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 observed mold on ceiling tiles in the dry food storage room and inside the tubing of the kitchen juice machine, indicating a failure to store and serve food and beverages in accordance with professional standards.
Two residents with severe cognitive impairment experienced escalating verbal and physical conflict over several weeks, with one resident exhibiting increasing aggression and behavioral disturbances. Despite repeated documentation of these behaviors and ongoing roommate conflict, the facility did not revise care plans, increase supervision, or notify the social worker. The situation culminated in a physical altercation where one resident sustained a head injury and required hospital evaluation.
A resident who was completely dependent and required two-person assistance for bed mobility and transfers was left unsupervised by a single CNA during incontinence care. The CNA, unaware of the care plan requirements, attempted to turn the resident alone, resulting in the resident falling from the bed and sustaining multiple serious injuries.
Two incidents of suspected abuse involving residents were not reported to the State Agency within the required two-hour timeframe. In one case, a resident had a psychotic episode and made physical contact with others, but the report was delayed to ensure accuracy. In another case, a resident alleged being choked by her spouse, but the allegation was not promptly communicated to management or reported as required.
A resident's clinical record lacked required documentation following an incident, including progress notes and consults. Although electronic communication suggested a wellness check occurred, an LPN confirmed that the resident was not seen by a psychiatrist and that no relevant notes were present in the medical record. This deficiency was confirmed through staff interviews and record review.
A resident with chronic lorazepam use was readmitted with an order for lorazepam, but did not receive any doses for several days due to the medication not being available. Nursing staff documented the delay, and the resident subsequently experienced withdrawal symptoms, including a seizure that required hospital transfer. Review of records confirmed the missed doses and lack of documentation for some scheduled administrations.
Admission assessments for four residents were completed by LPNs instead of an RN, contrary to state requirements and facility policy. Multiple admission evaluations, such as clinical admission, Braden Scale, and fall risk, were documented by LPNs, and this was confirmed by the DON during interviews.
A resident with chronic anxiety disorder and a physician's order for lorazepam did not receive the medication for two days due to pharmacy profiling errors and issues with matching the prescription to available emergency stock. Nursing staff documented missed doses and delays, and the resident ultimately experienced a seizure and required hospitalization after missing four doses.
Two residents with severe cognitive and physical impairments were not adequately supervised, resulting in one sustaining a fracture from contact with a bed enabler and another suffering a head laceration and sacral fracture after being left unsupervised in a bathroom. The facility failed to identify accident hazards, implement person-centered fall interventions, and provide timely emergency response, with staff misrepresenting incident details and care plans lacking clear supervision instructions.
Surveyors found that the facility did not ensure proper assessment, monitoring, or maintenance of bed rails for several residents. In multiple cases, residents were fully dependent on staff for mobility and unable to use bed rails as intended, yet the rails remained in use without documented reassessment. Additionally, there was no evidence of required preventive maintenance or safety checks for the bed rails, as confirmed by staff interviews.
Mold Observed in Food Storage and Beverage Equipment
Penalty
Summary
The facility failed to ensure that food and beverages were stored, prepared, and served in a manner that prevents foodborne illness. During observation, numerous ceiling tiles in the dry food storage room were found to have various sizes of black and gray circular areas that appeared to be mold. Additionally, the clear plastic tubing connecting the kitchen juice machine to the beverage dispenser contained several areas of a blackish gray substance that also appeared to be mold. These findings were reviewed with the Nursing Home Administrator, Quality Manager, and Director of Nursing during the exit conference. No information was provided regarding specific residents affected, their medical history, or their condition at the time of the deficiency.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident (R2) from abuse by another resident (R1), resulting in physical and psychosocial harm. R1 and R2, both with severe cognitive impairment, were roommates and had escalating verbal altercations over a period of several weeks. Documentation showed that R1 exhibited increasing agitation, aggression, and behavioral disturbances, including verbal and physical aggression toward staff and other residents. Despite repeated documentation of these behaviors and ongoing conflict between the two residents, the facility did not revise R1's care plan, reassess the risk of the roommate pairing, or implement additional interventions to prevent harm. Staff interviews and progress notes indicated that R1's behaviors became more difficult to redirect, and that both residents were involved in frequent verbal altercations. Staff reported that the behaviors had been ongoing and that interventions such as redirection were unsuccessful. The social worker was not notified of the escalating conflict, and no changes were made to the residents' room assignments or supervision levels prior to the incident. The facility also failed to obtain behavioral health services for R1, despite documentation of severe behavioral symptoms and cognitive impairment. The situation culminated in an unwitnessed physical altercation in which R2 was found on the floor with a head injury, and R1 was observed standing over him. R2 required transport to the hospital for evaluation and was diagnosed with a head injury, neck muscle strain, and a suspected wrist ligament injury. Interviews with staff and R2 confirmed that R1 had threatened and physically harmed R2, resulting in fear and ongoing psychosocial distress for R2. The facility's lack of timely intervention and failure to address the escalating conflict directly led to the incident of abuse.
Failure to Provide Required Supervision and Assistance During Incontinence Care
Penalty
Summary
A deficiency occurred when a completely dependent resident, with diagnoses including dementia, muscle weakness, contractures, and hemiplegia, was not provided adequate supervision and assistance during incontinence care. The resident's care plan specified the need for two staff members to assist with rolling side to side and for transfers using a Hoyer lift, due to her inability to move or assist herself. However, the care plan did not clearly document the required number of staff for all activities of daily living, and there was no care plan addressing safety or bed mobility related to the use of a low air loss mattress. On the day of the incident, a CNA who was new to the facility provided incontinence care to the resident alone. The CNA was not shown where to find the resident's transfer and bed mobility information and had observed other aides providing care alone, leading her to believe that single-person assistance was sufficient. While turning the resident onto her side, the resident rolled out of bed and fell face down onto the floor, resulting in multiple rib fractures, a clavicle fracture, and a splenic laceration. The resident was completely dependent and unable to assist in her own care or maintain her position in bed. Interviews with facility staff confirmed that the resident required two-person assistance for rolling and transfers, and that this requirement was not communicated or implemented during the incident. The facility's failure to ensure that the resident's care plan for two-person assistance was followed during incontinence care directly led to the resident's fall and subsequent injuries.
Failure to Timely Report Suspected Abuse Allegations
Penalty
Summary
The facility failed to report incidents of suspected abuse involving two residents within the required two-hour timeframe to the State Agency. In the first case, a resident experienced a psychotic episode and made physical contact with three other residents. The incident occurred at approximately 9:00 PM, but the report was not submitted to the State Agency until the following afternoon, well beyond the mandated reporting window. Staff interviews confirmed the timing of the incident and the delayed reporting, with the Assistant Director of Nursing acknowledging the late submission was due to the facility's desire to provide accurate data. In the second case, a resident alleged that her husband, who was also a resident, choked her. This allegation was reported by a CNA to a nurse, who then reported it to the nursing supervisor as per facility protocol. However, the Assistant Director of Nursing was not made aware of the allegation, and there was uncertainty among staff regarding the exact date of the incident and whether it was properly reported. The social worker confirmed that the resident's history of making similar allegations was discussed in an interdisciplinary team meeting, but there was no clear documentation or timely reporting of the specific abuse allegation to the State Agency.
Failure to Maintain Accurate Clinical Documentation
Penalty
Summary
The facility failed to ensure that the clinical record for one resident contained accurate and complete documentation. Specifically, after an incident, there was no evidence in the resident's clinical record of a progress note, consult, medication review, or visit summary. Although the facility provided electronic communication from a nurse practitioner indicating the resident was seen for a wellness check, an LPN confirmed that the resident had not been seen by a psychiatrist on the date in question and that no corresponding progress notes were present in the electronic medical record. This lack of accurate documentation was confirmed during interviews with facility staff and reviewed during the exit conference.
Significant Medication Error: Missed Lorazepam Doses Result in Withdrawal Seizure
Penalty
Summary
A resident with a history of anxiety disorder and chronic lorazepam use was readmitted to the facility with an order for lorazepam 2 mg twice daily. Upon readmission, the medication was not available, and multiple nursing staff documented in the electronic medical record that the resident was waiting for pharmacy delivery. Despite these notes, the resident did not receive any doses of lorazepam for several days following readmission. During this period, the resident began to experience withdrawal symptoms, culminating in a seizure that required transfer to the hospital. Hospital records confirmed that the resident had not received lorazepam since returning to the facility, and both the resident and hospital staff noted the absence of the medication. The resident reported a long-term history of lorazepam use and stated that she had not received her medication due to it being unavailable at the facility. A review of the medication administration record confirmed that several scheduled doses of lorazepam were not administered, with some doses lacking any documentation. Facility leadership confirmed during interviews that the resident did not receive any lorazepam doses during the specified period, resulting in benzodiazepine withdrawal and a seizure event.
Failure to Ensure RN Completion of Admission Assessments
Penalty
Summary
The facility failed to ensure that admission assessments for four residents were completed by a registered nurse (RN) as required by the Delaware State Code and the facility's own policy. Instead, licensed practical nurses (LPNs) completed multiple admission evaluations, including clinical admission, Braden Scale for pressure ulcer risk, lift/transfer evaluation, elopement evaluation, fall risk evaluation, dehydration risk evaluation, trauma informed care, and functional abilities and goals. The records for each resident showed that these assessments were documented and completed by LPNs at the time of admission or readmission, rather than by an RN. Interviews with facility staff, including the Director of Nursing (DON), confirmed that LPNs had performed several of the required admission evaluations. The deficiency was identified for all four residents reviewed for admission, with each case lacking RN-completed admission assessments as mandated. The findings were discussed with facility leadership during the exit conference.
Failure to Provide Timely Pharmaceutical Services Resulting in Missed Medication and Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to provide pharmaceutical services to meet the needs of a resident who was readmitted with diagnoses including diabetes and chronic anxiety disorder. Upon admission, the resident had an active order for lorazepam 2 mg orally twice daily, as documented in the hospital discharge summary and confirmed by the attending physician. However, the medication was not available for administration, and nursing staff documented multiple missed doses over a two-day period, noting that the resident was a new admit and the facility was waiting for pharmacy delivery. The delay in receiving lorazepam was due to a series of communication and procedural errors between the facility and the pharmacy. The pharmacy received the prescription but had the resident profiled under independent living rather than the skilled nursing facility, resulting in a lack of necessary allergy information and confusion about the resident's location. Additionally, the pharmacy could not release lorazepam from the emergency medication box because the available formulation (0.5 mg) did not match the physician's order (1 mg or 2 mg), and regulations required an exact match between the prescription and the medication formulation in the E box. As a result of these failures, the resident missed four doses of lorazepam and subsequently experienced a seizure, requiring transfer to the hospital. Documentation from the hospital confirmed that the resident had missed several doses of her chronic lorazepam regimen for unclear reasons, and the facility's records indicated that the medication was delivered only at the time the resident was experiencing a medical emergency and was unable to swallow.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that two residents received adequate supervision and were protected from accident hazards, resulting in harm. One resident, who was dependent, cognitively impaired, and legally blind, sustained a left upper extremity fracture after accidental contact with a bed enabler during care. The facility did not identify the left bed rail as a potential hazard, despite the resident's significant physical and cognitive limitations. Documentation showed that the resident was dependent for all activities of daily living, required a Hoyer lift for transfers, and had a history of pain complaints, but there was no evidence that the risk posed by the bed enabler was adequately assessed or mitigated. Another resident, also severely cognitively impaired and dependent for all activities of daily living, experienced multiple falls over several months, including unwitnessed falls in various locations. The resident's care plan identified a high risk for falls but lacked person-centered interventions tailored to her needs. On one occasion, the resident was left unsupervised in a bathroom by a CNA who left to obtain an incontinent brief, resulting in a fall that caused a scalp laceration and a subtle sacral fracture. The CNA misrepresented the location and details of the incident, and the facility did not thoroughly investigate the true circumstances of the fall until 12 days later. Additionally, after the unwitnessed fall with a head injury, the facility failed to implement timely emergency interventions. The resident was not assessed by a registered nurse at the scene before being moved, and there was a delay of nearly three hours before the resident was sent to the emergency room. Interviews with staff revealed gaps in communication and documentation, as well as a lack of clear instructions for staff regarding supervision requirements for high-risk residents. The facility's documentation and care plans did not provide adequate guidance to prevent such incidents, despite the residents' extensive histories of falls and cognitive impairment.
Failure to Ensure Appropriate Use and Monitoring of Bed Rails
Penalty
Summary
Surveyors identified that the facility failed to ensure appropriate use and ongoing monitoring of bed rails for three out of seven residents reviewed. The facility's policy required assessment by physical therapy, physician orders, informed consent, proper installation, care plan updates, and reassessment every six months. However, documentation and observations revealed that these steps were not consistently followed. For example, one resident had a left bed enabler for assistance with positioning, but subsequent assessments showed the resident was fully dependent on staff for all activities of daily living (ADLs) and required a Hoyer lift, with no evidence that the continued use of the bed rail was reviewed for appropriateness. Another resident had a right side bed enabler ordered for assistance with turning and repositioning, but was documented as dependent for bed mobility and required two staff for rolling in bed. During care, the resident was unable to use the bed rail due to a contracted hand, and staff confirmed the resident's dependence for turning. A third resident had a physician's order for a single bed rail, but was observed with bilateral bed rails in use. This resident also required two staff for turning and repositioning, and was unable to use one of the bed rails as intended during care. Additionally, the facility lacked evidence of preventive maintenance or safety checks for the bed rails in use. Staff confirmed that there was no documentation of such checks, despite the manufacturer's guidelines being available. These findings indicate that the facility did not ensure bed rails were used according to policy and did not maintain ongoing safety monitoring for residents using bed rails.
Some of the Latest Corrective Actions taken by Facilities in Delaware
- Implemented facility-wide in-service on current elopement policy and hourly face-to-face checks to reinforce staff compliance with resident-safety procedures (J - F0689 - DE)
- Established an hourly face-to-face monitoring protocol for residents identified as high elopement risk to provide ongoing supervision and early intervention (J - F0689 - DE)
- Updated resident care plans to include specific interventions for high elopement risk ensuring individualized preventive measures are documented and followed (J - F0689 - DE)
- Installed and tested window alarms and secured all unit windows to prevent unauthorized egress and enhance environmental safety (J - F0689 - DE)
- Provided nursing-staff training on fall-prevention techniques during resident care, emphasizing proper body mechanics and resident positioning to reduce fall risk (J - F0689 - DE)
- Required the involved CNA to repeat orientation with supervised shadowing before resuming independent resident care, reinforcing correct safety practices (J - F0689 - DE)
Failure to Prevent Elopement and Fall-Related Injury Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for two residents identified as being at risk for accidents. One resident, who was severely cognitively impaired and assessed as high risk for elopement, was admitted to a secured unit and repeatedly expressed a desire to leave the facility. Despite multiple documented episodes of exit-seeking behavior and verbalizations about wanting to return to his previous residence, the resident's care plan lacked person-centered interventions specific to elopement risk. The resident was able to elope from the facility during the overnight shift by opening an unsecured window, which was later found to lack an alarm and could be easily opened. Video review showed that staff failed to perform required visual checks, missing 18 out of 20 opportunities to observe the resident as per the care plan. Staff interviews revealed a lack of awareness regarding the resident's elopement risk and the need for frequent checks. Another resident, who was non-ambulatory, completely dependent on staff for all activities of daily living, and had severe intellectual disability and cerebral palsy, sustained a right femur fracture after falling from the bed during care. The resident was not care planned for falls because staff believed she was unable to move herself. During care, a CNA turned the resident on her side and, while reaching for a washcloth, the resident rolled off the bed and fell face down on the floor. The incident resulted in a right femur fracture requiring surgery. The facility's investigation confirmed that the resident was not provided adequate supervision or assistance to prevent the fall during care. Both incidents demonstrate failures in the facility's implementation of policies and procedures designed to prevent accidents and ensure resident safety. The first resident's repeated exit-seeking behaviors and high elopement risk were not adequately addressed through individualized care planning or environmental safeguards, and staff did not consistently follow monitoring protocols. The second resident's complete dependence on staff was not reflected in her care plan for fall prevention, leading to inadequate supervision during a high-risk activity.
Removal Plan
- All staff in the facility and staff reporting for scheduled shifts were in-serviced on the current elopement policy and face-to-face checks for residents at risk for elopement.
- The facility reviewed all current residents and identified residents deemed to be at higher risk for elopement. These residents were placed on every one-hour face-to-face checks.
- The care plans were updated to reflect specific interventions for high elopement risks.
- An alarm was placed on R1's window and all the windows on the units were checked and locked. When windows were found to be damaged, maintenance was called for immediate repair.
- R1 was moved to another secure unit with alarm on the window and double locks on both entrances.
- All the windows on the secure unit have hard wired alarms and were tested.
- Window limiters were approved by the fire marshal and will be installed upon delivery.
- Staff interviews conducted, and in-service education and training verified.
- Staff training records reviewed and verified.
- R2's care plan was revised and updated for 2 staff members assistance with bed mobility.
- All nursing staff were trained on fall prevention during resident care. The training included not rolling the resident away from the staff's body. Ensure that the resident is in the middle of the bed before turning him/her away from your body (if you must turn the resident away from you.)
- The certified nursing assistant (CNA) involved in the fall was required to re-take new hire orientation, which included shadowing another CNA before she could return to provide resident care independently.
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