Cadia Rehabilitation Silverside
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, Delaware.
- Location
- 3322 Silverside Road, Wilmington, Delaware 19810
- CMS Provider Number
- 085056
- Inspections on file
- 21
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Cadia Rehabilitation Silverside during CMS and state inspections, most recent first.
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 with severe cognitive impairment was subjected to alleged abuse by a CNA, who stuck her tongue out and threw wipes at the resident during care. The incident was witnessed and reported to an LPN, but not escalated to the Abuse Coordinator as required. The accused CNA continued working for several days before the incident was formally reported, in violation of facility policy and reporting requirements.
Staff failed to consistently follow infection prevention and control protocols, including proper use of PPE, hand hygiene, and adherence to transmission-based precautions. Multiple staff members, including nursing, housekeeping, and leadership, were observed entering rooms on enhanced barrier or contact precautions without appropriate PPE or hand hygiene, and performing resident care tasks without changing gloves or sanitizing equipment. These actions were contrary to facility policy and involved residents with conditions such as ESBL, MRSA, and those under COVID-19 precautions.
The facility did not ensure medications were administered as ordered, resulting in a medication error rate of 10%. Two residents received medications after meals that were prescribed to be given before eating, with nursing staff acknowledging the timing errors. The DON confirmed that medications are expected to be administered according to orders and packaging instructions.
The facility did not properly maintain the outdoor garbage area, as a large dumpster without a lid was left on site containing ripped garbage bags with exposed food waste, and garbage was observed scattered on the ground. Staff confirmed the lack of a policy for dumpster area maintenance and acknowledged that the area was not kept clean or secured against pests.
The facility did not properly inform residents about its grievance policy or the process for filing complaints, with several residents unaware of how to voice concerns or who to contact. In multiple cases, grievances related to housekeeping and personal property were not fully investigated or resolved, and staff interviews revealed inconsistent application of the grievance process.
Multiple residents experienced abuse or mistreatment, including a resident with severe cognitive impairment who was subjected to inappropriate behavior by a CNA, a resident who was struck by another resident, and a cognitively intact resident who reported rude and rough treatment by a CNA. In each case, there were failures in timely reporting, intervention, or prevention of abuse, as well as lapses in staff conduct and adherence to facility policy.
A resident with multiple diagnoses and intact cognition developed a swollen, bruised thumb after an altercation with a CNA. While the facility investigated and ruled out staff-to-resident abuse, no further investigation was conducted to determine the cause of the injury once abuse was unsubstantiated, contrary to facility policy regarding injuries of unknown origin.
A resident with hypertension was prescribed Propranolol HCl with instructions to hold the dose if the heart rate was below 50. On multiple occasions, staff failed to document the required heart rate before administering the medication, as confirmed by the DON.
A resident with cognitive impairment and a history of falls was not provided with required fall prevention measures, including a low bed and bilateral floor mats, as outlined in the care plan and physician orders. Multiple observations confirmed the absence of these interventions, and facility leadership acknowledged the deficiency.
A resident with severe cognitive impairment and an indwelling urinary catheter was repeatedly observed with the catheter bag and tubing in contact with the floor, contrary to facility policy and staff knowledge. Despite staff awareness that the resident frequently removed the bag from its proper position, no care plan was initiated or revised to address this ongoing issue.
The facility failed to notify the responsible party of a resident with severe cognitive impairment about an ulceration on the resident's left shoulder blade. Despite the facility's policy requiring such notifications, there was no documentation indicating that the responsible party was informed. The wound care nurse and the facility administrator confirmed the lapse in communication.
A resident's room was not properly cleaned, with observations confirming dirt, debris, and heavy dust buildup. The resident, who was cognitively intact and had chronic conditions, reported inadequate cleaning. The Housekeeping Director acknowledged the issue and cited a lack of training for a new employee.
The facility failed to protect two residents from physical abuse by CNAs. One resident with dementia reported being roughly handled by two CNAs, and another resident with functional quadriplegia reported similar rough treatment. Both incidents were substantiated through investigations, and the involved CNAs were terminated.
A resident reported that a CNA was rough with her during care, but the facility delayed reporting the incident to the State Agency by five days. The delay occurred because the DON initially considered it a customer service issue rather than an abuse allegation.
The facility failed to conduct thorough investigations into allegations of potential abuse involving two residents. In one case, a resident reported being injured by another resident, but the investigation was limited to interviews with the involved parties and a physical assessment. In another case, a resident reported rough handling by a CNA, but no additional interviews were conducted. Both investigations were deemed incomplete by the facility's administration.
The facility failed to complete a smoking assessment and secure smoking materials for a resident identified as a smoker. Despite the facility's non-smoking policy, the resident had smoking materials in his room and admitted to smoking off the property. Staff members were unaware of the resident's smoking activities and possession of smoking materials, leading to the deficiency.
The facility did not provide the required 30 days for a resident or their responsible party to rescind the Binding Arbitration Agreement, instead allowing only 21 days. This was confirmed by the Admission Coordinator, who noted that no arbitration cases had been pursued.
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 Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of staff-to-resident abuse involving a resident with severe cognitive impairment. The incident occurred when a Certified Nursing Assistant (CNA) stuck her tongue out at a resident and threw three wipes toward the resident's head during care. Another CNA witnessed the event and reported it to a Licensed Practical Nurse (LPN), but the incident was not reported to the facility's Abuse Coordinator until several days later. During this period, the accused CNA continued to work scheduled shifts in the facility. The resident involved had a history of cerebral infarction, unspecified dementia with agitation, and major depressive disorder, and was assessed as severely cognitively impaired. The incident was witnessed by a second CNA, who reported it to the LPN. The LPN did not escalate the report, believing that keeping the CNA away from the resident was sufficient. Additionally, a Unit Clerk learned of the incident but failed to report it immediately, only recalling to do so days later. The facility's policy required immediate reporting of suspected abuse to the appropriate authorities and immediate suspension of the accused staff member pending investigation. However, the delay in reporting allowed the accused CNA to remain on duty and interact with other residents. The deficiency was identified during a survey, which found that the facility did not follow its own policy or regulatory requirements for timely reporting of abuse allegations.
Removal Plan
- Implemented a Removal Plan to address the deficient practice
- Developed a Performance Improvement Plan (PIP) in response to the incident
- Reviewed the Performance Improvement Plan (PIP)
- Selected residents randomly for review regarding abuse
- Provided re-education to all staff for abuse and the proper reporting of abuse
Failure to Follow Infection Prevention and Control Protocols
Penalty
Summary
Multiple breaches in infection prevention and control protocols were observed throughout the facility, involving both nursing and non-nursing staff. Staff failed to follow established policies for transmission-based precautions, hand hygiene, and the use of personal protective equipment (PPE) during resident care. For example, an LPN entered a resident's room on enhanced barrier precautions without PPE, handled tube feeding equipment that had fallen on the floor without sanitizing it, and administered medications without proper hand hygiene. A CNA performed incontinent care and changed linens without changing gloves between dirty and clean tasks, and both the LPN and CNA failed to use PPE appropriately during these activities. Additionally, staff were observed entering and exiting rooms on enhanced barrier precautions without washing or sanitizing their hands, and in some cases, without donning required gowns or gloves. Housekeeping staff also failed to adhere to contact precaution protocols. One housekeeper entered a resident's room, which was under contact precautions for ESBL in urine, without wearing a gown or gloves and used the same cleaning equipment in multiple rooms. The housekeeper was unaware of the need to use PPE, and the infection preventionist confirmed that housekeeping staff should have been using PPE in such situations. Nursing staff were also observed entering the same resident's room without donning a gown, despite clear signage and available PPE supplies, and incorrectly believed that PPE was only necessary if direct contact with bodily fluids occurred. Further deficiencies were noted in medication administration practices, with a nurse observed popping medications into their hand before placing them in a medication cup, contrary to facility policy. Leadership staff, including the ADON and LPN supervisors, were observed entering and exiting rooms on enhanced barrier precautions without proper hand hygiene or PPE use. In one instance, linen was picked up from the floor without appropriate PPE. The facility's policies for COVID-19 precautions were also not consistently followed, with some staff uncertain about the requirements for droplet and contact precautions and the use of PPE for residents under quarantine.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration Timing
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required. During a medication pass observation, three errors were identified out of 30 opportunities, resulting in a 10% error rate. Specifically, one resident with attention deficit disorder and gastroesophageal reflux disease was administered ritalin and omeprazole after having already eaten breakfast, despite both medications being ordered to be given before meals. The nurse administering the medications acknowledged awareness of the timing requirements but cited other responsibilities as a reason for not adhering to the prescribed schedule. Another resident with diabetes was prescribed glipizide to be given 30 minutes before meals on specific days. However, the medication was administered after the resident had already received her breakfast tray. The nurse involved confirmed the timing of administration and did not provide further explanation when questioned about the correct timing. The Director of Nursing stated that medications are expected to be given as ordered and according to blister package instructions.
Improper Disposal and Maintenance of Outdoor Garbage Area
Penalty
Summary
The facility failed to maintain the outdoor garbage and dumpster area in a manner that would prevent pests from accessing garbage. Observations over several days revealed a large dumpster without a lid, filled with garbage bags, some of which were ripped or torn, exposing food scraps and containers. Garbage, including cigarette butts, paper, and cardboard, was also found scattered on the ground around the compactor area. The Dietary Manager confirmed the presence of garbage on the ground and acknowledged that maintenance was responsible for cleaning the area. The large dumpster had been used while the compactor was being repaired, but even after the compactor was returned, the dumpster remained on site, still uncovered and containing exposed waste. Interviews with facility staff indicated that there was no policy in place regarding the maintenance of the dumpster area. The Maintenance Director stated that the dumpster had been present for a couple of weeks and that waste management did not provide dumpsters with lids. Maintenance staff typically cleaned the area twice a week. The Registered Dietitian reported that her sanitation inspections included checking the dumpster area to ensure it was not overfilled, the lid was closed, and there was no garbage on the ground, but the large dumpster did not have a lid. The Administrator confirmed the absence of a facility policy for dumpster area maintenance and acknowledged that the dumpster should have been covered.
Failure to Inform Residents of Grievance Policy and Inadequate Grievance Resolution
Penalty
Summary
The facility failed to adequately inform residents about its grievance policy and the process for filing complaints, as well as the identity and contact information of the grievance official. Seven residents interviewed during a resident council meeting stated they were unaware of any formal complaint process or postings about grievances, and none knew who the designated grievance officer was, except for the social worker. The facility's grievance policy was posted in a location that was difficult to read, and there was no evidence that the grievance process was discussed in resident council meetings or communicated to residents who did not attend. In the case of one resident, a family member reported multiple grievances regarding poor housekeeping, including unclean rooms and bathrooms, and inadequate cleaning of public areas. While some grievances were documented and investigated, at least one concern related to housekeeping was not addressed or responded to, despite being reported on a Resident Concern Form. Interviews with staff confirmed that the grievance process was inconsistently followed, with some concerns not being investigated or resolved as required by policy. Two additional residents experienced issues related to personal property. One resident had a small refrigerator removed from her room without explanation, and there was no documentation or policy provided to justify the removal. Another resident reported a missing electric razor, which was not documented as a grievance or thoroughly investigated, despite the resident's dependence on the item for personal care and his report that previous razors had been broken during care. Staff interviews revealed a lack of clarity about whether these incidents should have been treated as grievances and how they should have been addressed according to facility policy.
Failure to Protect Residents from Abuse and Timely Reporting
Penalty
Summary
The facility failed to protect residents from abuse and did not ensure timely reporting and intervention in multiple incidents involving both staff-to-resident and resident-to-resident abuse. In one case, a resident with severe cognitive impairment experienced an incident where a CNA threw wipes at her head and made inappropriate gestures during care. The incident was witnessed by another CNA, who reported it to an LPN, but the event was not reported to the Abuse Coordinator until four days later. This delay allowed the CNA involved to continue working scheduled shifts after the incident. Another incident involved resident-to-resident aggression, where a resident with moderate cognitive impairment reported being struck in the face by another resident during the night. The incident was unwitnessed and only reported the following day. The care plans for both residents indicated a history or risk of behavioral issues, but the incident still occurred, and the facility's response included room changes and psychiatric evaluations after the fact. Interviews with staff and residents confirmed the event and the subsequent interventions, but the initial failure to prevent or immediately address the aggression was noted. A third incident involved a cognitively intact resident who, along with a family member, reported being treated rudely and roughly by a CNA during care, including being told to clean his room and experiencing pain when his brief was handled. The resident and family member reported the events to nursing staff, who then involved the social worker and ADON. The CNA involved admitted to making inappropriate comments, and the investigation could not identify a second staff member involved in the alleged rough handling. The facility's documentation and interviews confirmed that the resident experienced distress and pain as a result of the CNA's actions.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that an injury of unknown origin was properly investigated for one resident. The resident, who had diagnoses including cerebral palsy, major depressive disorder, and anxiety disorder, was cognitively intact at the time of the incident. The resident reported that a CNA pinched his thumb after he threw a soda can at her, resulting in a 1.5 cm by 1.5 cm purple area with swelling on his thumb. An initial investigation was conducted to determine if staff-to-resident abuse had occurred. The CNA involved was suspended, witnesses were interviewed, and video footage was reviewed, all of which led to the conclusion that the allegation of abuse was unsubstantiated. The emergency room records from the same day did not document the thumb injury, and the facility's investigation focused solely on the abuse allegation. After ruling out staff abuse as the cause, the facility did not pursue further investigation into the origin of the resident's thumb injury, despite facility policy requiring all injuries of unknown source to be investigated. Interviews with facility leadership confirmed that the injury should have been considered of unknown origin and investigated accordingly, but no additional documentation or follow-up was completed to determine how the injury occurred.
Failure to Document Heart Rate Prior to Propranolol Administration
Penalty
Summary
A deficiency occurred when the facility failed to follow physician's orders for a resident who was readmitted for hypertension. The physician's order required administration of Propranolol HCl 40 mg orally twice daily, with instructions to hold the medication if the resident's heart rate (HR) was less than 50. Review of the Medication Administration Record (MAR) showed that on several occasions, the required HR was not documented prior to medication administration: specifically, the morning dose on one date and the bedtime dose on four separate dates. The Director of Nursing (DON) confirmed that the HR was not taken as ordered on these dates.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
A deficiency was identified when staff failed to implement and follow fall prevention interventions for a resident with a history of falls and cognitive impairment. The resident, who had been readmitted with fractures to the right pelvis and shoulder, was assessed as being at high risk for falls due to impaired cognition, deconditioning, and gait/balance problems. The care plan included interventions such as bilateral fall mats, but did not reflect a physician's order for a low bed issued on a later date. Multiple observations over several days showed the resident in a standard-height bed without bilateral floor mats in place, contrary to the documented care plan and physician orders. Interviews and record reviews confirmed that the required fall interventions were not consistently implemented. The Assistant Director of Nursing (ADON) acknowledged that the resident did not have the prescribed bilateral floor mats and that the bed remained at standard height. This lack of adherence to the care plan and physician orders for fall precautions constituted a failure to ensure the environment was free from accident hazards and that adequate supervision and interventions were provided to prevent accidents.
Failure to Maintain Proper Catheter Bag Positioning and Care Planning
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was repeatedly observed with the catheter bag and tubing in direct contact with the floor while in bed. Multiple observations over several days documented the catheter bag hanging from the side of the bed, uncovered and either skimming or resting completely on the floor. Facility policy requires catheter bags to be positioned below the bladder but off the floor, and to be covered for privacy. Staff interviews confirmed knowledge of the correct procedure, but also acknowledged that the resident frequently removed the bag from its hook, resulting in improper placement. Record review revealed that there was no care plan initiated or revised to address the resident's non-compliance with catheter care management, despite the ongoing issue. The resident had severe cognitive impairment and a history of urinary tract infection, and required a catheter per physician orders. Staff, including CNAs and an LPN, confirmed the improper placement of the catheter bag and stated that the resident often pulled the bag off the hook. The DON stated that staff should monitor catheter placement and report any issues, and that care planning should occur if a resident repeatedly interferes with catheter management.
Failure to Notify Responsible Party of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure the responsible party for a resident with pressure ulcers was notified of the resident's change in condition. The facility's policy required staff to notify the provider and applicable POA/responsible parties of significant changes in the resident's condition. However, in the case of a resident with severe cognitive impairment, there was no documentation indicating that the responsible party was informed about an ulceration on the resident's left shoulder blade, which was identified during care and documented in an incident report and progress notes. The wound care nurse confirmed that the family was not notified of the abrasion on the shoulder, despite the facility's policy and the expectation that the staff would complete the incident report and notify the responsible party. The resident's medical history included Parkinson's disease, dementia, abnormal posture, muscle weakness, and acute embolism and thrombosis of the left iliac vein. The incident report and progress notes documented the presence of an abrasion on the resident's left posterior shoulder, which was attributed to a screw on the wheelchair. A physical therapy consult was recommended to evaluate the wheelchair and address the source of the abrasion. Despite these findings, there was no documentation of notification to the resident's responsible party, which was confirmed by both the wound care nurse and the facility administrator.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a resident's room was properly cleaned to maintain a homelike environment. The resident, who was cognitively intact and had multiple chronic conditions including respiratory failure and COPD, reported that their room was not being cleaned adequately. Observations confirmed the presence of dirt and debris around the bed, a heavy buildup of dust on the bed frame, air mattress pump frame, and bedside table. The resident expressed dissatisfaction with the cleaning, stating that the housekeeping staff had not been properly trained on how to clean the room effectively. Further observations revealed that the room remained in the same unclean condition over several days. The Housekeeping Director confirmed the heavy buildup of dust and dirt and acknowledged that a new employee might not have been adequately trained. The facility's housekeeping procedure outlined a five-step cleaning process, which included disinfecting horizontal surfaces and dusting hard-to-reach areas, but these steps were not followed in the resident's room.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to ensure that two residents remained free from physical abuse. Resident 86, who has dementia with mood and behavior disturbances, reported being roughly handled by two CNAs. The incident was substantiated through an investigation that included witness statements from another staff member and a resident. Both CNAs involved were suspended during the investigation and subsequently terminated for their actions. Resident 62, who has functional quadriplegia and cognitive communication deficits, reported being roughly handled by a CNA while being turned in bed. The resident's account was corroborated by another CNA who witnessed the incident and observed the resident visibly upset and crying. The CNA involved was terminated following an investigation that included interviews with the resident and the witnessing CNA. Both incidents were confirmed by the facility's Director of Nursing and Administrator, who were not employed at the time of the initial investigation but reviewed the substantiated reports. The facility's policy on abuse, neglect, and mistreatment was not adhered to, resulting in physical abuse of the residents.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure that an allegation of staff-to-resident abuse was reported timely to the State Agency. The incident involved a resident who reported that a Certified Nursing Assistant (CNA) had been rough with her while providing care and turning her in bed. The resident, who had a BIMS score indicating intact cognition, reported the incident to the administration on the same day it occurred. However, the Facility Reported Incident (FRI) was not submitted until five days later, despite the facility's policy requiring immediate reporting of such incidents. During an interview, the Administrator confirmed that the facility was aware of the allegations on the day they occurred but did not report the incident until five days later. The delay was attributed to the Director of Nursing (DON) initially considering the issue to be a customer service matter rather than an abuse allegation. This failure to report the incident in a timely manner had the potential to place the resident at risk for further abuse.
Incomplete Investigations into Allegations of Potential Abuse
Penalty
Summary
The facility failed to ensure a thorough investigation was completed related to allegations of potential abuse for two residents. In the first case, a resident with rheumatoid arthritis and moderate cognitive impairment reported that another resident, who was severely cognitively impaired, threw a wheelchair leg rest on her foot. The facility's investigation was limited to interviews with the two involved residents and a physical assessment of the injured resident, which showed no significant injury. No additional staff or resident interviews were conducted, and the investigation was deemed incomplete by the Director of Nursing (DON) and the Administrator during a follow-up interview with surveyors. In the second case, a resident with functional quadriplegia and intact cognition reported that a Certified Nursing Assistant (CNA) was rough during care. The facility's investigation did not include interviews with other residents or staff members. The Administrator admitted that she did not feel it was necessary to conduct additional interviews because the resident was alert and oriented. Upon further review, the Administrator confirmed that the investigation was incomplete. Both incidents highlight the facility's failure to adhere to its own policy, which mandates thorough investigations involving interviews with all persons identified as involved or with knowledge of the occurrence. The lack of comprehensive investigations into these allegations of potential abuse resulted in deficiencies in ensuring resident safety and compliance with regulatory requirements.
Failure to Complete Smoking Assessment and Secure Smoking Materials
Penalty
Summary
The facility failed to complete a smoking assessment and secure smoking materials for a resident identified as a smoker. Despite the facility's policy prohibiting smoking on the premises, the resident was found to have smoking materials in his room and admitted to smoking off the property. The resident's electronic medical record did not contain a smoking assessment, and staff members, including the Administrator and the Director of Nursing, were unaware of the resident's smoking activities and possession of smoking materials. Interviews with various staff members revealed that the resident had been smoking for some time, and smoking materials such as lighters and vapes had been repeatedly confiscated from his room. The resident confirmed that he smoked occasionally and did not inform the staff about his smoking activities or possession of smoking materials. The facility's failure to adhere to its smoking policy and properly assess and monitor the resident's smoking behavior led to the deficiency identified in the report.
Failure to Allow 30-Day Rescission Period for Arbitration Agreement
Penalty
Summary
The facility failed to allow 30 days for a resident or their responsible party to rescind the voluntary Binding Arbitration Agreement after it was signed. The facility's Attachment #3: Binding Arbitration Agreement stated that the agreement could be rescinded within twenty-one (21) days of the date upon which it was signed, instead of the required 30 days. This discrepancy was confirmed during an interview with the Admission Coordinator, who acknowledged that the form allowed only 21 days for rescission. No instances of arbitration being pursued were reported.
Latest citations in Delaware
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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