Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wilmington Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, stroke, DVT, HF, and anticoagulant use had a visible head injury that was seen by staff but not promptly reported, assessed, or followed with ordered neuro checks. Nursing staff across shifts failed to document or escalate the change in condition, and the resident was later found unresponsive and sent to the hospital for emergency surgery for a massive brain bleed. The report also describes delayed follow-up of abnormal labs and IV fluid orders for other residents, including AKI and hospital transfer.
A resident with diabetes and stroke had orders for pre-meal blood sugar checks, sliding-scale insulin, and scheduled heparin injections. The eMAR showed missing evidence that an LPN and other nurses completed ordered blood sugar monitoring and administered or documented insulin and heparin doses on multiple occasions, and staff interviews did not clarify why the entries were left blank.
A resident with cognitive impairment, poor memory, and muscle weakness fell forward out of her wheelchair while being wheeled in her room, sustaining a laceration to the eyebrow and a hematoma below the eye. The investigation stated that a housekeeping employee transported the resident in the wheelchair when her feet became stuck, and the facility record noted that footrests should be attached before wheelchair transport and that housekeeping staff should not transport residents in wheelchairs.
A resident with significant physical impairments and intact cognition reported that a CNA ignored his refusal of care, pulled open his brief, turned him with her leg, and applied wound cleanser to a sensitive peri-area wound despite his objections, leaving him upset and describing the encounter as assaultive. In a separate incident, a resident with dementia-related behavioral disturbance wandered into another resident’s room and struck that resident with a walker while staff were trying to redirect him, causing crying and a bruise to the hand.
Delayed Toileting and Personal Hygiene Care for Dependent Residents: A resident with ESRD, amputations, and a perineal wound was left in a soiled brief for about two hours after asking to be changed because staff deferred care until after dinner. Another dependent resident with severe cognitive impairment and hospice services was found saturated in urine and stool with two briefs on and a trash liner under the drawsheet. A third resident reported pressing the call light for help after a BM and waiting hours while staff said they were busy or unavailable.
Failure to timely report injuries, abuse, and neglect: A dependent resident with severe cognitive impairment and total transfer dependence was found with a hematoma and bruising to the forehead/eye area, but the injury was not reported to the State Survey Agency for more than 26 hours. Multiple CNAs, an AA, and an LPN observed the injury during care and rounds, yet the findings were not consistently escalated or documented. The facility also delayed reporting alleged neglect and other resident allegations, including missed care and a staff member not returning to provide care for the rest of a shift.
A resident with severe cognitive impairment and a neck fracture was not initially given an early lunch tray or a bagged lunch before an afternoon neurosurgeon appointment. A CNA told the resident lunch would be eaten later after the appointment, and an LPN said the resident would eat when he returned and initially reported no bagged lunch had been provided. After surveyor intervention, the LPN offered the resident a choice of a quick lunch or a bagged lunch, and the resident chose the bagged lunch.
A resident with a neck fracture and severe cognitive impairment repeatedly removed or refused to wear a prescribed neck collar when out of bed. Nursing notes documented frequent removal, and staff observed the resident out of bed and in the dining room without the collar in use. An LPN confirmed the refusal was not documented in the care plan as an identified behavior problem.
A resident with hyponatremia and electrolyte derangements had ordered CBC/CMP testing that was not completed after a difficult blood draw, and nursing notes did not show physician notification of the failed collection. The same resident’s stat lab order was not promptly followed up, and abnormal results were later faxed without immediate notification to the PA; staff described confusion during a lab vendor transition and lack of timely result reporting.
Incomplete and Backdated Nutrition Assessments in Resident Record: The facility failed to maintain accurate clinical records for a resident reviewed for nutrition. The resident was admitted, had one nutrition assessment completed by the contract RD, and was later transferred to the hospital and discharged. After discharge, the DON produced additional nutrition assessments dated earlier in the stay but signed later by another RD who stated she had never met the resident, and the contract dietary agency owner said she entered the information from notes and signed and dated it herself.
The facility failed to identify and correct a resident’s significant medication errors involving blood sugar checks, heparin, and insulin injections, and also failed to identify and correct quality issues related to the resident’s nutrition and hydration status that led to emergent hospitalization. The NHA confirmed these issues during the QAPI interview, and the findings were reviewed with the NHA, DON, and CRN at exit conference.
Failure to Follow Contact Precautions: Two residents were on contact precautions, one for MRSA and one for C-diff, but staff did not follow posted PPE requirements. An RN entered one resident’s room wearing only gloves while administering an injection, and a contracted dietician entered another resident’s room without gown and gloves after being told PPE was not needed if only asking questions.
A resident with stroke and dementia was found in bed on top of a plastic trash bag wearing two incontinence briefs, and another resident with intact cognition reported being left soiled for hours after requesting toileting/incontinence care. The events involved a hospice RN, CNA, and other nursing staff, and the resident stated the delay in care affected her self-esteem.
A resident’s STAT chest x-ray showed significant abnormal findings, including CHF, interstitial edema, cardiomegaly, pulmonary vascular redistribution, and bibasilar infiltrates, but the physician was not immediately notified. Nursing notes showed the result was left for the MD to review and was not reported to the on-call physician until the next morning, two days after the STAT order. The DON confirmed the result was not called in right away and was left in the MD’s book.
Failure to protect resident privacy and confidentiality was identified for two residents when handwritten care notes were observed posted in the hallway on top of enhanced barrier precaution signs outside their rooms. The notes included personal care details such as whether the residents were wet, when they were changed, and when they were checked, and an RN/IC confirmed the observations.
Failure to Thoroughly Investigate a Neglect Grievance: A cognitively intact resident who required assistance with toileting and incontinence care reported that after using the call bell for help with a BM, staff said they would return but did not change her for several hours. The grievance record did not identify who received the complaint or the findings of the investigation, and the DON could not produce investigation documents or identify the CNA and RN supervisor allegedly educated about the incident.
A resident with COPD and acute respiratory failure did not receive respiratory care as ordered and as outlined in the care plan. The record showed oxygen ordered at 2 LPM via NC every shift with saturation to remain at or above 92%, yet the chart included multiple room-air oxygen entries and two readings of 78% without documentation that they were errors or that the provider was notified. During observation, the resident was found without the NC in place, and an LPN obtained an O2 saturation of 82% before a second reading showed 95% and then 98%.
Unsecured and expired medications were found in an unlocked closet and on a medication cart, including blister packs for two residents with expired use-by dates and one pack missing tablets. An LPN/UM confirmed the medications should not have been stored in an unlocked, unsupervised closet and that expired meds should have been disposed. In a separate finding, a resident with dementia had an unused nystatin powder bottle in a bedside drawer instead of the treatment cart, and the LPN/UM confirmed it was stored in the wrong place.
A resident with cough and congestion had a STAT chest x-ray ordered, but the x-ray was not completed until more than 31 hours later. The radiology results showed significant findings, yet the result was not promptly reported to the physician; instead, it was left in the MD book and later communicated to the on-call physician. The DON confirmed the delay, and staff interviews showed confusion about whether the order was STAT.
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.
Failure to Assess and Report Head Injury and Abnormal Clinical Changes
Penalty
Summary
The facility failed to provide adequate treatment and care for a cognitively impaired, dependent resident who had a visible head injury. The resident had diagnoses including stroke, DVT, heart failure, and dementia, and was receiving aspirin and Eliquis. A CNA observed discoloration on the right side of the resident’s forehead around 6:00 AM and did not tell the nurse. The injury was later seen again during the next shift, but the CNA still did not report it. Nursing staff were informed of the bruising and swelling around 8:30 AM, yet the injury was not appropriately assessed or documented at that time, and neurological checks were not initiated as required by the facility’s neurological assessment guidance. Multiple staff members failed to identify, assess, or communicate the change in condition across shifts. The LPN who was informed of the bruise stated she checked the resident’s vital signs and neuros but did not document the findings, notify the provider, or tell the oncoming nurse. Another LPN on the later shift stated she did not see bruising or swelling, and a CNA on the evening shift said she saw the bruise but assumed staff already knew about it because of a fall mat near the bed. The facility record showed no evidence that the resident’s neurological status was monitored or that the provider was notified of the swelling and discoloration on the right side of the face. The resident was found unresponsive in bed more than 26 hours later and was sent to the hospital, where emergency surgery was performed for a massive brain bleed. A forensic nurse examiner stated the resident was completely unconscious on arrival, went immediately to surgery, and had approximately one quarter of the brain filled with blood. The report also includes additional deficiencies involving another resident whose abnormal lab results were not timely followed up, resulting in delayed treatment and hospital transfer for acute kidney injury, failure to administer ordered IV fluids when dehydration developed, and delayed care after a change in condition with critical labs and ICU admission.
Missed blood sugar checks and omitted insulin and heparin documentation
Penalty
Summary
R11 was admitted with diagnoses including diabetes and stroke and had physician orders for heparin sodium injections every eight hours for blood clot prevention, insulin lispro by sliding scale for diabetes, and blood sugar checks before meals. The facility’s record showed that from 2/1/26 through 2/14/26, R11 received insulin lispro coverage based on finger stick blood sugar results most of the time, but there were missed or refused opportunities documented during that period. On 2/15/26, the eMAR for medications given by E40, an LPN, lacked evidence that R11’s 12:00 PM blood sugar was monitored, lacked evidence that the ordered sliding scale insulin was administered or documented as not indicated, and lacked evidence that the 2:00 PM heparin injection was administered. On 2/16/26, the eMAR again lacked evidence that the 7:30 AM and 12:00 PM blood sugar checks were monitored, lacked evidence that the ordered insulin was administered or documented as not indicated, and lacked evidence that the 2:00 PM heparin injection was administered. Additional record review showed that on 2/25/26, 3/11/26, and 3/18/26, the eMAR lacked evidence that the 10:00 PM heparin injection was administered when documented as given by different nurses. Interviews with nursing staff and the PA reflected that they did not recall the missing documentation or receiving notification about unavailable medications, and the facility confirmed that the record lacked evidence that the blood sugar checks, insulin, and heparin injections were completed on the dates in question.
Failure to Provide Safe Wheelchair Transport
Penalty
Summary
The facility failed to ensure that one resident, admitted with diagnoses including right hip pain and heart failure, received adequate supervision and assistive devices to prevent accidents to the extent possible. The resident’s fall care plan identified her as at risk for falls related to cognitive impairment, poor memory, and muscle weakness, and her admission MDS documented a BIMS score of 00 and the need for partial to moderate assistance with wheelchair mobility. The resident fell forward out of her wheelchair while a staff member was wheeling her in her room, resulting in a laceration to the left eyebrow and complaints of right hip pain. Later, she was found lying on the floor near her room entrance with a hematoma below her left eye and was sent to the ER for evaluation. The facility’s investigative document stated that the resident asked a housekeeping employee to wheel her to her room, and the employee pushed her in the wheelchair when her feet became stuck and she fell out. The facility’s education document stated that footrests should be attached before transporting a resident in a wheelchair and that housekeeping staff should not transport residents in wheelchairs.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure a cognitively intact resident with end stage renal disease, blindness in one eye, recent amputations, and dependence on staff for toileting hygiene and transfers remained free from physical and emotional abuse during early morning incontinence care. The resident reported that a CNA entered his room, ignored his statement that he did not want care, pulled his brief down to check for urine or stool, and used her leg to turn him on his side. He also reported that the CNA sprayed wound cleanser on his peri-area despite his telling her it stung and asking her not to use it. The resident stated he slapped the spray container away, described the encounter as aggressive, and was upset and angry when recounting it to surveyors. Facility records showed conflicting accounts of the same event, but the resident’s statements consistently described unwanted and aggressive care. The grievance and investigation notes documented that the resident said the CNA continued care after he told her to stop, that she pulled his brief open, and that she used cleanser on a sensitive groin wound area. The resident was found wearing two briefs, and the facility documented that he felt the CNA did not believe him when he said he had not urinated in years. Surveyor interviews with therapy and nursing staff confirmed the resident was agitated and very angry when describing the incident. The facility also failed to ensure a resident in the locked dementia unit remained free from physical abuse by another resident. A resident with dementia-related behavioral disturbance, delusions, impaired judgment, and a history of physical aggression wandered into another resident’s room and struck the resident with a walker while staff were attempting to redirect him. The injured resident was crying and said, "he hit me," and a bruise was noted on the back of the right hand. Staff records described the aggressive resident as confused, yelling, and refusing to leave the room when the incident occurred.
Delayed Toileting and Personal Hygiene Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary personal hygiene and toileting care for dependent residents. For one resident with end stage renal disease, recent amputations, blindness in one eye, and a perineal wound, staff deferred his request to be changed after he returned from dialysis incontinent of bowel. He remained in a soiled incontinence brief for about two additional hours because staff told him they would change him after dinner, and the resident stated he was not changed until after 7:00 PM despite asking upon return to the facility. The resident was cognitively intact and required substantial to maximal assistance with toileting hygiene and transfers. He reported that he had a bowel movement at dialysis, could not use the bathroom there because of his inability to walk, and became emotional and angry when describing that he was told residents are not changed during mealtimes. Staff interviews confirmed that the assigned CNA told him she would change him after dinner, and the RN supervisor stated that all CNAs were in the process of dinner and no one was available. The facility also stated it did not have a policy about not changing a resident during meals. The facility also failed to ensure another dependent resident received timely hygiene care. That resident had stroke, dementia, severe cognitive impairment, was totally dependent for toileting and personal hygiene, and was always incontinent of bowel and bladder while receiving hospice services. During care, staff found the resident with two briefs on, one inside the other, and a plastic trash can liner under the drawsheet. The resident was saturated in urine with significant loose stool and redness to the sacral area and down the left leg, and staff statements indicated the condition appeared to have been present for some time. A third resident, who was cognitively intact and required assistance with toileting and brief changes, also reported delayed care after a bowel movement. The resident stated that after pressing the call light and telling staff he needed to be changed, he was told an aide would return but did not receive help for hours and sat in feces for an extended period. Staff interviews reflected that aides were busy, that one aide told the resident she would be back, and that another aide later said there were no aides available. The resident stated he reported the incident to facility leadership.
Failure to Timely Report Injuries, Abuse, and Neglect
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, and injuries of unknown origin to the State Survey Agency for four residents. One dependent resident with diagnoses including stroke, deep vein thrombosis, heart failure, and dementia had a BIMS score of 5 and required substantial to maximum assistance for bed mobility and total dependence for transfers. That resident was found with a hematoma to the right forehead and bruising around the right eye, but the injury was not reported to the State Survey Agency until more than 26 hours after it was first observed. Staff interviews showed that the resident’s head injury was seen by multiple employees during the overnight and morning shifts, but it was not consistently reported up the chain of command. A CNA stated she noticed discoloration on the resident’s forehead during the night and again later in the shift but did not tell the nurse. Another CNA and an AA saw bruising and swelling in the morning and told the unit manager or nurse, while the unit manager stated she did not assess the resident, notify the DON, update the provider, or document the change. The LPN who checked the resident later in the morning stated she saw a mildly raised area on the forehead, did not report it to anyone, did not document the neurological check, and did not tell the next shift nurse. The facility also failed to report incidents involving alleged abuse and alleged neglect within the required timeframe and failed to submit a required follow-up report. One allegation involved a resident who stated that a staff member did not return to provide care for the rest of the shift after assisting her to bed, and the facility incident report was submitted to the State Agency forty hours after the required reporting timeframe. The report also documents other resident allegations involving missed care and upset residents, with staff interviews noting that call lights were on, residents were upset, and a staff member did not provide hydration or snacks during the shift. Findings were reviewed with facility leadership during the survey process.
Failure to Support Resident Choice for Lunch Before Appointment
Penalty
Summary
The facility failed to ensure that one resident was given the right to self-determination through support of resident choice when the resident was not provided an early lunch tray or a bagged lunch before an afternoon neurosurgeon appointment until the surveyor intervened. The resident had been re-admitted with diagnoses including a neck fracture, and the quarterly MDS documented a BIMS score of 5 indicating severe cognitive impairment, while also noting adequate hearing and vision, clear speech, and independence with eating. The resident’s appointment was documented in the clinical record, and during observation in the dining room, staff were seen passing lunch trays to residents while the resident was present in a wheelchair. A CNA told the resident that the food tray was not there and that lunch would be eaten later after returning from the appointment. An LPN stated that the resident would eat lunch when returning from the 1:30 PM appointment and initially said no bagged lunch had been brought. After the surveyor stated it would be past lunch time when the resident returned, the LPN said she would try to ask the kitchen for a bagged lunch. The LPN then asked the resident whether he wanted a quick lunch in the dining room or a bagged lunch to take, and the resident chose a bagged lunch and requested soda in it. The resident’s father stated he appreciated that a bagged lunch was offered and said they did not want to miss the appointment even if lunch would be served late.
Failure to Care Plan Repeated Refusal to Wear Neck Collar
Penalty
Summary
The facility failed to develop a person-centered care plan to address R10’s repeated refusal to wear a neck collar when out of bed. R10 was re-admitted with diagnoses including a neck fracture, and the quarterly MDS documented severe cognitive impairment with a BIMS score of 5. A physician’s order directed that the neck collar be worn when out of bed every shift and monitored, but nursing progress notes repeatedly documented that the collar was frequently removed or refused. Observations and interviews showed R10 out of bed in a wheelchair and later in the dining room without the neck collar in use. During an interview, R10 stated the collar was uncomfortable. A CNA stated that R10 was supposed to wear the collar when not in bed but liked to take it off, and an LPN confirmed that multiple nursing notes documented refusal to wear the neck collar. The LPN also stated that this refusal was not documented in the care plan as an identified behavior problem.
Failure to Follow Up on Ordered and Stat Lab Results
Penalty
Summary
The facility failed to provide timely laboratory services for one resident when ordered lab work was not followed up after a failed specimen collection. The resident had a physician order for CBC and CMP for hyponatremia, and a lab report documented that the specimen was not obtained because of a difficult draw and that the lab should be rescheduled. The resident’s nurse progress notes did not show that the physician was notified that the CBC and CMP were not completed after the unsuccessful blood draw. During interview, the CRN stated that a phlebotomist attempted the draw but could not obtain the specimen, and that another draw was supposed to occur the next night but did not happen because staff did not know whether it was to come from one lab vendor or another during a change in service providers. The facility also failed to ensure timely reporting and follow-up of a stat lab order for the same resident. The resident had a stat order for CBC, CMP, magnesium, phosphate, B12, folate, and Vitamin D for electrolyte derangements, but the progress notes lacked evidence that nursing staff followed up on the results. Lab results were faxed later and showed abnormal values including elevated phosphorus, BUN, creatinine, and WBC, along with low hemoglobin and low sodium. The PA stated he was not immediately notified of the stat lab results and believed it was over the weekend, while an LPN stated that nurses should call and follow up with the lab and notify the physician, especially for critical results and a change in condition.
Incomplete and Backdated Nutrition Assessments in Resident Record
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards for one resident reviewed for nutrition. R11 was admitted on 1/17/26, had a nutrition assessment completed by the contract RD on 1/19/26, and was transferred to the hospital on 3/26/26 at 2:00 PM. A review of the electronic health record on 5/4/26 showed only that single nutrition assessment in the evaluation/assessment tab. During the survey, the DON confirmed that R11 was discharged from the facility on 3/26/26 and did not return after the hospital transfer. On 5/5/26, the DON presented copies of nutrition assessments dated 2/19/26 and 3/17/26 that had been completed by another RD and signed that same day, 5/5/26. The interim RD stated she had never met R11 and never completed a nutritional assessment for R11, and the owner of the contract dietary agency stated she typed the information into the template from the contract RD's risk management notes, signed it, and dated it on 5/5/26, while also stating she had not personally met R11 for a nutrition assessment.
Failure to Identify and Correct Significant Medication Errors
Penalty
Summary
The facility failed to identify and correct R11’s significant medication errors involving blood sugar checks, heparin injections, and insulin injections from 2/15/26 to 3/18/26. During the QAPI interview, the NHA confirmed that the facility also failed to identify and correct quality issues related to R11’s nutrition and hydration status, which resulted in emergent hospitalization on 3/26/26. The report further states that these issues were reviewed with the NHA, DON, and CRN during the exit conference.
Failure to Follow Contact Precautions
Penalty
Summary
The facility failed to ensure infection control and prevention practices were followed for two residents on contact precautions. One resident had an active physician order for contact precautions for MRSA. During observation, a contact precautions sign and an isolation cart with PPE were present outside the resident’s room, but an RN entered the room to administer an injection while wearing only gloves. When interviewed after leaving the room, the RN confirmed that a gown should have been worn before entering. Another resident had a physician order for contact precautions for C-diff. During a telehealth visit for vomiting, a contracted dietician asked an LPN whether PPE was needed before entering the resident’s room if only asking questions, and the LPN said no. The dietician then entered the room without applying PPE, despite a posted contact precautions sign outside the room instructing staff to apply gown and gloves before entry and an isolation cart with PPE available nearby. The surveyor reported the observation to the DON and CRN, and an inservice record later showed the dietician had been instructed on isolation requirements.
Failure to Maintain Resident Dignity During Incontinence Care
Penalty
Summary
The facility failed to ensure dignity for two residents during assistance with activities of daily living. One resident with diagnoses including stroke and dementia was found during care lying in bed on top of a plastic trash bag, wearing two incontinence briefs, with a plastic trash can liner underneath a drawsheet. A hospice RN and a CNA discovered the condition during rounds, and the incident was later reported in the facility’s incident report. Another resident with polyneuropathy, intact cognition, and a care plan requiring one staff member for toileting hygiene and incontinence care reported that after activating the call bell for a bowel movement, staff did not return to change her for hours. The resident stated she was left sitting in feces for about four hours after requesting help, and the grievance summary documented the delay in care and that a CNA and Nursing Supervisor received education.
Delayed Physician Notification of Abnormal STAT Chest X-ray
Penalty
Summary
The facility failed to ensure that the physician was immediately consulted when a resident’s stat chest x-ray showed significant abnormal findings. For R9, the record showed increased congestion on 6/5/26, and a nurse documented that the NP was made aware and gave a verbal order for a STAT chest x-ray. The chest x-ray was ordered for cough and congestion, and the radiology report later documented moderate congestive heart failure, moderate interstitial edema, cardiomegaly, pulmonary vascular redistribution, peribronchial cuffing, and bibasilar infiltrates, right greater than left. The record did not show that the physician was consulted when the abnormal chest x-ray result was received. Nursing documentation indicated the x-ray was pending on the evening of 6/6/26, then noted on the morning of 6/7/26 that the results were back and the MD would review them and give further instructions. The result was not reported to the on-call physician until the morning of 6/7/26, two days after the STAT x-ray order. During interviews, the LPN stated the result was reported to the on-call physician on the morning of 6/7/26 and that new orders were received for guaifenesin, azithromycin, and Lasix. The DON confirmed that the nurse who received the radiology report that evening or night shift did not immediately call the physician and instead left it in the MD’s book.
Failure to Protect Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to respect each resident's right to personal privacy and confidentiality of personal care for two residents. In the hallway outside of one resident's room, surveyors observed a ripped piece of white paper thumbtacked on top of an enhanced barrier precaution sign with handwritten notes stating, "NOT WET @ 5:55 AM 07/09/26." In the hallway outside of another resident's room, surveyors observed a similar ripped piece of white paper thumbtacked on top of an enhanced barrier precaution sign with handwritten notes stating, "CHANGED @ 4:50 CHECKED AGAIN @ 6:03 AM NOT WET 07/09/26." An RN/IC confirmed both observations during interview, and the surveyor later reviewed the observations with the DON and CRN.
Failure to Thoroughly Investigate a Neglect Grievance
Penalty
Summary
The facility failed to have evidence of a thorough investigation of a neglect allegation involving a resident who was cognitively intact with a BIMS score of 15 and who required assistance from one staff member for toileting, toileting hygiene, and brief changes. The resident was also documented as frequently incontinent of bowels and dependent for transferring to the toilet, with supervision or touching assistance needed for toileting hygiene. The grievance summary recorded the resident’s report that she turned on her call bell at 10:10 PM, an aide said she would return after being told the resident needed to be changed, and the resident stated she was not changed until 2:00 AM. The grievance documentation did not identify who the resident reported the concern to or the result of the findings, and it stated only that education was completed with the CNA and supervisor on duty. During survey interviews, the DON stated that the grievance had been marked resolved and that another RN UM had done the investigation and education, but the requested investigation documents could not be produced. The DON also could not identify the CNA or supervisor who were allegedly educated, and both the CNA and RN Supervisor assigned to the resident denied being aware of the incident or receiving education about it.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for a resident admitted with COPD, acute respiratory failure, and lung cancer. The resident’s care plan directed staff to administer oxygen as ordered and monitor pulse oximetry with clinician notification per parameters. The physician order summary documented oxygen at 2 LPM via nasal cannula every shift for COPD and to maintain oxygen saturation at or above 92%. The clinical record documented two oxygen saturation readings of 78% on room air, but there was no documentation that these readings were entered in error or that the physician was notified. Review of the vitals section from 6/1/26 through 6/30/26 showed eleven oxygen saturation entries documenting room air as the method of oxygen delivery. During observation, the resident was found in bed without the nasal cannula in place, and when the LPN applied it and obtained an oxygen saturation, the resident’s reading was 82%. A second pulse oximeter then showed 95%, and the first pulse oximeter later showed 98%.
Unsecured and Expired Medication Storage
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when an unlocked, unlabeled closet at the end of the locked dementia unit was found to contain a brown box of residents’ blister-pack medications. The box was labeled "Backup meds Arcadia Front" and contained medications for R24 and R15. E21, the LPN/UM, stated the closet was not used and could not explain why the medications were stored there. The box contained multiple expired blister packs for R24’s spironolactone 25 mg tablets and R15’s diltiazem 60 mg tablets, and one of R15’s blister packs was missing 2 tablets. E21 later confirmed that the residents’ medications should not have been stored in an unlocked, unsupervised closet and that the expired medications should have been properly disposed. Additional observations of the front medication cart assigned to E10, an LPN, showed more expired medications for R24 and R15. R24 had two Aldactone 25 mg blister packs with expired use-by dates, and R15 had one diltiazem 60 mg blister pack with an expired use-by date. In a separate finding, R14, who was admitted with dementia and had severely impaired cognition on the quarterly MDS, had an unused bottle of nystatin powder in the drawer of the bedside table. R14 stated that nursing staff never put it on him, and E21 confirmed the powder should have been kept in the treatment cart rather than in R14’s drawer.
Delayed STAT Chest X-ray and Late Reporting of Results
Penalty
Summary
The facility failed to provide a STAT chest x-ray when ordered for a resident with cough and congestion and failed to promptly report the x-ray results to the ordering practitioner. On 6/5/26 at 9:21 AM, a nurse documented that the NP was made aware of the resident and gave a verbal order for a STAT chest x-ray. The resident also had a physician order for a chest x-ray with two views at 3:00 PM the same day. However, the radiology record shows the chest x-ray was not completed until 6/6/25 at 4:54 PM, which the DON later confirmed was more than 31 hours after the STAT order was given. The radiology results report documented significant findings at 9:07 PM on 6/6/26, but the result was not promptly communicated to the physician. A nurse note at 6:13 AM on 6/7/26 stated the chest x-ray results were back and the MD would review them and give further instructions, and another note at 9:43 AM documented that the result was reported to the on-call physician. During interviews, the DON confirmed the delayed x-ray and stated the nurse who received the report from the x-ray company did not immediately call the physician but left it in the MD book. An LPN stated the evening nurse told her it was a regular chest x-ray order, not STAT, and another LPN stated the nurse working before his shift should have notified the on-call NP or MD when the x-ray was not completed right away.
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.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wilmington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Encore At Foulk | 0.7 mi | ★★★★★ | 2 | 0 |
| Cadia Rehabilitation Silverside | 1.5 mi | ★★★★★ | 10 | 0 |
| Encore At Wilmington | 2 mi | ★★★★★ | 6 | 0 |
| Kentmere Rehabilitation And Healthcare Center | 2.2 mi | ★★★★★ | 5 | 0 |
| Gilpin Hall | 2.6 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.