Citations in Delaware
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Delaware.
Statistics for Delaware (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Delaware
Surveyors found that controlled substances storage boxes in two medication rooms were either placed on top of the refrigerator or inside the refrigerator without being permanently affixed, as required. Staff confirmed that these medications were kept in the refrigerators and counted every shift, but the required permanent affixation was not in place. Facility leadership was informed of these findings.
The facility did not report allegations of abuse and an injury of unknown origin within the required two-hour timeframe for two residents. In one case, a hand fracture was reported to authorities about three days after discovery, and in another, a resident-to-resident abuse incident was reported approximately four hours after it occurred.
A resident's medication was found missing, and although the LPN and RN supervisor promptly notified the DON, the incident was not reported to the state agency within the required timeframe. The DON delayed reporting while conducting an investigation, resulting in a nineteen-day gap between the incident and state notification.
A controlled drug administration record for a resident showed a five-capsule discrepancy in morphine reconciliation, with staff unable to account for the missing doses. Interviews with an LPN, RN, and CNO confirmed the documentation error, which was attributed to a clerical or typographical mistake, and no clarification was found in the records.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
Surveyors found that residents were served meals without cups or glasses, requiring them to drink directly from plastic or paper containers, and staff frequently entered resident rooms without asking permission. One cognitively intact resident expressed discomfort with the lack of proper drinkware, and multiple staff members, including LPNs, CNAs, and housekeeping aides, were observed entering rooms without seeking consent, contrary to facility expectations.
Two residents did not have complete, person-centered care plans addressing all their medical needs. One resident with a gastrostomy lacked care plan approaches for tube blockage and dislodgment, while another with chronic pain and opioid use did not have non-pharmacological pain interventions included. Facility leadership confirmed these omissions during interviews.
Two residents did not receive care according to physician orders and professional standards. One resident with a surgical wound did not have a required vascular surgery follow-up appointment scheduled despite multiple recommendations, resulting in hospital transfer for worsening symptoms. Another resident on hospice did not have a hospice plan of care available or integrated into the facility’s care plan, and staff could not access up-to-date hospice interventions.
For eight days, the facility did not post daily nurse staffing information that included the resident census and total hours worked by licensed and unlicensed nursing staff per shift. This deficiency was confirmed through observation, record review, and interviews with facility leadership.
A resident repeatedly requested extraction of her remaining lower teeth and the provision of full dentures, as documented in multiple dental progress notes and interviews. Despite these ongoing requests and the facility's ability to perform extractions, the resident was not scheduled for the necessary procedure, resulting in a significant delay in receiving dental services.
Controlled Substances Storage Boxes Not Permanently Affixed in Medication Rooms
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage of controlled substances in two medication rooms. On multiple occasions, the storage box for controlled substances on the second floor was found placed on top of the refrigerator rather than being secured inside and permanently affixed. In the third-floor medication room, the controlled substances box was inside the refrigerator but was not permanently affixed as required. These findings were consistent over several days of observation. During an interview, a registered nurse confirmed that controlled substances requiring refrigeration were kept in the refrigerators and counted every shift, but did not address the lack of permanent affixation. The findings were reviewed with facility leadership during the exit conference. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Timely Report Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report allegations of abuse and injury of unknown origin within the required two-hour timeframe for two out of six residents reviewed. For one resident, an x-ray report indicating an acute hand fracture was received, but the injury of unknown origin was not reported to the State Agency until approximately three days later. In another case, an incident report documented an allegation of resident-to-resident abuse, but the facility reported the incident to the State Agency about four hours after the altercation. These delays in reporting were confirmed through record review and staff interview.
Delayed Reporting of Suspected Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the state agency within the required timeframe for one resident. According to the facility's abuse policy, all alleged incidents involving misappropriation must be reported to the NHA or designee immediately, and to the state agency within eight hours, or within two hours if serious bodily harm is involved. In this case, a nurse identified that six purple tablets were missing from a resident's medication count and immediately notified the nursing supervisor, who then informed the Director of Nursing (DON). Despite recognizing the incident as an allegation of misappropriation, the DON delayed reporting the incident to the state agency, citing the ongoing investigation as the reason for the delay. The incident, which occurred on July 19, was not reported to the state agency until August 7, nineteen days after the event. Interviews with staff confirmed the delay in reporting, and the deficiency was acknowledged by facility leadership during the exit conference.
Failure to Accurately Document Controlled Drug Reconciliation
Penalty
Summary
The facility failed to ensure the accuracy of medication reconciliation documentation for a controlled drug prescribed to a resident. According to the controlled drug administration record, thirty morphine capsules were received from the pharmacy. Subsequently, one capsule was administered to the resident, and the record indicated that twenty-nine capsules remained. However, the record later showed that twenty-four capsules were destroyed, which did not account for five capsules, resulting in a discrepancy. There was no documentation or clarification in the clinical or drug administration records to explain the missing five capsules. Interviews with facility staff, including the LPN and RN involved, revealed that neither could account for the five-capsule deficit. The LPN confirmed witnessing the destruction of the medications but did not recall any error, while the RN suggested the discrepancy might be a typographical error. The Chief Nursing Officer also acknowledged the discrepancy and referred to it as a clerical error. The issue was reviewed with facility leadership during the exit conference.
Improper Labeling and Storage of Drugs and Biologicals
Penalty
Summary
Drugs and biologicals in the facility were not labeled according to currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in noncompliance with regulations regarding the proper labeling and secure storage of medications and biologicals within the facility.
Failure to Promote Resident Dignity During Meal Service and Room Entry
Penalty
Summary
The facility failed to promote resident dignity in two key areas: meal service and staff entry into resident rooms. Observations revealed that residents, including one who was cognitively intact and had chronic respiratory failure and polyneuropathy, were served meals with only plastic, aluminum-sealed juice containers and paper milk cartons, without any cups or glasses provided. This practice was confirmed by the Director of Dietary, who stated that residents are not given cups or glasses with meals. One resident expressed dissatisfaction with this arrangement, stating a preference for a cup and discomfort with drinking from containers that others touch. Additional observations confirmed that meal trays throughout the unit lacked appropriate drinkware. Surveyors also observed multiple instances where staff, including LPNs, CNAs, housekeeping aides, and a contracted nurse practitioner, entered resident rooms without asking permission, despite sometimes knocking or announcing their presence. In several cases, staff entered rooms while residents were present, and in one instance, a staff member entered without knocking. During an interview, the Director of Nursing confirmed that the expectation is for staff to knock and ask permission before entering resident rooms. These actions were reviewed with facility leadership and management representatives during the exit conference.
Failure to Develop Comprehensive Care Plans for Residents with Complex Medical Needs
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for two residents with specific medical needs. One resident, admitted with a history of stroke, dysphagia, and a gastrostomy, had a care plan that did not include approaches for managing potential complications such as gastrostomy tube blockage and dislodgment. This omission was confirmed by the Assistant Director of Nursing upon review. Another resident, admitted with lupus and chronic pain, had care plans addressing pain and opioid use but lacked evidence of non-pharmacological interventions for pain management. These deficiencies were acknowledged by facility leadership during interviews and the exit conference.
Failure to Follow Physician Orders and Coordinate Hospice Care
Penalty
Summary
Two residents did not receive care and services in accordance with professional standards, their care plans, and physician orders. One resident was admitted with an infection of a left lower extremity amputation stump and had discharge orders to follow up with vascular surgery within 2–7 days. Despite wound care progress notes on multiple occasions recommending vascular surgery follow-up due to worsening wound condition, there was no documentation that the appointment was scheduled. The unit clerk was tasked with scheduling the appointment, but as of the date the resident was transferred to the hospital for increased redness and changes at the surgical site, the appointment had not been made. Another resident, admitted with chronic obstructive pulmonary disease and chronic congestive heart failure, was placed on hospice services. The facility failed to ensure the hospice plan of care was available and integrated into the resident’s comprehensive care plan. Staff interviews revealed that the hospice binder, which should have contained the hospice plan of care, was empty and not accessible at the nurse’s station. The facility-generated care plan did not incorporate the hospice plan, and there was no evidence of collaboration with hospice staff to address the resident’s end-of-life needs and interventions. The DON confirmed that the hospice plan of care was expected to be current and available, but this was not the case.
Failure to Post Required Daily Nurse Staffing Information
Penalty
Summary
For eight consecutive days during the survey period, the facility failed to post required daily nurse staffing information. Specifically, the postings did not include the resident census or the total number of hours worked by both licensed and unlicensed nursing staff per shift, as required. This deficiency was identified through observation and review of the facility's daily nurse staffing postings, which consistently lacked the necessary details. The issue was confirmed during interviews with facility leadership, including the Nursing Home Administrator, and was discussed during the exit conference with additional facility and management representatives. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Provide Timely Dental Extractions and Dentures
Penalty
Summary
A resident was admitted to the facility and, over the course of nearly a year, repeatedly requested dental services, specifically the extraction of her remaining lower teeth and the provision of full dentures. Multiple dental progress notes documented the resident's ongoing requests for extractions and dentures, with the treatment plan reflecting these needs. Despite these documented requests and the resident's continued desire for dental intervention, the necessary extractions and denture process were not initiated in a timely manner. During interviews, the resident reported having four loose lower teeth and expressed frustration at the lack of progress, demonstrating the mobility of one of her teeth. Facility staff confirmed awareness of the resident's requests and the dental team's ability to perform extractions on-site. However, the resident was not scheduled for extractions, and the upcoming dental appointment was only for an initial exam with a new dentist, not for the requested procedure. The delay in providing the required dental services was acknowledged by facility leadership.
Some of the Latest Corrective Actions taken by Facilities in Delaware
- Provided re-education to all staff on abuse and proper reporting procedures (J - F0609 - DE)
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of staff-to-resident abuse involving a resident with severe cognitive impairment. The incident occurred when a Certified Nursing Assistant (CNA) stuck her tongue out at a resident and threw three wipes toward the resident's head during care. Another CNA witnessed the event and reported it to a Licensed Practical Nurse (LPN), but the incident was not reported to the facility's Abuse Coordinator until several days later. During this period, the accused CNA continued to work scheduled shifts in the facility. The resident involved had a history of cerebral infarction, unspecified dementia with agitation, and major depressive disorder, and was assessed as severely cognitively impaired. The incident was witnessed by a second CNA, who reported it to the LPN. The LPN did not escalate the report, believing that keeping the CNA away from the resident was sufficient. Additionally, a Unit Clerk learned of the incident but failed to report it immediately, only recalling to do so days later. The facility's policy required immediate reporting of suspected abuse to the appropriate authorities and immediate suspension of the accused staff member pending investigation. However, the delay in reporting allowed the accused CNA to remain on duty and interact with other residents. The deficiency was identified during a survey, which found that the facility did not follow its own policy or regulatory requirements for timely reporting of abuse allegations.
Removal Plan
- Implemented a Removal Plan to address the deficient practice
- Developed a Performance Improvement Plan (PIP) in response to the incident
- Reviewed the Performance Improvement Plan (PIP)
- Selected residents randomly for review regarding abuse
- Provided re-education to all staff for abuse and the proper reporting of abuse
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