Cadia Rehabilitation Broadmeadow
Inspection history, citations, penalties and survey trends for this long-term care facility in Middletown, Delaware.
- Location
- 500 South Broad Street, Middletown, Delaware 19709
- CMS Provider Number
- 085050
- Inspections on file
- 19
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Cadia Rehabilitation Broadmeadow during CMS and state inspections, most recent first.
The facility’s Facility Assessment did not accurately reflect its resident population by failing to identify a distinct group of residents receiving Comfort Care, instead listing only Hospice and Palliative Care services. Facility records showed that 10 residents were on Comfort Care and two residents were on Hospice, but the Comfort Care group was not captured in the assessment. The DON and Administrator reported that the facility used the terms Palliative and Comfort Care interchangeably and tracked Comfort Care residents via an order listing with a “Palliative Care-Form on File.” The Administrator acknowledged that the Facility Assessment referenced Palliative but not Comfort Care and that staff had not differentiated the unique care needs of residents on Comfort Care versus those on Palliative Care, resulting in a deficiency under F684 Quality of Care.
The facility failed to inform two cognitively intact residents about the side effects and risks versus benefits of their prescribed psychotropic medications, including buspirone, duloxetine, and risperidone. EMR review showed no documentation of consent or risk–benefit discussions, and both residents reported either not being told about potential medication effects or not recalling any such discussion and being unsure of what medications they were taking. The DON confirmed there was no documentation of staff conversations about risks and benefits, despite a facility policy requiring resident education on psychoactive medications and documentation of that education in the medical record.
A resident with severe dementia and chronic pain developed a new right heel blister and a wound to the buttocks, but staff documented calling and leaving a message for the second-listed emergency contact instead of the primary contact when the change in condition was first identified. The primary contact later reported learning of both wounds days after the heel blister was initially noted and questioned why they had not been called first. The RN/Unit Manager and DON confirmed that facility policy requires staff to notify the first emergency contact about significant changes in condition and only proceed to the second contact if the first cannot be reached, and that this process was not followed or documented correctly for this resident.
A resident with traumatic brain injury, right-sided hemiplegia, and upper extremity contractures used a motorized wheelchair with a seat belt that staff routinely applied each morning and left on throughout the day, but this device was not assessed, ordered, or care planned as a restraint. The MDS documented no restraints, and the care plan referenced only a power chair with a back cushion, omitting the seat belt despite repeated observations of its use and the resident’s report of discomfort. CNAs stated they were trained to use seat belts on electric wheelchairs and believed some residents could remove them, while nursing and rehab leadership gave conflicting accounts and confirmed there was no EMR documentation or ongoing assessment of the seat belt, contrary to the facility’s restraint policy defining and governing physical restraints.
A resident with dementia, severe cognitive impairment, and a history of multiple falls was noted by a PTA to have increased edema on the right forearm during therapy, and later the same morning an LPN documented a hematoma, pain, and notification of the NP, who assessed right arm swelling with preserved range of motion and circulation. The resident was unable to explain the cause of the injury due to cognitive impairment, making it an injury of unknown origin. The Administrator and DON stated they determined whether such incidents needed to be reported and confirmed this event was not reported to the state, despite a facility policy requiring all alleged incidents, including injuries of unknown source, to be reported to the Administrator or designee and then to appropriate regulatory agencies and/or law enforcement.
A resident with dementia, severe cognitive impairment, and a history of multiple falls was care planned for fall risk and impaired cognition. During a therapy session, a PTA observed increased edema on the resident’s right forearm, and later an LPN documented a hematoma, resident pain, and inability to recall the cause, and notified the NP, who assessed right arm swelling in the context of multiple falls and advanced dementia. Despite the facility’s policy requiring all alleged incidents, including injuries of unknown source, to be reported to the Administrator or designee and investigated, the Administrator and DON acknowledged that this incident was neither reported to the state nor investigated.
A resident with a history of traumatic brain injury, right-sided hemiplegia, contractures, and use of a motorized wheelchair was repeatedly observed wearing a wheelchair seat belt, but the EMR contained no order or care plan addressing this intervention. The comprehensive care plan documented use of a power chair with a back cushion for safety and independence but did not identify seat belt use, despite the resident’s ongoing use of it. An RN/Unit Manager confirmed the absence of an order and care plan for the seat belt, and an MDS coordinator reported they did not capture seat belts on the MDS or review rehab assessments, though they expected staff to monitor positioning and removability. The DON acknowledged that wheelchair assessments and seat belt use should be reflected in the care plan, while the facility’s policy required interdisciplinary review and revision of comprehensive care plans after each assessment, which did not occur for this resident’s seat belt use.
A resident with moderately impaired cognition and documented need for partial assistance with oral care did not receive consistent help or supplies to brush her teeth, as evidenced by her repeated reports of not being offered morning or evening mouth care and observation of debris on her teeth and gums. Other residents reported they had to request toothbrushes and toothpaste, stating that staff would not bring these items unless reminded. Staff, including CNAs, SD, and DON, acknowledged that oral care is expected as part of routine AM/PM care and personal hygiene per facility education materials, yet one CNA stated she only sometimes offered evening oral care to this resident.
A resident on end-of-life comfort care with severe dementia and chronic pain had a care plan focused on comfort measures, but nursing documentation showed minimal assessment of pain and condition changes, with behavioral pain scores recorded on the MAR without narrative explanation. An NP ordered Hyoscyamine Sulfate for secretions and morphine for pain/SOB/comfort, yet MAR review showed an updated Hyoscyamine order with no evidence of administration, and nursing notes lacked detailed assessments of distress, restlessness, or impending death. Interviews with an RN/UM, an IP/SC, an LPN, and the DON revealed that staff relied on provider orders without a dedicated comfort care policy, did not consistently initiate alert charting for significant changes, and did not document objective pain behaviors or end-of-life assessments as required by facility policy.
A resident with COPD, chronic respiratory failure, CHF, and sleep apnea had a physician order for oxygen at 4 LPM via nasal cannula, with the care plan directing that oxygen be provided as ordered. However, on multiple observations the oxygen concentrator at the bedside was set to deliver 4.5 LPM, and the resident was unable to adjust the device independently. An RN/UM and the DON confirmed that the physician’s order specified 4 LPM, and facility policy required staff to read and note the ordered flow rate, indicating that staff did not follow the prescribed oxygen settings.
A resident with multiple chronic conditions had Comfort Care instructions listed in the EMR clinical profile, specifying no further hospitalization, no IV fluids, no weights, and allowance for labs, supplements, and antibiotics, but the corresponding physician order had been discontinued and was not active. An LPN explained that Comfort Care focuses on comfort and avoiding invasive procedures and believed there should be an active Comfort Care order, yet could not find it in the EMR. An RN/unit manager confirmed that such an order should appear in the active orders list and verified that no active Comfort Care order existed, resulting in an incomplete and inaccurate medical record.
The facility failed to follow its antibiotic stewardship policy and McGeer’s criteria when prescribing and monitoring antibiotics for a resident with Parkinson’s disease who developed respiratory symptoms and abnormal O2 saturation. Nursing staff documented low O2 saturation and lung congestion, and a chest x-ray showed bilateral lower lobe infiltrates with a right pleural effusion, after which a provider ordered a 7-day course of Amoxicillin-Clavulanate that was fully administered. A subsequent infection evaluation documented normal temperature, COPD, advanced age, no new or increased cough with purulent sputum, and concluded that protocol criteria for a lower respiratory infection were not met, while the EMR showed no fever, no lab work before starting the antibiotic, and no acute mental or functional changes. Infection surveillance logs lacked complete documentation of signs/symptoms, culture organisms, and whether McGeer’s criteria were met, and the IP later acknowledged the evaluation form did not align with McGeer’s criteria, indicating inconsistent application of the facility’s stewardship program.
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.
A resident with a history of stroke, chronic respiratory failure, and dysphagia choked while eating and became hypoxic and unresponsive. Despite a documented full code status, staff did not assess the airway, perform abdominal thrusts, or initiate CPR, instead applying a non-rebreather mask and preparing for transfer. Emergency personnel arrived to find the resident unresponsive and not receiving CPR, and resuscitation was started by paramedics. This failure to provide basic life support resulted in the resident's death and Immediate Jeopardy.
A resident with a history of stroke, chronic respiratory failure, and swallowing difficulties experienced a choking episode that progressed to severe respiratory distress. Nursing staff did not perform a thorough assessment or initiate CPR when the resident became unresponsive and pulseless, despite being a full code. Paramedics arrived to find the resident in cardiac arrest with no CPR performed, resulting in death.
A resident with significant medical conditions experienced a choking episode during which staff did not perform essential life-saving interventions such as airway clearance or CPR. Paramedics found the resident pulseless and noted that no emergency measures had been taken by staff. The incident was not identified or reported as neglect by facility leadership, contrary to policy requirements.
A facility failed to include staff competencies and emergency intervention skills in its assessment, resulting in inadequate response when a resident experienced respiratory distress after choking. Documentation showed staff did not identify or intervene appropriately, and the facility's assessment lacked evidence of training for such emergencies.
A resident with a history of aggressive behaviors and cognitive impairment physically struck another resident, resulting in visible injury. Despite care plan interventions for supervision and redirection, the facility did not prevent the incident, leading to a failure to protect a resident from physical abuse.
Failure to Accurately Include Comfort Care Population in Facility Assessment
Penalty
Summary
The facility failed to ensure its Facility Assessment included an accurate and comprehensive review of the resident population by omitting an identified group of residents receiving Comfort Care. The Facility Assessment for 2025–2026, dated 10/08/25 through 10/29/25, did not indicate or recognize a Comfort Care population and instead only identified residents on Hospice and Palliative Care services. Facility documentation showed that 10 residents, approximately 9.3% of the facility population, were receiving Comfort Care, while only two residents, approximately 1.9% of the population, were identified as receiving Hospice services. The Comfort Care population was therefore not reflected in the current Facility Assessment. During interviews, the DON and Administrator confirmed that the facility used the terms Palliative and Comfort Care interchangeably and that residents on Comfort Care were tracked via an Order Listing Report that documented residents with a “Palliative Care-Form on File.” The Administrator stated that a Comfort Care/Palliative Care Assessment was used in the nursing home setting like a wish list advanced directive to document care preferences, and acknowledged that the Facility Assessment used the term Palliative but not Comfort Care. The Administrator also stated that she had been told Palliative and Comfort Care were the same thing. As a result, the Facility Assessment did not distinguish or address unique and distinctive characteristics and care needs between residents receiving Comfort Care and those receiving Palliative Care, contributing to the cited deficiency under F684 Quality of Care.
Failure to Inform Residents of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure that residents were informed of psychotropic medication side effects and the associated risks versus benefits, as required by facility policy. One resident with bipolar disorder, major depressive disorder (MDD), and anxiety had an intact cognition with a BIMS score of 14/15 and was receiving buspirone for anxiety, duloxetine for MDD, and risperidone for delusional disorder. Review of the electronic medical record (EMR) showed no documentation of consent or any risk-versus-benefit discussion regarding these psychotropic medications with the resident or a representative. In an interview, this resident stated she had been told what medications she was on but not about potential effects related to the medications. The DON confirmed there was no documentation specific to review of potential effects of psychotropic medications with the resident or representative, despite the policy requiring such education and documentation. Another resident, admitted and later readmitted with diagnoses including MDD and anxiety disorder, had an intact cognition with a BIMS score of 15/15 and was receiving buspirone for anxiety and duloxetine for depression. EMR review similarly revealed no documentation of consent or risk-versus-benefit review for these medications. In an interview, this resident reported not remembering any discussion with staff about medication effects and was unsure of what medications she was taking. The DON stated there was no documentation of any staff conversation with this resident regarding risks versus benefits for the medications. Review of the facility’s psychoactive medications policy, last reviewed on 01/13/26, showed that residents are to be educated on the benefits and potential risks of these drugs and that such education is to be documented in the medical record, which did not occur for these two residents.
Failure to Notify Primary Emergency Contact of Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify the correct emergency contact of a resident’s change in condition. The resident was admitted with severe unspecified dementia with behavioral disturbance and chronic pain, and had a BIMS score of 2/15, indicating severe cognitive impairment. An annual MDS indicated the resident did not have unhealed pressure ulcers at that time. Nursing progress notes documented that on 11/03/24 a charge nurse alerted the writer that the resident was noted with a blister to the right heel, and a message was left for emergency contact #2, with no documentation that emergency contact #1 was called. During a later phone interview, the first emergency contact (FM1) reported receiving a call from a nurse on 11/06/24 stating the resident had developed a wound to the buttocks and heel, and was told the right heel blister had been first noted on 11/03/24 and that the nurse had called emergency contact #2. FM1 questioned why they were not contacted first, as they were listed as the primary contact, and the nurse could not explain. The RN/Unit Manager and the DON both stated that facility practice and policy require staff to notify the first listed emergency contact of a significant change in condition, and if that person cannot be reached, to then call the second contact and document both calls. The DON confirmed that for this resident, emergency contact #2 was called and a message left, but emergency contact #1 should have been contacted instead, contrary to the facility’s policy on provider and responsible party notification of significant changes in condition.
Unassessed Wheelchair Seat Belt Used as Physical Restraint
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical restraints when a seat belt on a motorized wheelchair was not identified or managed as a restraint. The resident had diagnoses including traumatic subarachnoid hemorrhage with loss of consciousness, lack of coordination, abnormal posture, right-sided hemiplegia, history of traumatic brain injury, aphasia following cerebral infarction, and contractures of the right elbow, wrist, and hand. The quarterly MDS documented the resident as cognitively intact with bilateral upper extremity range-of-motion limitations, use of a motorized wheelchair, and no restraints. The comprehensive care plan identified an ADL self-care performance deficit related to right hemiparesis and noted use of a power chair with a back cushion for safety and independence, but it did not identify any problem, intervention, or order related to a seat belt, despite the resident being observed repeatedly with a seat belt in use. Surveyors observed the resident on multiple occasions seated in the motorized wheelchair with a seat belt on, including observations where the buckle was off to the right side of the lap and the resident had a visible right arm contracture. When asked, the resident stated they could release the seat belt and later reported that the seat belt was not comfortable, indicating discomfort by leaning forward and touching the lower left back. CNAs reported that residents with electric wheelchairs had seat belts, that they placed the seat belt on this resident when transferring them into the wheelchair in the morning, and that it remained on all day until bedtime or toileting. CNAs also stated they had been trained during orientation and by rehab staff regarding seat belt use and believed some residents could remove the belts themselves. Interviews with nursing, MDS, and rehab leadership revealed inconsistent understanding and lack of assessment or documentation regarding the seat belt. The RN/Unit Manager confirmed there was no order or care plan for the resident’s seat belt use. The MDS coordinator stated seat belts were not captured on the MDS because rehab was believed to assess them and determine residents’ ability to remove them, and acknowledged these interventions should be care planned. The Director of Rehab stated the department did not use or assess seat belts, was unaware CNAs were applying them, and later provided a prior physical therapy plan of treatment documenting that the resident was able to unbuckle the seat belt upon command but needed assistance with buckling, and that the resident was at risk for falls and injury during power chair mobility. The last occupational therapy wheelchair assessment contained no documentation or assessment of the seat belt. The facility’s restraint policy defined physical restraints as devices that the individual cannot remove easily which restrict freedom of movement or access to the body, and required EMR documentation to support assessment and use of restraints, which was not present for this resident’s ongoing seat belt use.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency for one resident. The resident was admitted with metabolic encephalopathy, dementia, and a history of transient cerebral ischemic attack, and had a BIMS score of 7/15 indicating severely impaired cognition. The resident’s care plan identified a history of falls and increased fall risk related to deconditioning, poor safety awareness, impulsivity, muscle weakness, unsafe transfer behavior, medications, and prior falls, with interventions including following post-fall protocol, assessing for injuries, monitoring vital signs, and notifying the physician. Another care plan problem addressed impaired cognitive function related to dementia, with interventions to cue, reorient, and supervise as needed. On one morning, a PTA documented that during a therapy session the resident was noted to have increased edema on the right forearm and was unable to explain what happened or quantify pain due to cognitive impairment; nursing was notified. Later that morning, an LPN documented a hematoma to the resident’s right forearm, noted signs of pain, administered pain medication per physician order, and notified the NP. The NP’s progress note described right arm swelling in a resident with multiple falls and advanced dementia, with the resident unaware of the swelling and denying pain, and with full range of motion and intact circulation in the affected arm. During interviews, the Administrator stated that for their state, insignificant or non-serious injuries of unknown source did not have to be reported, and the DON confirmed the incident was not reported to the state. This was inconsistent with the facility’s abuse/neglect/mistreatment policy, which required that all alleged incidents, including injuries of unknown source, be reported to the Administrator or designee and then to appropriate regulatory agencies and/or law enforcement.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for one resident. The resident was admitted with metabolic encephalopathy, dementia, and a history of transient cerebral ischemic attack, and had a severely impaired cognitive status with a BIMS score of 7/15. The resident’s care plan identified a history of falls and increased fall risk related to deconditioning, poor safety awareness, impulsivity, muscle weakness, unsafe transfer behavior, medications, and prior falls, with interventions including following post-fall protocol, assessing injuries, monitoring vital signs, and notifying the physician. Another care plan problem identified impaired cognitive function related to dementia, with interventions to cue, reorient, and supervise as needed. On one date, a PTA documented on a Witness Written Summary that during a therapy session the resident was noted to have increased edema on the right forearm, and the resident was unable to explain what happened or quantify pain due to cognition; nursing was notified. Later that morning, an LPN documented on a Witness Written Summary that the resident had a hematoma to the right forearm, was unable to recall what happened, showed signs of pain, and was given pain medication per physician order, and the NP was made aware. The NP’s progress note the following day described right arm swelling in the context of multiple falls and advanced dementia, with the resident unaware of the swelling and denying pain, and with full range of motion and intact circulation in the affected arm. In interviews, the Administrator and DON stated they determine whether incidents need to be reported to the state, and the DON confirmed this incident was not reported or investigated. This was inconsistent with the facility’s abuse/neglect policy, which requires all alleged incidents, including injuries of unknown source, to be reported to the Administrator or designee and investigated, with reporting to appropriate regulatory agencies and/or law enforcement.
Failure to Update Care Plan for Resident’s Regular Wheelchair Seat Belt Use
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to review and revise a comprehensive care plan to reflect a resident’s regular use of a wheelchair seat belt. The resident had multiple neurologic and functional impairments, including traumatic subarachnoid hemorrhage with loss of consciousness, lack of coordination, abnormal posture, hemiplegia on the right dominant side, history of traumatic brain injury, aphasia following cerebral infarction, and contractures of the right elbow, wrist, and hand. The quarterly MDS showed the resident was cognitively intact with a BIMS score of 13/15, had functional limitations in bilateral upper extremity range of motion, used a motorized wheelchair, and required substantial/maximal assistance for bed mobility and transfers. The comprehensive care plan, initiated on admission and revised at later dates, identified an ADL self-care performance deficit related to right hemiparesis and documented use of a power chair with a back cushion for safety, comfort, and independence, but did not include any problem or intervention related to the use of a seat belt. During multiple observations on different days, the resident was repeatedly seen seated in a motorized wheelchair with a seat belt on. Review of the EMR by the RN/Unit Manager confirmed there was no physician order for a wheelchair seat belt and no care plan addressing seat belt use. The MDS Coordinator stated they did not capture seat belts on the MDS because they believed rehabilitation assessed residents and that residents would be capable of removing the belts, and acknowledged they did not review those assessments. The MDS Coordinator further stated they would expect staff to check positioning, security, and the resident’s ability to remove the belt, and confirmed such interventions should be identified in a care plan. The DON acknowledged that wheelchairs should be assessed on admission and quarterly and that the seat belt should be part of the care plan, and also confirmed there was no specific policy for care plan revisions, only a general comprehensive care plan policy. The facility’s care planning policy required that comprehensive care plans be developed, reviewed, and revised by the interdisciplinary team after each assessment, but this was not done for the resident’s seat belt use.
Failure to Provide Required Assistance With Oral Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs), specifically oral care, to a resident who required help. One resident, identified as R73, had diagnoses including dysphagia, cognitive communication deficit, bipolar disorder, and osteoarthritis, and a BIMS score of 12/15 indicating moderately impaired cognition. The quarterly MDS documented that R73 required partial/moderate assistance with oral care. During multiple interviews, R73 reported not being offered help to brush her teeth in the mornings or evenings and stated that supplies to brush her teeth were not brought to her. On observation, R73’s teeth and gums had a buildup of white and brown debris, and she did not have a toothbrush at the bedside. Other cognitively intact residents reported that they had to ask staff to bring their toothbrush and toothpaste, and that if they did not remind staff, the supplies would not be brought. Staff interviews, including with the Staff Development nurse, DON, and CNAs, confirmed that the facility’s expectation and CNA orientation education were that oral care is part of routine AM and PM care and that staff should offer mouth care and set up or perform oral care for residents unable to do it themselves. One CNA who usually worked with R73 in the evenings stated that she sometimes offered to have R73 brush her teeth. These findings show that, despite facility expectations and training materials stating that mouth care should be given in the morning, at bedtime, and as part of personal hygiene, R73 did not consistently receive the necessary assistance and supplies for oral care.
Failure to Monitor Comfort Care and Administer Ordered Hyoscyamine at End of Life
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and document comfort care for a resident on end-of-life care and failure to follow physician orders for Hyoscyamine Sulfate. The resident had severe cognitive impairment, was on a care plan focused on comfort care, and had diagnoses including severe unspecified dementia with behavioral disturbance, anxiety disorder, and chronic pain. The care plan specified comfort care parameters such as no hospitalization, no lab work, no tube feeding, no IV fluids, and liberalized diet and supplements, with pain assessment and physician contact for uncontrolled pain. From the beginning of November through early November, nursing progress notes and the MAR showed no documented pain or SOB, and pain assessments using a behavioral pain scale consistently recorded a pain level of 0, with no narrative documentation explaining the assessments. On a later NP visit, the NP documented that the resident had decreased oral intake but no respiratory distress or signs of pain or discomfort, and ordered Hyoscyamine Sulfate sublingual for excessive secretions, lorazepam PRN for agitation/restlessness, and morphine sulfate concentrate PRN for pain/SOB/comfort. Subsequent nursing documentation on the night a PRN morphine dose was given recorded that the resident was in distress and received morphine for comfort, but there was no detailed nursing note describing what type of distress the resident was experiencing. The MAR documented a behavioral pain score of 4/10 at that time, but there was no documentation of how that score was derived using the behavioral assessment, and no corresponding nursing note explaining the assessment. Later that same day, another note documented decreased responsiveness and inability to take PO food/fluids, with the daughter requesting that PRN morphine be made routine; the NP assessed the resident and ordered scheduled sublingual morphine every four hours along with PRN dosing. The MAR for that day showed the resident continued to be assessed each shift with a pain level of 4, again without documentation of how the behavioral pain score was determined or narrative nursing notes describing the assessment. The NP later changed the Hyoscyamine Sulfate order to 0.125 mg every four hours routinely, and then, after the resident was seen again for increased secretions, the order was increased to 0.25 mg every two hours for increased secretions/end of life. The DON, upon review, noted that the order for Hyoscyamine Sulfate 0.125 mg two tablets every two hours had administrative times marked with Xs and no documentation that the medication was administered, and could not explain why it was not given. Nursing notes from the time the increased Hyoscyamine order was written through the time of the resident’s death did not reflect ongoing assessments or documentation of further signs of impending death. Interviews with nursing staff and leadership confirmed that detailed assessments, alert charting, and documentation of pain behaviors and changes in condition were not completed, that there was no specific comfort care policy, and that staff education on comfort care was limited to general advance directive training.
Failure to Follow Physician Order for Oxygen Flow Rate
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy according to the physician’s ordered flow rate for a resident with chronic respiratory conditions. The resident’s face sheet showed diagnoses including COPD, and the quarterly MDS documented that the resident was cognitively intact with a BIMS score of 13 and was receiving oxygen therapy. The resident’s care plan, dated 07/22/24, identified altered respiratory status related to chronic respiratory failure, COPD, CHF, and sleep apnea, with an intervention specifying oxygen as ordered. Physician orders in the EMR, dated 06/30/25, directed oxygen at 4 LPM via nasal cannula. Despite this order, surveyor observations on three separate dates found the resident in bed with an oxygen concentrator delivering 4.5 LPM via nasal cannula. The concentrator was located approximately two feet from the left side of the bed, and the resident was not able to get out of bed to adjust the concentrator independently, as confirmed by the RN/Unit Manager. During an interview, the RN/Unit Manager verified that the oxygen was set at 4.5 LPM and that the physician’s order specified 4 LPM. The DON also confirmed that the order for the resident’s oxygen was 4 LPM. The facility’s policy on Nasal Oxygen Administration required staff to read and note the physician’s written order for nasal oxygen with the stated flow rate in liters per minute, which was not followed in this case.
Incomplete Physician Orders for Comfort Care Program
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident when the electronic medical record (EMR) did not contain an active physician order for the resident’s Comfort Care Program. The resident was admitted with multiple diagnoses, including heart failure, peripheral vascular disease, cerebral infarction with right-sided weakness, history of falls, and chronic obstructive pulmonary disease. The resident’s Clinical Profile in the EMR listed special instructions for “COMFORT CARE: NO further hospitalization, NO IV fluids, NO discontinuation of medication, NO weights, YES lab work, YES supplements, YES antibiotics.” However, review of the Order Summary in the EMR showed that the Comfort Care order had been discontinued on two separate dates and was not present as an active order at the time of review. During interviews, an LPN described Comfort Care as focused on keeping the resident comfortable and pain free, avoiding invasive or aggressive procedures while still treating conditions such as UTIs. The LPN stated that the unit manager would inform staff when a resident was placed on Comfort Care and that there was supposed to be an active Comfort Care order for this resident, but she was unable to locate it in the EMR. The RN/unit manager confirmed that there should be an active physician order for Comfort Care listed among the resident’s active orders and, upon review of the EMR, verified that no such active order was present. This discrepancy between the Clinical Profile instructions and the absence of an active physician order constituted the identified deficiency.
Failure to Follow Antibiotic Stewardship and McGeer’s Criteria for Pneumonia
Penalty
Summary
The deficiency involves the facility’s failure to implement an antibiotic stewardship program consistent with its policy and McGeer’s criteria when prescribing an antibiotic for one resident reviewed for antibiotic stewardship. The resident, admitted with Parkinson’s disease, was documented by nursing staff as not feeling well, with O2 saturation of 89–90% on room air improving to 96% on 2L oxygen, and a congested right upper lobe. A stat chest x-ray was ordered, which showed bilateral lower lobe infiltrates and a right pleural effusion. Based on these findings, a provider ordered Amoxicillin-Clavulanate 875-125 mg twice daily for seven days for bilateral lobe infiltrates, and the MAR showed the resident completed the full antibiotic course. The facility’s Potential Infection Evaluation dated two days after antibiotic initiation documented a normal temperature, O2 saturation of 89%, presence of COPD, age over 65, and no new or increased cough with purulent sputum, concluding that nursing home protocol criteria for a lower respiratory infection were not met and that the resident did not need an immediate antibiotic prescription but might need additional observation. The EMR showed no lab work prior to starting the antibiotic, no documented fever, and no change in function or mental status. The provider’s progress note confirmed the resident was started on Augmentin for pneumonia based on the chest x-ray. Review of the Infection Control Surveillance Log for the year revealed missing documentation of residents’ signs and symptoms, organisms from culture results when obtained, and whether McGeer’s criteria were met. The Infection Preventionist acknowledged that the Potential Infection Evaluation form used did not align with McGeer’s criteria, and the DON stated her expectation that residents’ symptoms meet McGeer’s criteria for antibiotic use, demonstrating that the facility did not consistently apply its Antibiotic Stewardship policy and McGeer’s criteria in this case.
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 Initiate CPR for Choking Resident with Full Code Status
Penalty
Summary
A deficiency occurred when staff failed to initiate CPR for a resident who was choking, became hypoxic, and unresponsive, despite the resident's documented full code status. The RN supervisor did not assess the resident's airway or respiratory status after the choking incident and only delegated the application of a non-rebreather mask and preparation for transfer, without initiating CPR or further emergency intervention. The resident was admitted with a history of stroke, chronic respiratory failure with hypoxia, and dysphagia, and was cognitively intact at admission. The resident's resuscitation form indicated full code status, requiring CPR in the event of cardiac or respiratory arrest. On the day of the incident, the resident choked while eating, was unable to speak, and exhibited signs of respiratory distress with low oxygen saturation and a high heart rate. Staff did not perform a thorough assessment, such as listening to lung sounds or performing abdominal thrusts, and did not initiate CPR when the resident became unresponsive. Emergency medical personnel arrived to find the resident unresponsive and not receiving CPR, and subsequently initiated resuscitation efforts. The failure to provide basic life support and initiate CPR as required resulted in the resident's death, and an Immediate Jeopardy was declared.
Failure to Recognize and Respond to Choking and Respiratory Distress
Penalty
Summary
Licensed nursing staff failed to demonstrate the necessary competencies to recognize and respond to an emergent situation involving a resident with a history of stroke, right-sided paralysis, chronic respiratory failure with hypoxia, and trouble swallowing. The resident, who was a full code, experienced a choking episode that progressed to respiratory distress, with oxygen saturation dropping to 64% and a heart rate of 149-150 beats per minute. Despite these critical changes, staff did not perform a thorough assessment, such as listening to lung sounds, and did not initiate CPR when the resident became pulseless and unresponsive. The non-rebreather mask used was not inflating, and the resident's oxygen saturation only improved slightly after being switched back to an oxygen tank at a higher flow rate. Video surveillance and interviews confirmed that the resident was brought back to her room in a wheelchair with her head down and chin to chest, appearing very pale and not breathing when paramedics arrived. Paramedics found the resident in cardiac arrest with no CPR having been performed by staff. The facility's policy required continuous monitoring and appropriate interventions for significant changes in condition, but these were not followed, resulting in the resident's death. The failure to provide competent nursing care and initiate life-saving interventions led to the declaration of Immediate Jeopardy.
Failure to Identify and Report Neglect After Choking Incident
Penalty
Summary
A resident with a history of stroke resulting in right-sided paralysis, chronic respiratory failure with hypoxia, and dysphagia experienced a choking episode. During this incident, staff failed to provide essential life-saving interventions, such as airway clearance, assessment of lung air movement, and initiation of CPR. Paramedic records indicated that upon arrival, the resident was pulseless and exhibiting agonal respirations, and no life-saving measures had been performed by facility staff prior to their arrival. An LPN present at the scene reported that after being alerted by the resident's spouse, he checked vital signs and increased supplemental oxygen but did not assess lung sounds or initiate further emergency interventions. The facility did not identify or report the incident as an allegation of neglect, as required by their own policies and state regulations. The DON stated during an interview that the incident was not reported to the State because he was unaware of any allegations of inappropriate care. The failure to recognize and report the lack of essential assessment and intervention following the choking event constituted a deficiency in the facility's abuse and neglect reporting procedures.
Failure to Assess and Train Staff for Emergency Response
Penalty
Summary
The facility failed to ensure its facility-wide assessment included nursing staff competencies and the necessary skill sets to provide the required level and types of care for its resident population. Specifically, when a resident experienced respiratory distress after choking on food, staff did not identify or appropriately intervene despite being informed of the situation. Documentation showed that the resident had decreased oxygen levels and became unresponsive, yet the facility's assessment lacked evidence of staff training and interventions for medical emergencies such as choking with respiratory distress. The incident was reviewed with facility leadership during the exit conference. A review of the facility's assessment document for 2024-2025 revealed no evidence of staff training or protocols for handling medical emergencies, including choking incidents with respiratory distress, which contributed to the deficiency.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency was identified when a resident with moderately intact cognition, who used a manual wheelchair, reported being physically struck in the face by another resident. The incident occurred after dinner, and the charge nurse observed redness on the affected resident's left eyelid. The resident who committed the act had a history of dementia, depression, anxiety disorder, and was care planned for impaired cognition and potential physically aggressive behaviors, including hitting and striking out. Interventions for this resident included redirection, allowing time to calm down, and speaking in a calm voice. Despite these interventions being documented in the care plan, the facility failed to prevent the occurrence of resident-to-resident physical abuse. The incident was reported to the State Agency, and the facility's policy stated a commitment to protect residents and prevent abuse. However, the measures in place were not sufficient to ensure the safety of the resident who was struck, resulting in a failure to protect the resident from physical abuse.
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Three residents who were dependent on staff for bed mobility and transfers did not receive adequate supervision and safe handling during care and transfers, resulting in serious injuries. A resident who was totally dependent for bed mobility slid from the bed to the floor while a CNA focused on gathering supplies during care, later being found to have an ankle fracture. Another resident with a prior brain bleed, craniotomy, and left-sided paralysis, requiring a mechanical lift with two staff, sustained a head injury when a Hoyer lift was improperly positioned or controlled during transfer from a shower bed to a wheelchair, causing the lift bar to strike the top of the head and leading to ongoing head and neck pain. A third resident needing extensive assistance fell between a shower bed and her regular bed when a CNA attempted to transfer her without locking the shower bed wheels, resulting in acute L2–L3 compression fractures confirmed by CT.
A resident who required set-up assistance for eating spilled coffee onto bare upper thighs while being prepared for morning care, initially resulting in nonblanchable redness with intact skin and no reported pain. During later incontinence care, staff identified a broken blister on the resident’s right upper thigh, cleansed the area, and applied skin prep, but did not notify the MD until more than a day after the blister was first noted. An NP confirmed that although she had been informed of the coffee spill itself, there was no documentation that the subsequent change in skin condition had been communicated to a provider, resulting in a failure to promptly notify the on-call provider of the new skin alteration.
A resident with significant neurologic impairment and multiple contractures slid from bed and was assisted to the floor during the night shift, but an RN did not complete the initial post-fall assessment until the following day shift. An LPN documented that the resident was seated after the event, denied pain, had ROM and VS assessed, and was assisted back to bed with a CNA. The DON later reported that the CNA and LPN did not report the event as a fall because the resident was assisted down, and the LPN stated she relied on the CNA’s account when completing the incident report and was unsure if the RN had been notified.
A resident reported an allegation of physical abuse by a CNA during the night shift, which was documented in the clinical record. Facility policy required that all alleged violations be reported to the Administrator, state agency, APS, and other required agencies immediately but no later than two hours after the allegation. Instead, the allegation was reported to the state agency approximately nine hours after it was made. An RN acknowledged not reporting the allegation right away and waiting for the day shift, and the DON confirmed that the reporting timeframe was not followed.
A resident with dementia and a care plan for false accusations alleged physical abuse by a CNA. Facility policy required staffing or room changes to protect residents from an alleged perpetrator, but the CNA remained on duty providing care to other residents for the rest of the shift. An LPN and an RN confirmed that the CNA continued working with residents, with the CNA only being stopped from caring for the accusing resident’s room, resulting in a failure to fully implement the abuse protection policy.
A resident with CHF and kidney disease requiring dialysis was admitted and assessed as having congestive heart failure, but the baseline care plan lacked CHF-related interventions and there was no timely physician order for fluid restriction despite a nutrition assessment referencing a 1500 mL limit. A physician note identified the resident as high risk for rehospitalization and called for strict I&O and daily weights, yet a formal fluid restriction order was not entered until several days later, only after the responsible party requested it. The next day, the resident was sent to the hospital from dialysis for chest pain and shortness of breath. In interviews, the MD, RN, and DON all confirmed the resident should have been placed on fluid restriction and monitoring upon admission and that this was not done in a timely manner.
Surveyors found that dietary staff repeatedly failed to wear required hair and beard restraints while preparing food, washing dishes, and serving meals, and the Dietary Manager acknowledged that restraints should be worn at all times but that the facility had run out of them. These unsanitary practices occurred during routine kitchen operations and affected nearly all residents who received meals from the kitchen, with only two residents receiving nutrition via feeding tubes.
Surveyors found that medication carts were left unlocked and unattended in two separate locations. One cart on a hall outside a resident room was left unlocked while an LPN was inside the room with the privacy curtain pulled and unable to see the cart, with only a CNA present further down the hall. Another cart at the nurses’ station, shared by nurses on two halls, remained unlocked while the ADON walked past it twice and then left the area, leaving no one at the station until returning several minutes later to lock it. Facility policy required all medication and treatment carts to be locked when not in use and not left unattended while unlocked.
The facility did not provide required written information on advance directives and the right to accept or refuse medical and surgical treatment to two residents, one cognitively intact and one with moderately impaired cognition, as confirmed by EMR review showing no such documentation. The SSD reported having no written materials explaining types of advance directives or any signature page confirming verbal explanations or resident understanding. The AD stated the admission packet only asked whether a resident had or wanted an advance directive and did not include written definitions or explanations. The Administrator acknowledged being unaware of regulatory requirements and of the facility policy, which states that residents have the right to formulate an advance directive and to accept or refuse treatment, and that written information must be provided in an easily understood manner.
A cognitively intact resident with mild cognitive impairment reported to her son that a male CNA entered her room at night to provide incontinent care, which she refused, and that he returned and made an inappropriate sexualized remark when she again refused care. The son called the facility to report the concern, and the Admissions Director stated she immediately informed the DON, in line with protocol to notify leadership of abuse-related grievances. However, the DON reported she did not recall receiving the grievance and only became aware of the allegation when law enforcement arrived several days later after receiving a family complaint. The DON confirmed that the SSA was not notified of the abuse allegation until four days after the initial grievance, despite facility policy and leadership acknowledging that alleged abuse must be reported to the SSA within two hours.
Failure to Provide Adequate Supervision and Safe Transfers Resulting in Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate assistance and supervision to prevent accidents for three residents who were dependent on staff for mobility and transfers. One resident with anoxic brain injury, multiple contractures, abnormal posture, and idiopathic progressive neuropathy was documented on multiple MDS assessments as requiring substantial/maximal assistance for bed mobility and was described by nursing and therapy staff as totally dependent and unable to move or roll in bed without physical assistance. During nighttime care, a CNA entered the room in response to a call light, found that the resident had vomited, and focused on looking for towels while standing on one side of the bed. The CNA reported that the resident then began sliding off the opposite side of the bed; the CNA ran around the bed but was unable to prevent the resident from sliding off, and instead lowered the resident to the floor in a seated position. Subsequent imaging confirmed a stable right ankle fracture, and interviews with the NP, OT, LPN, and other CNAs confirmed that the resident was dependent for bed mobility and could not independently roll or slide out of bed, indicating that the resident did not receive the level of hands-on assistance and supervision consistent with their documented needs. A second resident with a history of brain bleed, seizure disorder, craniotomy, and left-sided paralysis had a care plan and therapy determination requiring a mechanical (Hoyer) lift with two staff for all transfers and was completely dependent on staff for bathing and transfers. During a transfer from a shower bed back to a wheelchair using a mechanical lift, the resident reported that the hooks of the lift were not properly attached to the bars, causing the front of the lift to become unbalanced and tilt backward, dropping the resident into the chair and allowing the lift bars to strike the top of the resident’s head at the craniotomy site. The resident stated that the lift was not moving when staff attempted to place him in the chair and that this type of incident had not occurred during prior showers, when he was typically returned to his room on the shower bed and transferred in bed. One CNA described that while assisting with the transfer, the lift appeared stuck and positioned sideways over the wheelchair; when she voiced concern and attempted to correct the position, the lift rose and the bar hit the resident’s head. The other CNA involved stated that as she operated the lift controls, the resident’s weight shifted, the lift tipped back, and the bar struck the top of his head. The physician documented a head strike from the Hoyer lift with subsequent head and neck pain, and the resident required repeated PRN pain medication for ongoing head and neck pain. A third resident with cerebral infarction and rheumatoid arthritis had orders and MDS documentation indicating a need for extensive to maximal assistance with bed mobility and dressing. After receiving a shower, this resident was brought back to the room on a shower bed. The facility’s incident report documented that the CNA lowered the side rail of the shower bed, pushed the shower bed against the resident’s bed, turned the resident on her side, removed the bath sheet, and began pushing the Hoyer pad underneath. During this process, the resident rolled and fell between the two beds to the floor, becoming very anxious and crying. A subsequent CT scan at the hospital revealed acute L2 and L3 vertebral compression fractures. In a later interview, the CNA acknowledged that she must have forgotten to lock the wheels on the shower bed before attempting the transfer, and described that when she rolled the resident to place the Hoyer pad, the shower bed separated from the resident’s bed, allowing the resident to fall between them. These events demonstrate that the resident did not receive adequate supervision and safe handling during the transfer process, despite her documented need for extensive assistance with mobility.
Failure to Timely Notify Provider of New Skin Blister After Coffee Spill
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a provider of a change in a resident’s skin condition following a coffee spill incident. The resident was admitted earlier in the month, and the admission MDS documented that the resident required set-up assistance for eating. On the morning of 3/30/26, a nurse documented that the resident placed a cup of coffee on the bed railing, and when he let go, the cup fell onto his lap, spilling hot coffee onto his bilateral upper thighs while he was not wearing pants and was about to receive morning care. At that time, the nurse documented nonblanchable redness on both upper thighs with all skin intact, and later that day a wound care RN documented that there was no scalded skin present and the resident denied pain. A late entry nurse’s note documented that during incontinence care on 3/31/26, a broken blister on the resident’s right upper thigh was identified, cleansed with saline, patted dry, and skin prep applied. Review of incident documentation showed that the physician was not notified of this blister until 4/1/26 at 8:38 AM, more than 24 hours after the blister was first identified. During interview, the NP stated she had been notified of the coffee spill on 3/30/26 but, upon reviewing the physician binder, confirmed there was no evidence that the change in skin condition noted on 3/31/26 had been communicated to a provider at that time. The facility therefore failed to notify the on-call provider when the resident experienced a change in skin condition after the coffee spill incident.
Failure to Obtain Timely RN Post-Fall Assessment After Assisted Descent to Floor
Penalty
Summary
The facility failed to ensure that an RN performed and documented an initial post-fall assessment for a resident who slid off the bed and was lowered to the floor during the 11 PM–7 AM shift. The resident had significant medical conditions including anoxic brain injury, abnormal posture, multiple contractures of the upper and lower limbs, and idiopathic progressive neuropathy. A facility-reported incident documented that the resident sustained a fall with later complaint of ankle pain, with an X-ray obtained and results unclear, and a repeat film obtained two days later. The clinical record showed that the initial post-fall assessment was not completed by an RN until 8:34 AM on the 7 AM–3 PM shift by the ADON, and there was no evidence of an RN assessment during the overnight shift when the fall occurred. A witness summary completed by an LPN documented that the resident was in a seated position after the fall, denied pain, had range of motion assessed, denied pain again, had vital signs taken, and was assisted by a CNA back to bed. During interviews, the DON stated that the fall was not reported by the CNA and the LPN because they did not consider it a fall since the resident was assisted to the floor. In a phone interview, the LPN confirmed being called by the CNA about the fall, stated that care and an assessment were provided, and indicated uncertainty about whether the RN was notified, noting that the written incident report was based on what the CNA reported and that the LPN was not present at the time of the fall.
Failure to Timely Report Allegation of Staff-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure immediate reporting of an allegation of staff-to-resident physical abuse in accordance with its abuse policy and regulatory time frames. The facility’s abuse policy, last updated January 2026, required that all alleged violations be reported to the Administrator, state agency, adult protective services, and other required agencies immediately but no later than two hours after the allegation is made. On 6/12/25 at 3:31 AM, an incident note in the clinical record documented that resident R83 alleged physical abuse by a CNA (E8). However, the allegation was not reported to the State Agency until 11:21 AM the same day, approximately nine hours after the allegation was made, exceeding the required reporting timeframe. During an interview on 4/23/26 at 11:06 AM, an RN (E6) confirmed that the allegation was not immediately reported and stated that the DON later informed her it should have been reported right away rather than waiting for day shift. In a separate interview at 11:14 AM, the DON (E2) confirmed these findings. The deficiency centers on the delayed reporting of the abuse allegation to the State Agency despite clear policy requirements for immediate notification. The survey findings were reviewed with the Nursing Home Administrator (E1), the DON (E2), and others at the exit conference on 4/23/26 at 3:00 PM.
Failure to Remove Accused Staff From Resident Care After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from further potential abuse by not immediately removing an accused staff member from resident care following an allegation of physical abuse. The facility’s abuse policy, updated January 2026, states that room or staffing changes are to be made as necessary to protect residents from the alleged perpetrator. On 6/12/25 at 11:21 AM, the facility reported an allegation of staff-to-resident physical abuse involving resident R83 and CNA E8. Record review of E8’s timesheet showed that after this allegation, E8 remained in the facility working with residents until 7:05 AM. During interview, LPN E7, who was assigned to R83’s unit at the time, confirmed that E8 continued caring for residents after R83’s accusation and stated that R83 had dementia and a care plan for false accusations, and that E8 was only stopped from caring for R83’s room for the rest of the shift. RN E6 also confirmed that E8 continued caring for residents after the allegation and stated that she instructed E8 to care for other patients. These findings were reviewed with the NHA (E1) and DON (E2) during the exit conference. The resident involved, R83, had dementia and a documented care plan for false accusations, which influenced staff’s decision to limit E8’s contact only with R83 rather than removing E8 from all resident care. Despite the facility’s written policy requiring protective staffing or room changes to safeguard residents from an alleged perpetrator, E8 remained on duty providing care to other residents for the remainder of the shift after the allegation of physical abuse was made.
Failure to Implement Timely Fluid Restriction and Monitoring for Resident With CHF and Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and monitoring consistent with professional standards of practice for a resident admitted with congestive heart failure and kidney disease requiring dialysis. The resident was hospitalized for multiple conditions, including heart failure, and then admitted to the facility with diagnoses of congestive heart failure and kidney disease. An admission assessment by an RN documented congestive heart failure, but the baseline care plan did not include any interventions related to this diagnosis. A nutrition assessment documented that the resident was on a therapeutic meal plan with a 1500 mL fluid restriction and indicated ongoing monitoring of oral intake, weight, skin integrity, and labs, yet the physician’s orders and dietary intake records did not contain an order for fluid restriction. A physician progress note documented that the resident had multiple complex comorbidities, including heart failure, and was at high risk for rehospitalization without proper care, specifying a plan for strict intake and output and daily weights. An admission MDS later confirmed that the resident was cognitively intact, experiencing shortness of breath, and had an active diagnosis of heart failure. A physician’s order for a 1500 mL fluid restriction was not written until several days after admission, at the request of the resident’s responsible party. The following day, nursing documentation showed the resident was sent to the hospital from dialysis for chest pain and shortness of breath. In interviews, the MD, the admitting RN, and the DON all confirmed that the resident should have been placed on a fluid restriction and monitoring upon admission, and the DON acknowledged that the fluid restriction order was not implemented in a timely manner.
Failure to Ensure Dietary Staff Used Required Hair and Beard Restraints During Food Service
Penalty
Summary
The deficiency involves failure to maintain sanitary conditions in the kitchen, specifically related to staff not using required hair and beard restraints during food service activities. During an observation and interview with the Dietary Manager (DM) on 03/29/26 from 9:25 AM to 10:28 AM, two Dietary Aides (DA1 and DA2) were seen engaged in food preparation and dishwashing without wearing beard or hair restraints, which the DM confirmed. In a subsequent observation and interview with the DM on 03/31/26 from 8:55 AM to 11:36 AM during the meal serving line, DA1 and DA3 were again observed not wearing beard or hair restraints, and the DM stated that such restraints should be worn at all times and acknowledged the facility was out of beard/hair restraints. These conditions affected 78 residents who received meals from the kitchen, out of a total census of 80 residents, with 2 residents receiving nutrition via feeding tubes. The observations document that multiple dietary staff members repeatedly failed to use required protective restraints while handling food and dishes, and that the facility lacked an adequate supply of beard/hair restraints, as confirmed by the DM. The report specifies that this failure occurred during both food preparation and meal service times and applied to nearly all residents receiving meals from the kitchen.
Unattended, Unlocked Medication Carts Left Accessible in Two Locations
Penalty
Summary
The deficiency involves the facility’s failure to keep medication carts locked and secured when not in use, as required by facility policy and professional standards. During an early morning observation on 04/01/26 at 4:53 AM, a medication cart on the [NAME] Hall in front of room W102 was found unlocked while an LPN was inside the resident’s room with the privacy curtain pulled. The medication cart was not visible from inside the room, and the only other staff member in the area, a CNA, was further down the hall delivering linen to another room. At 4:59 AM, the LPN returned to the cart and locked it, confirming that it had been left unlocked and out of her line of sight. A second unsecured cart was observed on 04/01/26 at 5:56 AM at the nurses’ station, where the medication cart shared by nurses on the [NAME] and East Halls was left unlocked. The ADON walked past this unlocked cart twice and then left the nurses’ station to go down the East Hall at 6:00 AM, leaving the cart unattended and still unlocked. At 6:05 AM, the ADON returned and locked the cart. In an interview at that time, the ADON stated that it was the expectation that all medication and treatment carts be kept locked when not in use. Review of the facility’s “Storage of Medication” policy, revised November 2020, confirmed that compartments containing drugs and biologicals are to be locked when not in use and that unlocked carts should not be left unattended.
Failure to Provide Required Written Information on Advance Directives and Treatment Rights
Penalty
Summary
The facility failed to provide written information regarding advance directives and the right to accept or refuse medical and surgical treatment to two residents reviewed for advance directives. One resident was admitted with hemiplegia and hemiparesis following cerebrovascular disease and major depressive disorder and had a BIMS score of 15/15, indicating intact cognition. Review of this resident’s EMR, including the admission record and MDS, showed no evidence that written information on advance directives had been provided. A second resident was re-admitted with heart failure, stage three chronic kidney disease, malignant neoplasm of the upper lobe of the left bronchus, and pain, and had a BIMS score of 12/15, indicating moderately impaired cognition. Review of this resident’s EMR also revealed no evidence that written information regarding advance directives had been provided. During interviews, the SSD stated she did not have any written information to provide residents about the distinct types of advance directives and that there was no signature page to indicate a verbal explanation was provided or that residents understood their right to accept or refuse medical and surgical treatments. The AD reported that the admission packet contained only one page asking if a resident had an advance directive or wished to formulate one, and that she did not have written information defining the types of advance directives to give residents on admission. The Administrator stated she was not aware of the regulatory guidance requiring written information on advance directives and the right to accept or refuse medical and surgical treatment, and was unaware that the facility’s own policy required this. The facility’s “Advanced Directives” policy, revised November 2025, stated that residents have the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment, and that written information must be provided in a manner easily understood by the resident or representative.
Failure to Timely Report Allegation of Sexual Abuse to SSA
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of sexual abuse to the State Survey Agency (SSA) within the required two-hour timeframe. A cognitively intact resident, admitted with cognitive communication deficit and mild cognitive impairment and having a BIMS score of 15/15, was the subject of an allegation reported by her son. On a grievance/concern form dated 09/18/25, the son reported that a male aide entered the resident’s room in the middle of the night stating he needed to check if she was wet; the resident refused, and the aide returned later, at which time the resident again refused. The facility’s investigation report dated 09/22/25 documented that the assigned CNA made an inappropriate verbal remark to the resident, stating, “you don’t know what you are missing,” when she refused incontinent care. An incident tracking form dated 09/22/25 at 8:21 PM showed that a police officer came to the facility and informed staff that they had received a complaint from the resident’s family alleging the resident had been spoken to in a manner that made her uncomfortable, and that the male staff assigned to her care made the same remark when she refused care. The Admissions Director stated she received the telephone call from the resident’s son on 09/18/25 describing the male staff entering the room, the resident’s refusals of care, and the uncomfortable comment, and that she immediately informed the DON of the concern, consistent with facility protocol to notify the Administrator and DON of all grievance and abuse concerns. The DON stated she did not remember receiving the grievance/concern form and reported that she first learned of the alleged abuse on 09/22/25 when a police officer came to the facility after receiving an allegation of abuse. The DON confirmed that the SSA was notified of the abuse allegation on 09/22/25, four days after the son’s grievance, and acknowledged that the SSA should have been notified on 09/18/25. The Administrator/Abuse Coordinator, who was out on leave at the time and unaware of the grievance, confirmed that alleged violations involving abuse should be reported to the SSA within two hours after the allegation is made. The facility’s written policy on abuse, neglect, exploitation, mistreatment, and misappropriation of property, dated 06/15/25, states that alleged violations involving abuse are to be reported to the SSA within two hours after the allegation is made, which did not occur in this case.
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