
The facility failed to provide adequate pressure ulcer care for several residents, leading to harm. One resident's sacral ulcer was not properly staged or monitored, and weekly skin assessments were not completed. Another resident developed a stage II ulcer due to inconsistent repositioning and failure to follow wound care orders. Additionally, the facility did not document dressing changes or complete required skin audits for other residents.
A resident with a history of acute kidney injury and diabetes was administered both Metformin and Ibuprofen daily, despite pharmacy warnings about the risk of acute renal failure from this combination. The medications were continued even as the resident's renal function worsened, and there was no evidence that staff addressed the drug interaction or adequately monitored oral intake. The resident was ultimately hospitalized for acute kidney failure after receiving these medications together.
The facility failed to adhere to food safety standards, with issues such as lack of hand drying towels, uncovered cooked pork with insects, unsecured sausage patties in the freezer, and improper temperature logs. Additionally, the nourishment refrigerator had spills, unlabeled food, and an open juice container without a date. These deficiencies were confirmed by the Director of Dietary Services and the Regional Director of Clinical Reimbursement.
The facility failed to create comprehensive person-centered care plans for several residents, resulting in unmet needs for continence management, fall prevention, and pressure ulcer care. Residents experienced frequent incontinence episodes, falls, and untreated pressure ulcers due to the lack of individualized assessments and interventions.
The facility failed to update care plans for two residents. One resident's care plan was not revised to address frequent incontinence despite a documented change in condition. Another resident's hospice care plan lacked clarity on bathing responsibilities and did not specify the frequency and nature of hospice services, including medical equipment and supplies.
The facility failed to conduct comprehensive bowel and bladder assessments for several residents, leading to deficiencies in individualized care planning to restore and maintain continence. Residents experienced frequent incontinence episodes without reassessment or updated care plans, despite expressing dissatisfaction and a desire to regain continence. Staff interviews revealed a lack of clarity on procedures for addressing continence issues, indicating systemic problems in the facility's approach to continence care.
A facility failed to ensure a resident received hospice care as per the agreement with the Hospice Provider. The facility did not collaborate on a sacral pressure ulcer care plan, failed to update the Hospice Provider on medication changes, and lacked current hospice documentation in the resident's record. An observation revealed missing contact information and outdated documentation in the hospice binder. A Hospice RN confirmed the absence of necessary documentation, and the Hospice Provider later provided inaccurate medication information.
The facility failed to implement Enhanced Barrier Precautions for residents with indwelling feeding tubes and chronic wounds. Staff did not consistently use PPE during high-contact care activities, such as wound care, and there were misunderstandings about PPE requirements. Observations showed a lack of gowns and gloves during care, contributing to the deficiency.
The facility failed to educate and offer up-to-date COVID-19 vaccinations to four residents. The clinical records of these residents lacked evidence of being offered the latest COVID-19 vaccination, with the last documented vaccinations occurring on various past dates. These deficiencies were discussed during an exit conference with facility leadership and an Ombudsman representative.
A facility failed to align a resident's care plan with her documented treatment wishes. The resident was admitted with a DNR order, but her DMOST form, signed by her and a Nurse Practitioner, indicated she wished for full treatment in case of cardiac or respiratory arrest. This discrepancy was confirmed by the DON and discussed during the exit conference.
A resident's preference for shower times was not facilitated by the facility, leading to missed showers. Despite being scheduled for showers twice a week, the resident did not receive them due to a mismatch in documentation and scheduling. Staff interviews revealed the resident was already dressed when approached for showers, and there was no documentation of refusals or discussions to determine the resident's preferred shower time.
A facility failed to accurately document a resident's sacral skin condition in the annual MDS assessment, misclassifying a Stage 3 pressure ulcer as Moisture Associated Skin Damage (MASD). The error stemmed from reliance on the Wound Care Consultant's documentation, which did not stage the ulcer, leading to an inaccurate assessment. This issue was identified during a survey and discussed with facility leadership.
The facility failed to schedule a nephrologist follow-up for a resident with acute kidney injury and did not properly monitor orthostatic vital signs for another resident on multiple blood pressure medications, leading to falls. These deficiencies highlight a lack of adherence to person-centered care plans and physician orders.
A resident with a stroke diagnosis did not receive the prescribed therapy devices to maintain mobility, as observed on multiple occasions. The care plan required a therapy carrot and palm guard, but these were not applied, and staff confirmed the devices were missing. The issue was discussed with facility leadership.
A resident with severe cognitive impairment and high fall risk fell out of bed while receiving care, due to inadequate supervision. The resident, dependent on staff for mobility, sustained a scrape and hematoma, requiring hospital evaluation.
A resident with multiple health issues, including malnutrition, was not monitored according to the facility's policy for weekly weight checks, despite being under 100 pounds. The resident experienced an 11% weight loss over two months, and there was a delay in implementing a dietician's recommendation for a nutritional supplement.
A facility failed to properly label and date tube feeding bottles for a resident admitted with a stroke and difficulty swallowing. Observations on two occasions revealed that the tube feeding bottles at the resident's bedside lacked dates, a fact confirmed by an RN. These findings were reviewed with facility leadership and an Ombudsman representative.
A resident with a physician's order for oxygen therapy was not receiving the prescribed treatment, despite documentation indicating administration. Observations showed the resident without oxygen therapy, and an LPN confirmed the omission due to high oxygen saturation levels, suggesting a need to update the order to PRN.
A facility failed to provide appropriate pain management for a resident during wound care, as the resident was not administered pain medication prior to the procedure despite being at risk for pain due to advanced age and osteoarthritis. The resident was observed moaning during repositioning and wound dressing removal, and was only given Tylenol after the procedure. This deficiency was discussed with facility leadership and an Ombudsman representative.
The facility did not post the required daily nurse staffing information in a conspicuous area accessible to residents and visitors. Observations revealed outdated staffing information in the lobby and incomplete staffing sheets in four units, lacking the facility name, daily census, and total worked hours for RNs, LPNs, and CNAs. Interviews confirmed non-compliance with federal requirements.
A resident with high blood pressure was not properly monitored before administering Norvasc, as required by physician orders. The facility failed to document blood pressure readings prior to medication administration on multiple occasions and administered the medication even when the resident's systolic blood pressure was below the prescribed threshold. These deficiencies were discussed with facility leadership, but no additional information was provided.
The facility failed to educate and offer influenza and pneumococcal vaccinations to three residents. One resident's record lacked evidence of an up-to-date pneumococcal vaccination offer, another was not offered an influenza vaccination for 2023, and a third was not offered a pneumococcal vaccination. These issues were discussed with facility leadership and an Ombudsman representative.
A resident did not receive Ensure as requested by her family and recommended by the dietician, due to a 22-day delay in obtaining a physician's order for the supplement, despite repeated requests and documented preference.
Trash dumpsters were repeatedly observed with open lids and overflowing with clear bags of facility waste, including feces-soiled briefs and used PPE gloves, which were also found scattered on the ground around the dumpsters and behind the fence. Facility leadership confirmed these unsanitary conditions.
The facility failed to maintain accurate clinical records for three residents, including outdated medical progress notes, undocumented care during a shift, and an incorrect Fall Risk Scoring Tool. These deficiencies were confirmed by staff interviews and reviewed during an exit conference.
Failure to Maintain Infection Control and Safe Sharps Disposal
Penalty
Summary
The facility failed to properly implement and maintain infection prevention and control measures for two out of five residents reviewed. For one resident with a positive C. difficile diagnosis, staff did not use the appropriate germicidal bleach wipes for disinfecting high-contact surfaces, instead relying on alcohol-based hand sanitizer, which is not effective against C. difficile spores. Staff interviews revealed a lack of awareness regarding the correct disinfectant, and the proper supplies were only presented after prompting by the surveyor. Additionally, the facility did not consistently initiate Enhanced Barrier Precautions (EBP) for residents at increased risk of multidrug-resistant organism (MDRO) acquisition, such as those with wounds or indwelling medical devices. For another resident with chronic wounds and a midline catheter, EBP signage and PPE supplies were not in place immediately after the catheter placement and were removed prematurely after the catheter was taken out, despite ongoing risk factors. The facility also failed to adhere to safe sharps disposal practices as required by OSHA and FDA guidelines. A sharps container in a resident bathroom was observed to be overfilled on multiple occasions, and staff confirmed that containers were only replaced when full, rather than when they reached the recommended three-fourths capacity. These lapses in infection control and environmental safety protocols were confirmed through observation, staff interviews, and record review.
Failure to Inform Residents of Daily Menu Options
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ rights to a dignified existence and self-determination by not effectively informing them of the daily menu. During resident interviews, one resident reported that menus were not provided and that residents did not know what they were having until the food arrived; if they did not want the served meal, they had to wait to order something else. Another resident stated that there was no menu or calendar of what was being served, although alternate items would be provided if the resident did not like the meal. The resident council president confirmed that residents previously received menus but no longer did so. During a tour, the surveyor observed that the daily menu was posted at the entrance of the common dining and activity room on both floors, but multiple staff interviews confirmed that residents were not otherwise provided menus or made aware of daily meals prior to service. Two CNAs stated that residents were not given menus and only learned of the meals when they were served, with one CNA indicating they tried to look at the posted menu to inform residents if asked. The Food Service Director confirmed that residents were not distributed or made aware of the daily menu, noting only that residents received a copy of the always-available options. The Director of Recreation also confirmed that the activities department was not distributing menus to residents. These findings were reviewed with the NHA, DON, and corporate nurse during the exit conference.
Failure to Enter Wound Care Orders Upon Admission
Penalty
Summary
A resident with diagnoses including diabetes mellitus, congestive heart failure, and epilepsy was readmitted to the facility with four wounds present on admission. Although a wound assessment report was completed by a nurse practitioner and documented treatment orders for these wounds, a review of the clinical record several days later revealed that no current orders for wound care had been entered. During interviews, a registered nurse confirmed that wound care and dressing changes were being performed without documented orders, and that official orders for dressing changes were only entered several days after the resident's readmission. This failure to ensure that wound treatment orders were entered at the time of admission resulted in a lack of documented physician orders for the resident's immediate wound care needs.
Failure to Document Urostomy and Pelvic Drain Output as Ordered
Penalty
Summary
A deficiency was identified when staff failed to document the output from a resident's urostomy and pelvic drains as ordered. The resident, who had a history of bladder cancer, recent urinary tract and pelvic infections, a urostomy, and pelvic drain, was admitted with physician orders and care plans specifying that the amounts drained from both the urostomy and pelvic drains should be recorded. However, review of the Treatment Administration Record (TAR) for August showed multiple instances where documentation of the amounts drained was missing for both the urostomy and pelvic drains. During an interview, an LPN confirmed that Certified Nursing Assistants (CNAs) may have emptied the urostomy without informing the nurse, resulting in the amounts not being recorded. These findings were confirmed during the exit conference with facility leadership.
Failure to Monitor and Maintain Nutrition and Hydration for Two Residents
Penalty
Summary
Two residents were identified as not having their nutritional and hydration needs adequately monitored and maintained, resulting in deficiencies related to weight monitoring, dietary orders, and fluid intake documentation. One resident, with a history of chronic wounds, diabetes, dementia, acute kidney injury, and moderate protein calorie malnutrition, was dependent on staff for eating and required a mechanically altered diabetic diet. Despite facility policy requiring regular weight monitoring, there was a lack of weight documentation for this resident during critical periods, including after a significant weight loss of 23.3% over 57 days. Staff interviews confirmed that weights were not obtained as required, and the most recent weights used in assessments were outdated. Additionally, there was confusion and inconsistency regarding the resident's dietary orders, including portion sizes and vegetarian status, which were not clearly communicated or implemented by kitchen staff. Another resident, who was severely cognitively impaired and dependent for eating, had care plans in place to address risks of dehydration, constipation, and weight changes. However, review of CNA documentation revealed multiple shifts across several months where there was no evidence that fluids were offered or consumed, despite care plan interventions requiring encouragement and assistance with fluid intake. Interviews with CNAs and nursing staff confirmed that fluids should be offered and documented at least once or twice per shift, but the documentation did not reflect this practice for numerous shifts. The deficiencies were confirmed through record review, staff interviews, and direct observation. The facility failed to adhere to its own policies and care plans regarding weight monitoring, dietary order implementation, and hydration support, resulting in inadequate monitoring and provision of nutrition and fluids for the affected residents.
Failure to Timely Complete Ordered Laboratory Tests
Penalty
Summary
A deficiency occurred when the facility failed to ensure that ordered laboratory tests were completed in a timely manner for a resident with a urostomy tube who was admitted with a history of recurrent urinary tract infections (UTIs) and blood in the urine. On 7/28/25, a physician ordered a urinalysis with culture and sensitivity (UA/C&S) after reddish urine was observed in the resident's urostomy bag. Although the order was placed and documented in the facility's lab tracking form for collection on 7/29/25, the urine sample was not collected until 7/30/25. The clinical record lacked documentation explaining the delay in collection. During interviews, nursing staff confirmed that the labs were not obtained in a timely manner, and the process for lab orders was described as placing the order in a lab book, typically to be completed during the overnight shift.
Failure to Use Dignified Language When Referring to Residents Needing Feeding Assistance
Penalty
Summary
Facility staff failed to honor residents' right to be treated with respect and dignity when an LPN/unit manager referred to two residents as "feeders" during a dining observation. On 9/26/25 at 1:00 PM, while a surveyor observed dining inside one resident's room, the LPN/unit manager stated that this resident and her roommate were both "feeders" and that staff should be in the room to assist and feed them. This terminology was identified by the surveyor as not respecting the residents' dignity. The finding regarding the use of the term "feeders" to describe the two residents was discussed with the LPN/unit manager on 9/26/25 and later reviewed with the nursing home administrator, DON, and corporate nurse on 9/29/25, confirming that the deficiency involved staff referring to residents in a manner that did not support their dignity and respect.
Inaccurate MDS Dental Coding Due to Lack of Oral Assessment and Review of Dental Consult
Penalty
Summary
Surveyors identified a deficiency in accurate assessment and MDS coding for one resident related to dental status. The resident’s clinical record showed a quarterly MDS dated 2/11/25 in which Section L (Oral/Dental Status) was coded as no mouth or facial pain, discomfort, or difficulty chewing. A subsequent Dental Report of Consultation dated 3/23/25 documented recommendations to restore cavities and noted that teeth were extensively decayed with root tips that would need extraction in the future if symptoms or swelling began. Despite this, the 5/14/25 quarterly MDS again indicated no mouth or facial pain, discomfort, or difficulty chewing, and the 8/12/25 annual MDS Section L was coded as showing no cavities or broken natural teeth, no inflamed or bleeding gums, no loose natural teeth, and no mouth or facial pain or difficulty chewing. During interview, the RN MDS coordinator stated she completed the 8/12/25 MDS, confirmed she did not physically assess the resident’s teeth, and acknowledged she was not aware of the dental consult note or the dentist’s findings of decayed cavities and root tips recommended for extraction. The dentist reported that he did not personally check the resident’s teeth at that time and only saw the consult at the time of the survey, stating he had not been made aware of any dental issues by nursing staff. These actions and inactions resulted in inaccurate MDS coding of the resident’s oral/dental status over two review periods.
Failure to Initiate PASARR Referral After New Psychotropic Use and Psychotic Disorder
Penalty
Summary
The facility failed to coordinate assessments with the PASARR program by not initiating a new PASARR screening for one resident after a significant change in mental health status and qualifying psychotropic medication use. Facility clinical guidelines stated that while admitted, if a resident has a change in condition, a PASARR evaluation may be required when there is a significant change in mental or physical health status since the last evaluation, or if serious mental illness, intellectual disability, or a related condition is suspected and not previously identified. A PASARR Level I completed on 6/13/25 for this resident documented no mental health diagnoses, no mental health medications, and that no further screening was required. The resident was admitted on 7/25/25, and on 7/27/25 a physician ordered quetiapine, an antipsychotic, at bedtime for psychosis. An admission MDS dated 7/31/25 documented a psychotic disorder, current use of antipsychotic and antidepressant medications, and receipt of 45 minutes of psychological therapy on one day. Between 9/15/25 and 10/15/25, a physician ordered lorazepam, an anti-anxiety medication, as needed for agitation, anxiety, and psychosis. During an interview on 9/22/25, the Social Services Director confirmed that no PASARR referral had been made for this resident, and this finding was later reviewed with the NHA, DON, and Corporate Nurse during the exit conference.
Failure to Provide Timely Feeding Assistance to Dependent Resident
Penalty
Summary
The facility failed to ensure that a dependent resident received necessary assistance with eating to promote adequate nutrition. The resident had been re-admitted with a diagnosis including malnutrition and was documented in an OT evaluation as being dependent with eating. A facility nutrition assessment also documented that the resident required full assistance with feeding. Despite these documented needs, during a lunch meal observation, staff actions did not provide timely feeding assistance. On the observed day, a staff member entered the resident’s room and placed the food tray on an overbed table that was standing against the wall, then left the room without assisting the resident. Shortly afterward, a CNA entered the room, attempted to shut the door, and stated she was going to feed the resident, but then left the room and did not return while the surveyor remained to observe. During this period, the resident stated, "I am very hungry" when asked if she was alright. Several minutes later, an LPN/unit manager entered, moved the overbed table across the bed, set up the food tray, uncovered the food items, and began offering the meal. In a subsequent interview, the LPN stated that the CNA should have attended to the resident and assisted her with lunch instead of leaving the room in haste.
Failure to Provide Person-Centered In-Room Activity Program for a Cognitively Intact Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an ongoing, person-centered activity program for a cognitively intact resident who prefers to remain in her room. The resident’s MDS documented moderate hearing difficulty, impaired vision, dementia, and bilateral hearing loss, with activity preferences that included a strong interest in pets and some interest in reading and music, while group activities, going outside, religious services, and keeping up with the news were of low importance. The activity care plan listed numerous self-directed activities and friendly visits, including pets, arts and crafts, music, outdoor activities, and puzzles, with a goal that the resident would report satisfaction with these activities. However, the only listed interventions were to facilitate video calls with family and to provide friendly visits as needed. An activity assessment later documented that the resident wished to participate in activities in the center, wanted 1:1 staff time, and liked self-directed activities. Record review showed that monthly documentation of 1:1 and friendly visits was limited and lacked detail, with only 13 documented visits in each of two full months and 10 visits in the first 22 days of the following month, and no indication of time spent or which staff provided the visits. During observations, the resident was seen in bed with no TV, no music, no pictures on the walls, a newspaper in the trash, and stuffed animals placed out of reach. On a morning when the activity calendar listed a daily meet & greet, morning snack, and an outdoor activity with an activity aide, the aide was observed briefly giving the resident cookies and promising to return, but not engaging in extended interaction or taking the resident outdoors, despite documentation that the resident had been invited and attended certain activities that day. The Director of Recreation confirmed that pet visits, which the resident enjoys, were not on the activity calendar and were not documented, and that weekly family calls for the resident were also not captured in the activity log or care plan. The care plan was acknowledged as not person-centered with measurable objectives and timeframes.
Failure to Ensure Ordered Low Air Loss Mattress Was Functioning for At-Risk Resident
Penalty
Summary
A resident identified as R54, who was assessed as at risk for pressure ulcers on a quarterly MDS and had fragile skin, had a physician order dated 6/5/25 for an alternating low air loss mattress with placement and function to be checked every shift. During multiple surveyor observations on 9/22/25, R54 was seen asleep in bed on her left side with the low air loss device not turned on. On 9/23/25, an observation with an LPN (E43) showed that the low air loss mattress device was not plugged into the wall outlet behind the head of the bed; once it was plugged in, the device powered on and displayed a green light. R54 reported that she does not get out of bed. Review of the September 2025 eTAR showed that for the period covering 9/22/25 into 9/23/25, the nurse on the 7:00 AM to 3:00 PM shift (E44, LPN) did not sign off the ordered preventative treatment, leaving it blank, while the 3:00 PM to 11:00 PM nurse (E45, LPN) and the 11:00 PM to 7:00 AM nurse (E39, LPN) both signed off the treatment as completed. Despite these electronic records indicating completion on two shifts, surveyor observations and the subsequent check with E43 confirmed that the low air loss mattress was not plugged in or functioning as ordered. The facility therefore failed to ensure that this resident at risk for pressure ulcers received the physician-ordered preventative treatment every shift.
Incomplete and Missing Dialysis Communication Forms for a Dialysis-Dependent Resident
Penalty
Summary
The facility failed to provide complete dialysis-related care and services for a resident with end-stage renal disease who was admitted with a physician’s order to receive dialysis three times a week. Review of the resident’s clinical record and dialysis communication forms for September showed that required pre-dialysis information was frequently incomplete or missing. On multiple dates, the pre-dialysis communication forms lacked documentation of meals, medications, changes in condition, and the signature of the person completing the form. For example, on one date only blood pressure and pulse were documented, and on another date only blood pressure, pulse, and a staff signature were recorded. On two additional dates, the pre-dialysis communication forms were completely blank. Further record review revealed that dialysis communication forms for several scheduled dialysis visits were absent from the medical record. Specifically, there was no evidence of completed forms for three dialysis dates early in the month. During interviews, the medical records staff member confirmed that the forms for those dates could not be located. An LPN stated that assigned nurses are responsible for completing the dialysis communication form and described that they ensure the resident has medications, obtain vital signs, and get food from the kitchen before sending the resident to dialysis with a yellow folder given to transportation. The RN unit manager on the resident’s unit confirmed the findings, and the deficiency was later reviewed with the NHA, DON, and corporate nurse during the exit conference.
Failure to Implement Recommended Monitoring for Antipsychotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to act upon a medication regimen review (MRR) recommendation for a resident receiving antipsychotic medication. The facility’s MRR policy, last updated in August 2020, states that recommendations are to be acted upon and documented by facility staff and/or the prescriber. The resident was initially admitted on 4/24/25, discharged to the hospital between 5/1/24 and 7/15/24, and then re-admitted on 7/15/25 with multiple diagnoses including dementia, anxiety, and major depressive disorder with psychotic symptoms. On 7/15/25, an admission MDS assessment documented that the resident was receiving antipsychotic medications, and a care plan was created for antipsychotic use with an intervention to monitor behaviors. Also on 7/15/25, an MRR documented that the resident’s antipsychotic required monitoring, and this recommendation was signed by the physician on 7/18/25. A physician’s order dated 7/16/25 directed that the resident receive an antipsychotic twice daily for psychosis. However, during record review and an interview on 9/26/25, an LPN confirmed that there was no ongoing monitoring intervention in place on the record, stating that there should be something based on medications every shift and suggesting it may have fallen off when the resident left and then returned. The finding was later reviewed with the NHA, DON, and corporate nurse during the exit conference on 9/29/25. This sequence of events shows that although the need for antipsychotic monitoring was identified in the MRR and acknowledged by the physician, the facility did not ensure that the recommended monitoring intervention was implemented and documented as required by its own policy.
Failure to Provide Timely Follow-Up Dental Care After Identified Dental Needs
Penalty
Summary
The facility failed to promptly provide routine and emergency dental care for a resident who had documented dental needs following a dental examination. The facility’s policy on Dental Service Needs, dated 1/29/25, required nursing to collaborate with Social Services to secure dental resources and assist residents in making appointments. The resident was admitted on 11/25/22 and had a care plan initiated on 8/26/24 addressing independence with oral care, with a goal to remain free from dental complications and interventions that included performing oral exams as needed and referring to a dentist when indicated. On 3/23/25, a dental consultation documented recommendations for the resident to return to restore cavities and noted that extensively decayed teeth and root tips would need extraction in the future if symptoms or swelling began. Despite these recommendations, the resident’s quarterly MDS assessment on 5/14/25 indicated intact cognition and no dental issues, and there was no evidence that the resident was seen by the dentist for follow-up after the March 2025 exam. During an interview on 9/18/25, the resident reported not remembering being seen by a doctor, stated that their teeth were loose and falling out, and that this was affecting chewing and eating. The surveyor observed chipped and decayed teeth at that time. On 9/23/25, an LPN Unit Manager confirmed that the resident had not been seen by the dentist sooner after the March recommendation and stated that the resident was only on a list to be seen for a six‑month follow‑up visit. These findings were later discussed and reviewed with the NHA, DON, and Corporate Nurse on 9/29/25.
Failure to Post Information on How to File State Agency Complaints
Penalty
Summary
The facility failed to ensure that information on how residents can formally complain to the State Agency was displayed in a format and language residents understood. During a resident council meeting on 9/24/25 at 1:45 PM, all residents in attendance denied knowing how to make a formal complaint to the state of Delaware. Later that day at 2:08 PM, during a tour of the facility to check required postings, the surveyor observed that the first-floor bulletin case, which displayed information for residents and visitors, did not include information on how to make a complaint to the state agency. At 2:27 PM, the Nursing Home Administrator (E1) confirmed this finding. On 9/29/25 at 1:25 PM, the same finding regarding the lack of posted information about how to file a complaint with the state agency was reviewed with the NHA (E1), the DON (E2), and the Corporate Nurse (E3) during the exit conference.
Failure in Pressure Ulcer Management and Care
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure ulcers from developing for several residents. For one resident, the facility did not initiate and implement a sacral pressure ulcer care plan with appropriate interventions and hospice involvement. The resident's sacral pressure ulcer was not appropriately staged, and there was a lack of evidence that the ulcer was being assessed and monitored. Additionally, the facility did not complete weekly skin assessments and failed to document turning and repositioning of the resident, which are critical for pressure ulcer prevention and management. Another resident was admitted with a scar on the sacrum, which later developed into a stage II pressure ulcer. The facility did not follow the physician's orders for wound care management, as the prescribed treatments were not administered as ordered. The resident's care plan lacked a regular timed turning and repositioning task, leading to inconsistent repositioning intervals, sometimes extending to ten to fourteen hours, which contributed to the development of the pressure ulcer. For other residents, the facility failed to document dressing changes and complete skin audits as required. One resident's clinical records lacked evidence of treatment for open areas on the groin and sacral area, and the facility did not complete the required daily or weekly skin audits. These deficiencies indicate a systemic failure in the facility's pressure ulcer prevention and management practices, resulting in harm to the residents.
Failure to Prevent Significant Medication Error Resulting in Acute Kidney Injury
Penalty
Summary
A significant medication error occurred when a resident with a history of acute kidney injury, diabetes, and metastatic cancer was prescribed and administered both Metformin and Ibuprofen daily over several days, despite two pharmacy warnings about the risk of acute renal failure from this drug combination. The resident's clinical records show that Ibuprofen was initially ordered as needed for pain, but due to the resident's cognitive deficits and to facilitate participation in physical therapy, the nurse practitioner changed the order to a scheduled dose. The facility's electronic medical record system generated drug interaction alerts on two occasions, both of which were acknowledged by nursing staff, but the medications continued to be administered together. During the period when both medications were given, the resident experienced poor oral intake, and the facility initiated hypodermoclysis to address dehydration and elevated calcium levels. Despite these interventions, the resident's laboratory results showed a progressive and significant increase in creatinine and BUN, indicating worsening renal function. The clinical documentation lacked evidence that nursing staff were actively encouraging or monitoring the resident's oral intake during this time. The resident ultimately required emergency transfer to the hospital for acute kidney failure, where it was noted that the ongoing administration of Ibuprofen, in combination with Metformin and dehydration, contributed to the acute renal injury. Throughout the episode, multiple progress notes by medical staff referenced the resident's acute kidney injury and the need for hydration, but there was no documentation that the potential interaction between Metformin and Ibuprofen was addressed or that the medications were discontinued in response to the pharmacy warnings. The resident was harmed as a result of the continued administration of these medications, as evidenced by the need for hospitalization and intravenous treatment for acute kidney failure.
Food Safety Deficiencies in Kitchen and Storage Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial kitchen tour, it was observed that there were no hand drying towels at the handwashing sink, a cooked pork roast was left uncovered on a counter with flying insects present, and pork sausage patties were stored in an open, unsecured plastic bag in the walk-in freezer. Additionally, the walk-in freezer temperature was recorded at 27 F, and logs from July showed temperatures ranging from -6 F to 35 F. Further observations revealed that the first-floor nourishment refrigerator contained spilled substances, unlabeled resident food items, and an open juice container without an open date. These findings were confirmed by the Director of Dietary Services and the Regional Director of Clinical Reimbursement.
Failure to Develop Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for six residents, leading to deficiencies in addressing their specific needs. For four residents, the facility did not conduct necessary bowel and bladder assessments to create individualized care plans aimed at restoring and maintaining continence. These residents experienced frequent episodes of incontinence, and their care plans only included generic interventions such as checking and changing briefs, without any tailored strategies to improve their continence. One resident, identified as a high fall risk due to severe cognitive impairment, did not have a person-centered fall care plan with appropriate interventions. Despite being dependent on staff for daily activities and having a high fall risk score, the care plan lacked specific measures such as using a low bed or non-skid socks. This oversight resulted in the resident sustaining a fall and requiring emergency hospital evaluation. Another resident, who was at risk for pressure ulcers, developed a sacral pressure ulcer that was not addressed with a person-centered care plan. The clinical records showed a lack of evidence for a tailored care plan to manage the pressure ulcer, despite documentation of the ulcer's severity and treatment needs. These deficiencies were reviewed with facility leadership and a representative from the Ombudsman's Office during the exit conference.
Failure to Update Care Plans for Incontinence and Hospice Services
Penalty
Summary
The facility failed to review and revise the care plan for a resident admitted on 8/20/24, who was initially documented as cognitively intact and continent of bowel and bladder. However, the admission MDS assessment on 8/26/24 indicated that the resident had moderate cognitive impairment and was frequently incontinent of bowel and bladder. Despite this change in condition, the care plan was not updated to reflect the resident's frequent incontinence, nor were appropriate interventions implemented to address this issue. During an interview, the MDS Coordinator confirmed the resident's frequent incontinence as documented in the MDS assessment. Another resident, admitted to hospice services on 8/4/23, had a care plan that was not adequately reviewed and revised. The care plan, initially established on 8/14/23 and revised on 9/23/24, did not specify who was responsible for the resident's bathing needs after the hospice aide stopped visiting the facility as of 1/1/24. Additionally, the care plan lacked details on the frequency and nature of hospice services, including visits from nursing, chaplain, and social work, as well as the medical equipment, supplies, and medications to be provided to the resident.
Failure to Conduct Bowel and Bladder Assessments
Penalty
Summary
The facility failed to conduct comprehensive bowel and bladder assessments for several residents, which led to deficiencies in individualized care planning to restore and maintain continence. For instance, one resident was readmitted with a urinary tract infection but did not receive a reassessment for bowel and bladder needs, despite experiencing multiple episodes of incontinence. Another resident, who was initially continent upon admission, became frequently incontinent without any documented efforts to restore continence, and expressed dissatisfaction with the lack of toileting assistance. Additionally, the facility did not perform necessary assessments for residents who had previously been continent before admission but became incontinent after entering the facility. One resident, who had a history of being continent, experienced frequent incontinence episodes and expressed a desire to regain continence, yet there was no evidence of a reassessment or a plan to address this issue. Another resident, who was admitted with a urinary tract infection, was not reassessed for bowel and bladder needs, and subsequently experienced a fall while attempting to use the bathroom, highlighting the lack of appropriate interventions. The facility's failure to update care plans based on residents' changing continence status was further evidenced by the case of a resident who was frequently incontinent according to the admission MDS assessment, yet the care plan was not updated to reflect this change. Interviews with staff revealed a lack of clarity on procedures for initiating voiding diaries or reassessments, indicating systemic issues in the facility's approach to continence care. The facility's documentation and care planning processes did not adequately address the residents' needs, leading to ongoing incontinence issues and dissatisfaction among residents.
Failure to Ensure Hospice Care Coordination and Documentation
Penalty
Summary
The facility failed to ensure that a resident received hospice care and services as per the written agreement with the Hospice Provider. Specifically, the facility did not notify and collaborate with the Hospice Provider on developing and implementing a sacral pressure ulcer plan of care with interventions to meet the resident's needs. Additionally, the facility did not update the Hospice Provider that the resident's eight medications were discontinued, and failed to ensure that current Hospice documentation was present and readily accessible in the resident's facility clinical record. The resident's clinical record revealed that the facility did not review, revise, and collaborate with the Hospice Provider on the resident's care plan. The resident was not being bathed or showered by Hospice staff for a significant period. An observation of the resident's hospice binder at the nurse's station showed the absence of contact information for the Hospice Care Team, and outdated documentation, including a lack of current recertification, care plan, and medication list. During an interview, a Hospice RN confirmed the absence of necessary documentation in the hospice binder and was unable to verify if the hospice nurse assessed the resident's sacral pressure ulcer. The Hospice Provider later provided documentation that inaccurately listed medications the resident was no longer taking. The findings were reviewed with facility management, but no further information was provided to the Surveyor.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an infection control program using Enhanced Barrier Precautions (EBP) for four residents reviewed for infection control. These residents included individuals with indwelling feeding tubes and chronic wounds, which met the criteria for EBP. Observations revealed that staff did not consistently use personal protective equipment (PPE) such as gowns and gloves during high-contact care activities. For instance, during a wound care dressing change for a resident with a PEG tube, an LPN did not wear a gown. Similarly, another resident's room lacked PPE for staff use during care, and staff confirmed they had not been using PPE during direct care activities. Further observations showed that staff failed to wear appropriate PPE during wound care for residents with pressure ulcers. In one case, an LPN and a CNA did not wear gowns while performing wound care on a resident with stage 4 pressure ulcers. Another resident with a chronic sacral pressure ulcer was also not provided with EBP, and staff did not wear gowns during wound dressing changes. Interviews with staff revealed misunderstandings about PPE requirements, with some believing that only gloves were necessary or that goggles were only required for specific procedures.
Failure to Educate and Offer COVID-19 Vaccinations
Penalty
Summary
The facility failed to provide education regarding the benefits and potential side effects of COVID-19 immunizations to four residents (R9, R30, R53, and R76) out of five sampled for COVID-19 vaccinations. Additionally, the facility did not offer these residents an up-to-date COVID-19 vaccination. Specifically, R9's clinical record showed the last documented COVID-19 vaccination was received on April 9, 2021. R30's record indicated the last vaccination was on November 22, 2023. R53's record showed the last vaccination was on December 6, 2022, and R76's record indicated the last vaccination was on September 10, 2021. These findings were reviewed during an exit conference with the Nursing Home Administrator (E1), Director of Nursing (E2), Assistant Director of Nursing (E3), Vice President of Operations (E46), and a representative from the Ombudsman's Office.
Failure to Align Resident's Treatment Wishes with Care Plan
Penalty
Summary
The facility failed to ensure that a resident, identified as R118, was fully informed and able to participate in her treatment decisions. R118 was admitted with a physician order for Do Not Resuscitate (DNR) status. However, a review of her clinical records revealed a Delaware Medical Orders for Scope of Treatment (DMOST) form, signed by both R118 and a Nurse Practitioner, indicating her wish for full treatment (Full Code) in the event of cardiac or respiratory arrest. Despite this, the facility did not align her care plan with her documented wishes, as evidenced by the discrepancy between the DNR order and the DMOST form. This finding was confirmed during an interview with the Director of Nursing and was discussed during the exit conference with facility leadership and a representative from the Ombudsman's Office.
Failure to Facilitate Resident's Shower Preferences
Penalty
Summary
The facility failed to support and facilitate a resident's right to self-determination regarding their shower schedule. The resident, identified as R76, expressed that choosing between different types of baths was very important to them. Despite being scheduled for showers every Tuesday and Friday during the day shift, the facility's documentation system was set up for staff to document on Mondays and Thursdays. This discrepancy led to R76 not receiving showers on the scheduled days, and there was no documentation of refusal by the resident. Interviews with the resident and staff revealed that R76 was already dressed by the time staff approached him for a shower, which led to the showers not being provided. The CNAs failed to document any refusals, and there was no evidence that nursing staff engaged in discussions with R76 to determine his preferred shower time. The lack of communication and documentation resulted in the resident not receiving showers as per his preference, and the issue was acknowledged during an exit conference with the Nursing Home Administrator and Director of Nursing.
Inaccurate MDS Assessment of Resident's Pressure Ulcer
Penalty
Summary
The facility failed to accurately reflect a resident's sacral skin condition in the annual Minimum Data Set (MDS) assessment. The resident, identified as R26, was reviewed for pressure ulcers, and it was found that the facility did not document the resident's sacral skin condition as a Stage 3 pressure ulcer. Instead, the annual MDS assessment inaccurately recorded the condition as Moisture Associated Skin Damage (MASD), despite the wound assessment report indicating full thickness tissue loss with slough present, which aligns with a Stage 3 pressure ulcer. The discrepancy arose from the facility's reliance on the Wound Care Consultant's documentation, which did not stage the sacral pressure ulcer. During an interview, the MDS Coordinator confirmed that the MDS was coded based on this documentation, leading to the misclassification. The issue was discussed during an exit conference with facility leadership and a representative from the Ombudsman's Office, highlighting the failure to accurately assess and document the resident's medical status.
Failure to Schedule Follow-Up and Monitor Orthostatic Vital Signs
Penalty
Summary
The facility failed to ensure that a resident, identified as R116, received treatment and care in accordance with their person-centered care plan. R116 was admitted with an acute kidney injury and required a follow-up appointment with a nephrologist as documented in the hospital interagency nursing communication record. Despite the admission paperwork indicating that all follow-up appointments would be scheduled by the unit clerk, the nephrologist appointment was not scheduled. Additionally, there was no evidence of discussions between facility staff, R116, and their family member regarding the follow-up appointment. Another resident, R127, experienced a deficiency in care related to the monitoring of orthostatic vital signs. R127, who was on multiple medications for high blood pressure, had three falls within six days. A physician ordered orthostatic vital signs to be taken daily for three days due to these falls. However, the facility failed to measure these vital signs according to standards of practice, as the blood pressure readings were not taken in the required positions (lying, sitting, and standing). This failure was confirmed by a registered nurse during an interview, indicating a lack of adherence to physician orders and standards of practice for monitoring orthostatic hypotension in R127.
Failure to Apply Prescribed Therapy Devices for Resident Mobility
Penalty
Summary
The facility failed to provide necessary assistance to maintain or improve the mobility of a resident, identified as R105, who was admitted with a diagnosis of stroke. The resident's care plan required the application of a therapy carrot to the left hand and a palm guard to the right hand, to be worn as tolerated during the day. Despite these orders being documented in the resident's care plan and Kardex, observations on multiple occasions revealed that the resident was not wearing the therapeutic devices, and they were not found by the bedside. On several dates, the resident was observed without the prescribed therapy devices, and during an interview, an LPN confirmed that the devices should have been in place. The LPN found the left palm guard in the resident's closet but was unable to locate the therapy carrot for the right hand. These findings were discussed during an exit conference with facility leadership and a representative from the Ombudsman's Office, highlighting the facility's failure to adhere to the prescribed care plan for the resident's mobility needs.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident identified as R64, who was at high risk for falls due to dementia and muscle weakness. R64 was admitted with a fall score of 18, indicating a high fall risk, and had a care plan that included interventions such as using a low bed and placing items within reach. Despite these measures, R64 fell out of bed while receiving care from a CNA, who had momentarily turned away to get lotion. This incident resulted in a scrape and hematoma on R64's forehead, necessitating an emergent transfer to the hospital for evaluation. The resident was severely cognitively impaired, with a BIMS score of 00, and was dependent on staff for bed mobility and repositioning.
Failure to Monitor and Address Nutritional Needs
Penalty
Summary
The facility failed to maintain acceptable parameters of nutrition for a resident, identified as R83, who was admitted with multiple diagnoses including pneumonia, malnutrition, swallowing disorder, and dementia. Upon admission, R83 weighed 96.6 pounds, which was below the facility's threshold for weekly weight monitoring. Despite this, the facility did not adhere to its policy of obtaining weekly weights for residents under 100 pounds. R83's weight fluctuated significantly, with a recorded 11% loss over two months, indicating a decline in nutritional status that was not adequately monitored. Additionally, there was a delay in implementing a dietary recommendation made by the dietician. Although the dietician recommended adding a nutritional supplement, Magic Cup, to R83's meal plan, the order for this supplement was not written until 10 days later. This delay, coupled with the failure to conduct weekly weight checks, contributed to the facility's inability to effectively manage R83's nutritional needs, as evidenced by the significant weight loss observed during the resident's stay.
Failure to Label and Date Tube Feeding Bottles
Penalty
Summary
The facility failed to adhere to the standard of care for the proper labeling and dating of tube feeding bottles for one resident, identified as R105, who was reviewed for tube feeding. R105 was admitted to the facility with a diagnosis of a stroke and difficulty swallowing food and liquids. On two separate occasions, observations were made where the tube feeding bottle being administered at R105's bedside had no date written on it. This was confirmed during an interview with a registered nurse, E24, who acknowledged the absence of a date on the tube feeding bottle. These findings were discussed during an exit conference with the nursing home administrator, director of nursing, assistant director of nursing, vice president of operations, and a representative from the Ombudsman's Office.
Failure to Administer Prescribed Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with physician orders and the comprehensive person-centered care plan for one resident. The resident, who was readmitted to the facility and had a physician's order for oxygen therapy at 2 liters per minute via nasal cannula due to shortness of breath, was observed multiple times without receiving the prescribed oxygen therapy. Despite the presence of an oxygen concentrator and tubing at the resident's bedside, the resident was not receiving oxygen therapy during several observations. The Medication Administration Records for September indicated that licensed nurses had signed off on the administration of oxygen therapy every shift, yet the resident was not observed receiving it. An LPN confirmed that the resident had an active order for oxygen therapy every shift but stated that it was not administered because the resident's oxygen saturation level was above 95%. The LPN acknowledged the need to inform the physician to potentially change the order to PRN. These findings were discussed during an exit conference with facility leadership and a representative from the Ombudsman's Office.
Failure to Administer Pain Medication Prior to Wound Care
Penalty
Summary
The facility failed to ensure appropriate pain management for a resident during wound care, which was inconsistent with the resident's care plan and professional standards of practice. The resident, identified as R26, was care planned for being at risk for pain due to advanced age, osteoarthritis, and being more sedentary or bedbound. The care plan included observing for physical indicators of pain and administering medications as ordered. However, during an observation of wound care rounds, the resident was noted to be moaning during repositioning and the removal of a saturated sacral wound dressing, indicating pain. Despite the resident's evident discomfort, the LPN did not administer any pain medication prior to the wound care procedure. A review of the electronic Medication Administration Record (eMAR) showed that the resident was last medicated with Tylenol for pain the previous night. It was only after the wound care observation that the LPN administered two Tylenol tablets to the resident. This failure to administer pain medication prior to the procedure was discussed during an exit conference with facility leadership and a representative from the Ombudsman's Office.
Failure to Post Required Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with federal requirements for posting daily nurse staffing information in a conspicuous area accessible to residents and visitors. On October 2, 2024, an observation in the main lobby revealed that the staffing information displayed was outdated, covering the period from September 22 to September 28, 2024, and lacked the current daily census, correct date, and worked hours for RNs, LPNs, and CNAs. Additionally, observations of four units within the facility showed that the staffing sheets did not include the facility name, daily census, or total worked hours per shift for each discipline. Interviews with the HR Director and the Nursing Home Administrator confirmed that the postings did not meet federal requirements. These findings were discussed with facility leadership and a representative from the Ombudsman's Office during the exit conference.
Failure to Monitor and Administer Blood Pressure Medication Appropriately
Penalty
Summary
The facility failed to properly monitor and administer blood pressure medication for a resident, identified as R116, who was admitted with a diagnosis of high blood pressure. A physician's order required that Norvasc, a blood pressure medication, be held if the resident's systolic blood pressure (SBP) was less than 110. However, the resident's electronic medication administration records (eMARs) and nurse's notes for August and September 2024 showed that blood pressures were not consistently taken prior to medication administration. Specifically, there were four missed opportunities in August and three in early September where blood pressure readings were not documented before giving the medication. Additionally, the resident received the medication on three occasions in September when their SBP was below the prescribed threshold, with readings of 98/51, 109/76, and 107/69. These findings were reviewed with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON), but no further information was provided to the surveyor.
Failure to Provide Immunization Education and Offer Vaccinations
Penalty
Summary
The facility failed to provide education regarding the benefits and potential side effects of influenza and pneumococcal immunizations to three residents or their representatives, and subsequently did not offer the immunizations. Specifically, one resident's clinical record lacked evidence of being offered an up-to-date pneumococcal vaccination, despite having received the PCSV23 vaccine previously. Another resident's record did not show evidence of being offered an influenza vaccination for the year 2023. Additionally, a third resident's record lacked evidence of being offered a pneumococcal vaccination. These deficiencies were discussed during an exit conference with the Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, Vice President of Operations, and a representative from the Ombudsman's Office.
Delay in Providing Nutritional Supplement per Resident Preference
Penalty
Summary
A resident was admitted to the facility and, according to a nutrition note, had variable oral intake but no issues with chewing or swallowing. During the initial nutrition assessment, the resident's family member communicated that the resident enjoyed drinking Ensure and requested that she receive one between meals. The dietician recommended adding Ensure once daily based on this preference. Despite this recommendation and a subsequent reiteration of the request during a care conference, the facility did not obtain a physician's order for Ensure until 22 days after the initial recommendation. As a result, the resident did not receive Ensure as requested and recommended during this period.
Failure to Maintain Sanitary Conditions in Waste Disposal Area
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for residents, staff, and the public as evidenced by repeated observations of improper trash disposal near the facility. On multiple occasions, trash dumpsters were found with open lids and clear bags of facility waste, including contaminated feces-soiled resident briefs and used PPE gloves, hanging over the sides and scattered on the ground around the dumpsters. Despite some removal of the waste, soiled items remained behind the dumpsters and along the back fence for several days. Facility leadership, including the NHA, confirmed these findings during interviews.
Deficiencies in Clinical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for three residents, leading to deficiencies in documentation. For one resident, medical progress notes were repeatedly copied over several months without updating the resident's current medical status. This included outdated information about medications and treatments that had been discontinued, as well as the omission of ongoing treatment for a sacral pressure ulcer. The nurse practitioner responsible for these notes did not ensure that the documentation reflected the resident's actual care needs and medical condition. Another resident's care was not documented during a specific shift, and a family member reported finding the resident incontinent. Additionally, the facility did not accurately complete a Fall Risk Scoring Tool for a third resident after a fall incident. The tool was initially completed with incorrect data and was not updated or corrected following the incident. These documentation failures were confirmed during interviews with facility staff, including the Director of Nursing, and were reviewed during an exit conference with facility leadership and a representative from the Ombudsman's Office.
Latest citations in Delaware
Multiple cognitively impaired residents with known behavioral issues, including wandering, agitation, and physical aggression, were not adequately protected from resident‑to‑resident abuse. In one case, a resident with dementia and PTSD was pushed to the floor by another resident who had a history of combative behavior, resulting in multiple fractures and facial lacerations after staff initially documented the event as an unwitnessed fall. In another case, two residents with dementia and psychotic features engaged in a physical altercation in a dayroom after one placed his hand on the other’s chest, leading to mutual punching. A separate incident occurred when a resident with dementia and behavioral disturbances entered another resident’s room, pulled at the bedcovers, yelled that the room was his house, and allegedly struck the other resident, who was later noted with puffiness around one eye. In all incidents, the involved residents had documented behavioral care plans and significant cognitive impairment, yet physical confrontations still occurred.
A resident with dementia, spinal stenosis, and total dependence for transfers, care-planned for Hoyer lift use with two-person assist, was being transferred from a shower bed to a Geri-chair when the Hoyer lift tipped sideways. Staff reported the lift’s legs had been widened and that one CNA manually pushed the feet apart instead of using the control, and straps may have been unevenly positioned. The resident was lowered to the floor while still in the sling and sustained a small skin tear to the elbow; imaging later showed no fractures. The DON stated that three CNAs were involved, including one on light duty who was not supposed to be using the lift, and that no mechanical defect was found with the lift.
The facility failed to thoroughly investigate several allegations of verbal and potential physical abuse involving four cognitively intact residents with conditions including hemiplegia, rheumatoid arthritis, type 2 DM, epilepsy, and heart disease. In each case, the facility’s investigations were limited, often including only the directly involved resident and omitting interviews with other potentially knowledgeable residents or staff. One resident reported a verbal altercation with a CNA after a fall to the floor, another reported being verbally abused by a roommate’s family member, a third reported a male CNA was too rough and upset while changing linens, and a fourth reported a staff member insulted her and refused brief care. Investigation files lacked broader resident and staff interviews, timely physical and psychosocial assessments, and review of the accused staff member’s employee record, contrary to the facility’s abuse policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
A resident with rectal cancer and intact cognition reported that an RN on night shift confronted him when he returned from smoking off campus, spoke to him loudly about his smoking, used profanity, and threatened to have staff refuse to buzz him back into the building. A CNA corroborated that the RN was upset about being called in to work and used curse words toward the resident, but did not report the incident at the time because the RN was the night supervisor. The resident reported the event to the Social Services Director the next day, yet the facility initially treated it as a grievance rather than abuse and delayed submitting a report to the State Survey Agency until weeks later, after determining it was a reportable abuse incident.
Two residents did not receive required ADL and hygiene care as care planned. One resident with dementia and osteoarthritis, dependent for toileting and personal hygiene, was not toileted during an evening shift, with CNA documentation showing no toileting and the oncoming CNA finding the resident’s clothing, linens, and mattress saturated with urine; the assigned CNA reported care resistance but did not notify an RN or LPN. Another resident with dementia and stroke, requiring assistance with dressing and personal hygiene, remained in bed in pajamas into the afternoon without having received morning care, despite CNA documentation indicating dressing was completed; the CNA later confirmed that care was only provided after being questioned by an RN supervisor following a family complaint.
A resident with left-sided weakness after a stroke, high fall risk, and total dependence for ADLs and bed mobility was being turned onto their side for peri care by an aide when they fell from the bed to the floor, sustaining head trauma and a scalp laceration while on blood thinners. The care plan required extensive to total assistance with two-person support for bed mobility, but the fall occurred during care without documentation of the required level of assistance, indicating the facility did not provide adequate supervision and assistance to prevent accidents as outlined in its own fall prevention practices.
A resident with significant upper extremity weakness and recent surgery was discharged home to a multi-story residence without confirmed DME delivery, home health services, or caregiver support. Although referrals for home health, skilled nursing, and DME were made and family attended a discharge care plan meeting, staff did not verify that services were active, did not set or confirm a start-of-care date with the agency, and did not confirm delivery of a hospital bed. The resident, who lived alone and could not manage fine motor tasks, arrived home without in-home assistance, reported difficulty with eating and self-care, and was later found by an HHA RN in unsafe conditions, unable to access food or medications, leading to emergency transport back to the hospital.
A resident with dementia, Parkinson’s disease, CHF, and a history of AKI had documented fluid goals and was identified as at risk for dehydration and malnutrition, yet daily intake records repeatedly showed fluid consumption well below the recommended amounts. Despite severely impaired cognition, poor oral intake, and documented changes in mentation, lethargy, falls, and restlessness, the facility did not consistently implement or document enhanced monitoring, assistive feeding measures, or timely provider consultation focused on hydration. The resident was hospitalized twice with AKI, dehydration, hypotension, and anemia, and staff interviews confirmed that while expectations existed to encourage fluids and notify providers when goals were not met, there was no clear evidence that these expectations were carried out for this resident.
A resident with cardiac conditions was discharged home with a documented post-discharge plan for home health aide, home health RN/LPN, and PT/OT, but the facility did not complete the home health referral before discharge. The resident went home with a family member and, according to a complaint, did not receive PT, OT, or a nursing wellness check for about a week. The SW later confirmed the referral for home health and therapy services was not requested until several days after discharge, and services did not begin until even later, despite therapy recommendations that are typically communicated to social services to arrange home care.
The facility failed to consistently revise care plans to reflect residents’ current needs and behaviors and did not ensure a cognitively intact resident was involved in ongoing care planning. One resident participated in an initial care conference but was not included in later care plan updates. Another resident with an order for a palm protector was frequently observed without it and often refused it, yet the care plan did not address refusals. Two cognitively impaired residents whose MDS assessments showed dependence for bathing had care plans that still listed only setup or one‑person assist. A cognitively impaired resident with combative behaviors and an incident of striking another resident had a behavior care plan that was not updated to include attempts to hit other residents or the risk of resident‑to‑resident altercations.
Failure to Prevent Resident‑to‑Resident Physical Abuse Among Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from resident‑to‑resident physical abuse. One resident with dementia, agitation, depression, anxiety, and PTSD, and a BIMS score indicating moderate cognitive impairment, was pushed to the floor by another resident after that resident entered his room and followed him into the hallway. Staff initially documented the event as an unwitnessed fall after hearing loud screaming and finding the resident on the floor with complaints of right shoulder and left wrist pain, active bleeding from facial lacerations, and clamminess. Subsequent review of surveillance footage showed that another resident walked into the victim’s room, then followed him out and pushed him, causing the fall that resulted in multiple fractures, including a closed left distal radius fracture, a closed, displaced comminuted right proximal humerus fracture, and a closed, displaced distal clavicle fracture. The resident who pushed him had dementia with mood disturbances, bipolar disorder with psychotic features, PTSD, insomnia, and depression, and a BIMS score indicating severe cognitive impairment. His care plan identified a behavior problem related to bipolar disorder and dementia, including wandering, refusal of care, and physical aggression toward staff and others, such as biting a CNA and swinging a walker at a CNA. The care plan directed staff to anticipate and meet his needs, divert him with alternative objects or activities, intervene to protect the rights and safety of others, and conduct safety checks. Despite these identified risks and interventions, he was able to enter another resident’s room and subsequently push that resident in the hallway, resulting in serious injury. Another incident involved two residents with significant cognitive impairment and behavioral symptoms, including delusions, physical behaviors toward others, agitation, and a tendency to invade others’ personal space. One resident, who was described as aggressive toward others, easily agitated, and prone to getting into others’ personal space, walked next to another resident sitting in a dayroom chair and placed his hand on that resident’s chest. The seated resident responded by punching him in the face with the back of his fist, and the first resident then punched back. Staff and psychiatric documentation noted this altercation and ongoing behavioral concerns such as combativeness with care, agitation, and wandering, but the record contained no additional progress notes describing the incident itself beyond the brief psychiatric follow‑up entry. A further incident occurred when a resident with anxiety, major depressive disorder, dementia with behavioral disturbances, agitation, and severe cognitive impairment entered another resident’s room on the memory care unit. The resident in the room, who had depression, anxiety, dementia without behavioral disturbances, PTSD, insomnia, hallucinations, verbal behaviors toward others, other behavioral symptoms, and wandering, reported that he was hit in the face. Staff heard yelling and found the intruding resident pulling covers at the foot of the bed and yelling that the room was his house, while the other resident sat on the side of the bed and stated that he had been hit and told staff to get a gun and shoot the other resident. Slight puffiness was noted around the reporting resident’s left eye. The intruding resident’s care plan documented compulsiveness, invading others’ personal space, yelling, restlessness, physical aggression, and attempts to assist other residents he believed needed help, with interventions to divert him, familiarize him with his surroundings, and intervene to protect the rights and safety of others. Despite these identified behaviors and interventions, he was able to enter another resident’s room, engage in a confrontation, and allegedly strike the resident.
Resident Injury from Improper Hoyer Lift Operation During Transfer
Penalty
Summary
The deficiency involves the facility’s failure to prevent an accident during a Hoyer lift transfer, resulting in a fall and skin tear injury to a resident. The resident had diagnoses including spinal stenosis, Alzheimer’s disease, vascular dementia with behavioral disturbance, bipolar disorder, and pain, and was documented on the MDS as dependent on staff for transfers from bed to chair. The care plan and physician orders specified that the resident required a Hoyer lift with assistance of two staff for transfers. On the day of the incident, the resident was being transferred via Hoyer lift after a shower, from a shower bed back to a Geri-chair. Progress notes and the post-fall evaluation documented that the fall occurred in the bathroom during a Hoyer transfer with staff assistance of two, and that the Hoyer lift tipped sideways. The resident was found on the floor in the sling, with staff reporting that the Hoyer lift’s legs were widened and that as the resident was being positioned over the chair, the lift tipped to the side. Staff held the sling on each side of the resident’s head and lowered the resident to the floor, after which a skin tear measuring 1.0 cm x 0.1 cm was noted on the elbow. The facility’s investigation determined that the Hoyer tipped because one CNA pushed the lift’s feet apart manually instead of using the designated button to open the legs. Interviews indicated that the manual mechanical lift used at the time was considered less steady and required manual operation of a foot pedal to open the legs, and that the straps may have been more to one side than the other. The DON reported that three CNAs were involved with operating the lift at the time of the incident, including one CNA on light duty who was not supposed to be using the Hoyer lift, and that the lift itself was later found to have no mechanical problems. As a result of the tipping incident, the resident sustained a skin tear to the elbow and required diagnostic imaging to rule out fractures.
Incomplete Investigations of Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of verbal or potential physical abuse as required by its abuse, neglect, and exploitation policy. One cognitively intact resident with hemiplegia following a stroke reported a verbal altercation with a CNA after sliding to the floor while being assisted back to bed. The resident requested use of a Hoyer lift, the CNA told him he could get himself up, and an argument ensued in which the CNA told the resident it was not his room and did not leave until directed by an LPN. The facility’s investigation file for this incident contained only the resident’s interview and no interviews with other residents on the unit who might have had knowledge of similar verbal abuse by the CNA. Another cognitively intact resident with rheumatoid arthritis, hypertension, and peripheral vascular disease reported that her roommate’s daughter came into her room and verbally abused her after the roommate had been relocated due to aggression. The daughter allegedly cursed at the resident, calling her an offensive name and telling her she was going to hell. The investigation file for this incident contained no interviews with other residents on the unit to determine whether they had experienced verbal abuse by this family member or had knowledge of the event. The DON acknowledged that no such interviews were conducted. A third cognitively intact resident with type 2 diabetes and epilepsy reported, through her daughter, that a male CNA wearing a red shirt was too rough with her and appeared upset about having to change her linens. The facility’s investigation into this potential staff-to-resident abuse included an interview with the resident but did not include interviews with other interviewable residents in the same area who might have had knowledge of the incident. A fourth cognitively intact resident with type 2 diabetes and heart disease, later discharged, reported that a staff member entered her room, called her a poor excuse for a human being, and refused to assist with changing her brief. The investigation documentation for this allegation lacked interviews with additional residents or staff, did not show that the resident was promptly assessed physically and psychosocially in relation to the allegation, and did not include a review of the accused staff member’s employee record, resulting in an incomplete investigation contrary to facility policy requiring identification and interviews of all involved persons and others who might have knowledge of the allegations.
Failure to Protect Resident From Verbal Abuse and Delay in Reporting Incident
Penalty
Summary
The facility failed to protect a cognitively intact resident from verbal abuse by a staff member. The resident, admitted with rectal cancer and independently ambulatory with a rolling walker, reported that during an overnight shift he left the campus to smoke and, upon returning and walking toward the nursing station, was confronted by an RN. According to the resident’s report, the RN told him that when she was on the night shift he was not allowed to go outside, using profanity toward him, and further stated that if he went out the door she would instruct staff not to buzz him back into the building. A CNA later confirmed that the RN had been upset about being called in to work, spoke loudly to the resident about his smoking, and used curse words when he responded to her. The incident was not promptly reported to facility administration despite occurring during the night shift, with the CNA stating that the RN involved was the supervisor at the time. The resident reported the incident the following day to the Social Services Director, but the facility did not immediately recognize or treat the allegation as reportable abuse. Instead, the administration initially considered it a grievance and investigated it in that manner. The incident report was not submitted to the State Survey Agency until several weeks after the resident’s report, and only after the facility later determined that the event constituted a reportable abuse incident.
Failure to Provide Required ADL and Hygiene Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL assistance to maintain grooming and personal hygiene for two dependent residents. One resident with dementia, osteoarthritis, and moderately impaired cognition was care planned to receive partial to substantial assistance with personal and oral care, scheduled toileting every two hours, and assistance with toilet transfers. CNA documentation for an evening shift showed “N/A” for all scheduled toileting times, and a facility incident report stated that the CNA assigned to this resident failed to provide incontinence care during that shift. The oncoming night-shift CNA later found the resident’s clothing, linens, and mattress saturated and soaked with urine and provided the needed care, with the prior-shift LPN confirming the condition when notified. The assigned CNA reported the resident was resistant to care but did not notify the LPN or RN for assistance or document the issue. The second resident, with dementia, stroke, weakness, and moderately impaired cognition, was care planned for an ADL self-care deficit requiring setup or cleanup assistance with eating, partial to substantial assistance with personal hygiene and oral care, and substantial assistance with toileting, showering/bathing, and lower body dressing. On a morning shift, the resident’s daughter-in-law reported to the LSW that she did not believe the resident had received morning care because he was still in bed wearing pajamas and had not yet received his lunch tray. A CNA statement indicated the resident had eaten breakfast and was later found asleep in bed, and CNA documentation for that shift showed the dressing task as completed. However, the facility’s follow-up summary documented that the CNA confirmed care had not been provided to the resident prior to being questioned by the RN supervisor, and the LSW confirmed that the CNA changed the resident only after the family reported the concern and nursing was notified.
Failure to Provide Adequate Supervision and Assistance During Bed Mobility for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for a resident with significant functional and cognitive impairments. The resident was admitted with left-sided weakness after a stroke and was care planned as extensively to totally dependent for bed mobility, requiring the support of two persons. A fall risk evaluation documented a score of 10, indicating high fall risk, and a quarterly MDS assessment showed the resident was unable to participate in a cognitive assessment and was completely dependent on staff for all ADLs. Despite these identified needs and risks, the resident was being turned onto their side for peri care by an aide when they fell from the bed to the floor. During this incident, the resident sustained head trauma and a small scalp laceration, and was on blood thinners at the time of the fall. The fall occurred while the aide was providing peri care and turning the resident, but the report does not document the presence of a second staff member, despite the care plan indicating the need for two-person assistance for bed mobility. The facility’s own policy on falls emphasized instituting individualized practices to minimize fall risk and maximize safety for residents identified as high risk, but the resident’s documented high fall risk and total dependence were not adequately addressed in the supervision and assistance provided at the time of the fall.
Failure to Ensure Safe Discharge with Confirmed Home Services and Support
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s discharge home included confirmed durable medical equipment (DME), home health services, and adequate caregiver support. The resident was admitted with spinal stenosis, cervical disc disorder, muscle weakness, carpal tunnel syndrome, and a recent post-fasciotomy to the right arm, and was documented as cognitively intact with a BIMS score of 14/15. Despite these physical limitations, the facility discharged the resident home in the evening via medical transport to a three-story residence, where no caregiver support was present. The facility’s own policy required a post-discharge plan of care developed with the resident and representative, and orientation to ensure a safe and orderly transfer or discharge, but the record lacked evidence that services were confirmed as in place prior to discharge. Prior to discharge, the social worker documented that the resident would have a safe discharge home with services and supports in place, and that referrals for home health care, skilled nursing services, and DME had been made, with family members in attendance at the discharge care plan. However, the clinical record did not contain confirmation that these services were actually arranged and active before the resident left the facility. The resident was discharged with medications called to the pharmacy for home delivery, but there was no documentation that the hospital bed had been delivered or that home health nursing, therapy, or home health aide services were scheduled to start at the time of discharge. The social worker later acknowledged not informing the agency of a specific start-of-care date, assuming the agency and VA would contact the resident, and confirmed not calling to verify delivery of the hospital bed. After discharge, it was discovered that the hospital bed ordered days earlier was not delivered until the morning after the resident arrived home, and that therapy, RN, and HHA services had not yet begun or contacted the resident by the time the facility followed up. The resident reported living alone, being unable to use their hands, needing a caretaker, and having to rely on a sister-in-law for limited assistance with hygiene, meals, and rearranging furniture for the bed that arrived later. The significant other confirmed that no one lived with the resident, that they had their own health issues, and that neither they nor their son stayed with the resident after discharge. When a home health RN eventually visited, the resident was found sitting on a couch in minimal clothing, reporting not having eaten adequately for two days, having little or no accessible food, and being unable to open medications or bottles due to impaired fine motor skills. The RN observed the resident’s inability to grip or perform fine motor tasks, assisted with toileting, and then contacted the agency director and emergency services due to the unsafe conditions in which the resident had been left. These events led surveyors to determine that the facility failed to ensure services and caregiver support were in place prior to discharge, resulting in an immediate jeopardy situation.
Removal Plan
- Audited discharge documentation related to home health services, appropriate caregiver/family support, and any necessary services to meet residents' care needs to determine if any residents were affected.
- Reviewed planned discharges by the Administrator, DON, Director of Social Services, and Director of Rehabilitation to ensure home health services, appropriate caregiver/family support, and necessary services to meet the resident's care needs are in place before discharge.
- Completed a root cause analysis identifying failure to have a robust discharge care plan meeting with the interdisciplinary team (IDT), resident, and resident representative.
- Reviewed the procedure for safe and effective discharge planning with the IDT.
- Re-educated the discharge planning IDT on the discharge policy and procedure to ensure sufficient preparation and orientation for a safe discharge.
- Implemented review of residents scheduled to be discharged to ensure appropriate discharge planning is in place.
- Implemented review of residents scheduled for discharge to ensure ADL support is in place, durable medical equipment is available prior to or on the discharge date, medications are available upon discharge, and identified needs/support are available.
- Implemented review of residents scheduled for discharge to ensure safe discharge planning is in place and to address any issues identified.
- Implemented oversight during utilization review by the NHA/designee to ensure discharge planning preparation and services are in place prior to discharge.
- Initiated audits and educational in-services to the IDT team and conducted staff interviews to confirm education received regarding discharge to the community and/or transfers to other facilities.
Failure to Maintain Adequate Hydration Resulting in Recurrent AKI and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate hydration for a resident with significant medical conditions, including acute kidney injury (AKI), congestive heart failure (CHF), dementia, and Parkinson’s disease. Upon admission, the resident’s care plan identified potential for altered nutrition and included interventions such as assisting at meals, encouraging oral fluids, and monitoring for additional nutrition interventions. A nutrition assessment established an initial fluid goal of 1943–2098 mL/day and documented that the resident was at risk for dehydration and malnutrition, with early labs showing a BUN of 29, creatinine of 1.4, and eGFR of 53. The admission MDS documented that the resident was severely cognitively impaired and required setup assistance for feeding and hydration. Daily fluid intake records from CNA task flow sheets and the MAR showed that the resident’s intake frequently fell below the recommended fluid goals, with multiple days of intake under 1200 mL and some days as low as 360–720 mL. A malnutrition risk assessment identified the resident as at risk for malnutrition due to severe dementia and tremors. A subsequent nutrition note on 5/12/25 documented that the resident’s average fluid intake was 330 mL/day, recommended discontinuing a prescribed hydration pass due to CHF, and set a new fluid goal of 1635–1766 mL/day, while continuing to recommend encouraging oral fluids. Despite these documented risks and low intakes, there is no evidence in the record of intensified monitoring or additional interventions to ensure the resident met the revised fluid goals. The resident experienced multiple clinical deteriorations associated with poor intake and changes in condition. On 6/1/25, after a day with only 360 mL of recorded intake, the resident was transferred to the hospital following falls, hypotension, and confusion, and was admitted with AKI and dehydration. After readmission to the facility, nursing documentation noted low oral intake and a plan to discuss adding the resident to an assist-to-feeding list, but the record lacked evidence that this occurred. Subsequent notes documented lethargy, increased confusion, agitation, restlessness, and continued poor intake, yet a physician progress note following two unwitnessed falls did not include an assessment of hydration status or interventions to improve hydration. On 6/19/25, labs showed a BUN of 62 mg/dL and creatinine of 1.7 mg/dL, and the resident was again sent to the hospital and admitted with AKI, hypotension, and anemia, requiring IV fluid resuscitation. Staff interviews confirmed expectations to monitor intake, encourage fluids, and notify providers when fluid goals were not met, but there was no documentation that the provider was consistently notified or that appropriate interventions were implemented in response to the resident’s ongoing inadequate fluid intake and changes in condition.
Failure to Arrange Timely Home Health Services Prior to Discharge
Penalty
Summary
The facility failed to ensure a timely referral for home health care services prior to discharge for one resident. Facility policy dated 5/1/25 required sufficient preparation and orientation to residents to ensure an orderly transfer or discharge. The resident was admitted on 7/28/25 with diagnoses including aortic valve replacement, aortic regurgitation, and congestive heart failure. A discharge summary dated 8/11/25 documented a post-discharge plan for home health aide, home health RN/LPN, and occupational and physical therapy. The resident was discharged home with a family member on 8/12/25. A complaint received by the Division on 9/30/25 stated that the resident was discharged to a family member's home without a home health care agency referral and that, after one week at home, the resident had not received any physical or occupational therapy or a wellness check from a nurse. During an interview on 2/16/26, the social worker reported needing to check if a referral was made and later confirmed that the referral for home health and therapy services was not requested until 8/15/25, with services opened on 8/20/25. The director of therapy confirmed that physical and occupational therapy were recommended for the resident and stated that such recommendations are typically communicated to social services to set up home care. Findings were reviewed with facility leadership during the exit conference.
Failure to Revise Care Plans and Involve Resident in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise person‑centered care plans and to involve a cognitively intact resident and/or representative in the care planning process. One resident with an intact BIMS score of 15 was admitted and had a documented care conference shortly after admission, but there was no evidence of any subsequent care conferences during the following year despite multiple care plan updates. The resident reported not recalling quarterly care plan meetings, and staff confirmed that no care conferences occurred after the initial one, with no documentation that the resident or representative participated in the later care plan revisions. Additional residents’ care plans were not revised to reflect current, individualized needs and behaviors. One resident had a physician’s order for a right palm protector or substitute, was repeatedly observed without it in place, and routinely refused it according to nursing and CNA interviews, yet the care plan did not address potential refusals. Two cognitively impaired residents whose MDS assessments documented dependence for bathing had care plans that continued to list only setup assistance or one‑person assist, without updating to reflect full dependence. Another cognitively impaired resident with documented combative behaviors toward staff and a reported incident of striking another resident with a remote had a behavior care plan that was not revised to include the new behavior of attempting to hit other residents or the potential for resident‑to‑resident altercations.
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