Coral Springs Rehab & Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, Delaware.
- Location
- 505 Greenbank Road, Wilmington, Delaware 19808
- CMS Provider Number
- 085004
- Inspections on file
- 19
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Coral Springs Rehab & Healthcare during CMS and state inspections, most recent first.
Staff failed to follow standardized menus, recipes, and portion sizes for a beef stew lunch meal. Policy required use of planned cycle menus and standardized recipes, including specific ingredients and preparation steps for regular and pureed beef stew, as well as defined portion sizes for each diet level. Observations showed the cook pureeing stew that lacked required vegetables and later adding carrots only to the regular stew, and serving the regular stew with a smaller ladle and the pureed stew with only one scoop instead of the specified two. In interviews, the cook reported not using recipes and relying on a spreadsheet for portions, while dietary leadership and the RD stated they expected adherence to menus, recipes, and portion sizes to meet residents’ nutritional needs.
Surveyors found multiple dietary service deficiencies, including undated and improperly stored food items, such as prepared sandwiches, lunch meat, cut fruit, and raw pork stored above ready-to-eat items, as well as open and unlabeled frozen products. Dietary staff reported they had not been trained to check dish machine temperatures or sanitizer levels, and when a DD tested the machine, no sanitizer was being dispensed and required monitoring logs were incomplete. In addition, a staff member responsible for cooking and serving checked temperatures only for items listed on a log, omitting some hot foods on the steam table, and a DD later determined that at least one hot vegetable item was not at the required temperature for service.
Surveyors found multiple medication and treatment carts unlocked and unattended in several halls, despite facility policy requiring all drugs and biologicals to be stored in locked compartments and carts to be secured when not in the direct line of sight of the nurse. On several occasions, an LPN left a cart unlocked while going down another hall or off the floor for 10–15 minutes, and another LPN left a cart unlocked while responding to a yelling resident in a nearby room. The unlocked carts contained OTC medications, insulin pens and vials, inhalers, nebulizer medications, and resident bubble packs of prescription drugs such as anticoagulants, antipsychotics, antihypertensives, analgesics, diuretics, and potassium chloride. Staff, including agency nurses, acknowledged they had been trained to keep carts locked, and leadership stated they expected carts to be locked when out of the nurse’s sight.
A resident with intact cognition and a history of anxiety, conversion disorder, rheumatoid arthritis, and depression was administered a suppository after repeatedly refusing it and reporting prior bowel movements. The nurse did not verify the resident's report by checking the EHR or consulting with the CNA, as required by facility policy, and proceeded to administer the medication after multiple requests. Supervisory staff confirmed that the protocol was not followed, resulting in a failure to respect the resident's right to refuse treatment.
The facility did not report allegations of abuse and injuries of unknown origin to the state survey agency within required timeframes for three residents. In one case, a CNA delayed reporting witnessed staff-to-resident abuse, and the incident was not reported until over four hours later. Another resident's injury of unknown origin was reported 26 hours after discovery, and an altercation between two residents was reported more than three hours after it occurred. Facility leadership confirmed these delays did not meet policy requirements.
A resident with severe cognitive impairment was allegedly subjected to physical and verbal abuse by an LPN during care, as witnessed by a CNA who delayed reporting the incident. The facility's investigation included staff interviews, medical assessment, and police notification, but failed to assess other cognitively impaired residents for possible abuse, resulting in an incomplete investigation.
A resident with significant mobility impairments was transferred using a mechanical lift by only one staff member, contrary to facility policy requiring two staff for such transfers. During the transfer, the lift made contact with a chair base, causing the resident to be lowered to the floor and resulting in pain and an emergency department visit. Staff interviews confirmed the transfer was not performed according to established procedures.
A resident with dementia, osteoarthritis, and lumbar disc displacement, care planned for fall risk and use of a concave mattress, was found over multiple observations to be using a bed that was visibly uneven and tilting to one side. The resident reported the bed had been broken for a long time, had told family and staff, and expressed fear of falling due to the lopsided bed. An LPN operating the bed confirmed it was uneven, and the Maintenance Director later identified the bed frame as broken and could not recall the last room audit, while the Administrator stated she was unaware of the problem despite facility policy requiring prompt reporting and maintenance of furniture in disrepair.
A resident with Parkinson's Disease and dementia was hospitalized due to the facility's failure to initiate a bowel protocol as per the care plan. Despite orders to monitor bowel movements and initiate interventions after three days without a bowel movement, the protocol was not followed on two occasions, leading to fecal impaction and hospitalization. Staff interviews confirmed the oversight in protocol initiation.
A resident with severe cognitive impairment and extensive leg wounds did not receive consistent pain management before dressing changes, despite hospital discharge instructions and family concerns. The facility failed to administer Oxycodone as needed, leading to the resident experiencing pain during wound care. The resident's condition worsened, resulting in rehospitalization for a wound infection.
The facility failed to ensure qualified personnel were present during kitchen operations, leading to delays in meal delivery and inadequate meal service. Breakfast trays were often delivered late, sometimes close to lunchtime, and meals lacked reasonable portions or selection. These issues were confirmed through interviews and a review of facility records.
The facility failed to maintain a sanitary and comfortable environment, with dirty floors, rusted fixtures, and disrepair observed in multiple rooms. Shower rooms had cleanliness issues, and there was a shortage of clean linens, affecting care. Staff confirmed these deficiencies, and frequent changes in maintenance directors contributed to inconsistent oversight.
The facility failed to develop and implement individualized care plans for residents with seizure disorders and those using bed rails. A resident with a seizure disorder had no specific care plan despite an active medication order. Additionally, three residents using bed rails lacked person-centered care plans, as confirmed by facility staff during interviews.
The facility failed to update care plans for several residents, resulting in deficiencies in person-centered care and infection control. A resident with dementia had an outdated activity care plan, while two residents with bed rails had care plans that did not reflect their current use. Additionally, three residents with medical conditions lacked care plans focused on infection control precautions. These issues were confirmed by facility staff during interviews.
The facility failed to comply with the Delaware Nursing Scope of Practice by allowing LPNs to perform assessments that should have been completed by RNs. This included post-fall and admission assessments for several residents, which were conducted by LPNs instead of RNs, as required by state regulations. Interviews revealed a lack of awareness among LPNs regarding their scope of practice limitations.
The facility failed to properly assess and document the use of bed rails for several residents, lacking evidence of medical necessity, risk assessments, and informed consent. Observations showed bed rails installed without proper evaluation, posing potential risks. Interviews revealed communication gaps between rehabilitation and maintenance staff, and the facility did not provide necessary documentation to surveyors.
The facility failed to provide drinks consistent with the needs and preferences of several residents. A resident reported not being offered fluids regularly, and observations confirmed this. Additionally, nine residents did not receive coffee or tea with their breakfast, despite these being indicated on their meal tickets. Staff interviews revealed this was a recurring issue, and the Dietary Supervisor was unaware of the problem.
The facility failed to maintain sanitary conditions in its food storage and preparation areas. Observations included debris in the walk-in freezer, spills in the refrigerator, and food stored on the floor. Uncovered and undated food items were found, and the ware washing area had food debris and improperly stored clean mugs. A snack refrigerator contained undated and unlabeled items. These issues were confirmed by an RN and discussed with facility leadership.
The facility failed to maintain accurate medical records and provide adequate medical diagnoses for anticoagulant prescriptions. Urine culture results were not documented in residents' EMRs, and medication orders lacked proper medical indications. Additionally, discrepancies were found in the documentation of enteral feed water flushes and incontinence care plans.
The facility failed to implement enhanced barrier precautions for residents with indwelling devices, such as catheters and PICC lines, resulting in staff providing care without appropriate PPE. An environmental tour also revealed infection control issues, including uncleanable materials and uncovered wash bins on dusty floors.
The facility failed to ensure antibiotics were prescribed according to recognized standards for three residents. One resident received antibiotics without a urine culture, another lacked a final microbiology report for a UTI, and a third received an undocumented antibiotic dose for a COPD exacerbation. These issues indicate deficiencies in the facility's antibiotic stewardship and infection control practices.
The facility failed to document pneumococcal vaccinations for four residents, despite orders and records in the DELVAX system. The Infection Preventionist confirmed the lack of documentation and acknowledged that the facility had not held a vaccine clinic the previous year. This issue was reviewed with facility leadership and a representative from the Ombudsman office.
The facility failed to treat residents with respect and dignity. A resident's catheter bag was improperly positioned, visible from the hallway, and staff were unaware of the care plan details. Additionally, a CNA was observed inattentive and using a cellphone while sitting between two residents during lunch, showing a lack of engagement and respect.
The facility failed to support the self-determination of three residents by not allowing them to go outside independently, despite their care plans indicating a preference for outdoor activities. Residents reported restrictions on accessing an enclosed courtyard without staff supervision, which was not always available. Additionally, one resident faced scheduling conflicts due to late lunch tray deliveries, impacting their ability to participate in activities.
A facility failed to notify the Ombudsman of a resident's transfer to the hospital, as required. The resident was admitted in August and transferred in April, but the facility's records lacked evidence of notification to the Ombudsman. The Nursing Home Administrator confirmed the oversight during an interview, and the issue was reviewed with facility staff and an Ombudsman representative.
The facility failed to notify the state PASARR authority for two residents diagnosed with new mental disorders, as required. One resident was diagnosed with adjustment disorder with depressed mood and prescribed citalopram, while another was diagnosed with a delusional disorder and prescribed Risperdal. The facility did not refer these cases for PASARR Level II screening, and errors in the PASARR application were not corrected.
The facility failed to provide outdoor activities for two residents, despite their care plans indicating the importance of such activities. Both residents, who were cognitively intact and had mobility aids, reported being unable to go outside without staff supervision, which was often unavailable. Their activity logs showed minimal participation in outdoor activities, with none recorded in October. The deficiency was confirmed by the Activities Director and discussed with facility leadership.
A facility failed to provide appropriate services to maintain a resident's bladder continence. Initially documented as continent, the resident's care plan inaccurately noted incontinence, and staff were not informed about assisting with toileting. Despite occasional incontinence, there was no evidence of interventions to restore continence, and the resident expressed a desire to use the toilet independently but feared falling. The deficiency was confirmed by the NHA and DON.
A resident with a care plan for nutrition risks was not provided with the appropriate food texture as per his physician's order for a regular diet. Despite the resident's requests for regular texture food, he continued to receive mechanical soft meals. An LPN was unaware of the resident's dietary needs, leading to the deficiency being confirmed by a Regional Clinical Consultant.
The facility failed to accommodate meal preferences for two residents, resulting in one receiving an incorrect lunch despite requesting an alternative, and another reporting no alternative breakfast options. Communication lapses between staff and the kitchen were identified as contributing factors.
The facility failed to provide evening snacks to two residents, leading them to store food in their rooms due to inconsistent meal times and insufficient snack availability. Interviews with CNAs revealed that snacks were sometimes unavailable, and backup snacks were inaccessible after hours. These issues were discussed with facility leadership and an Ombudsman representative.
The facility failed to document the COVID-19 vaccination status of two residents in their EMR, despite records in the DELVAX system confirming their vaccinations. The Infection Preventionist acknowledged the lapse in maintaining vaccination records and the absence of a vaccine clinic in the previous year. These findings were reviewed with facility leadership and an Ombudsman representative.
The facility did not have the survey results from the past three years readily accessible to residents, family members, and legal representatives. The survey results binder was kept behind the reception desk, as confirmed by the receptionist. This issue was discussed with the NHA, DON, RCC, RDO, and an Ombudsman representative.
Failure to Follow Standardized Menus, Recipes, and Portion Sizes for Beef Stew Meal Service
Penalty
Summary
The facility failed to follow its planned menus and standardized recipes for a lunch meal, affecting both regular and pureed beef stew preparations and portions. Facility policy required that nourishing, palatable meals be provided based on RDAs, with standardized cycle menus planned in advance and utilized, and that cooks prepare menu items following written menus and standardized recipes. For the lunch meal in question, the facility’s recipe for beef stew specified beef, Spanish onions, red potatoes, carrots, and celery, and the pureed version was to be made by processing the prepared beef stew until smooth. Observations showed the cook preparing pureed beef stew without potatoes or carrots present in the stew being pureed, and then adding carrots only to the regular beef stew, indicating the recipe was not followed for the pureed diet. The facility’s menu extension for that lunch specified that regular diets were to receive beef stew using an 8 oz serving spoon or two #8 (4 oz) disher scoops, and pureed diets were to receive two #8 (4 oz) disher scoops. However, observations showed the cook serving the regular beef stew with a 6 oz ladle and the pureed beef stew with only one #8 (4 oz) disher scoop, contrary to the planned portions. In interviews, the cook stated he did not follow any recipes because he believed the facility did not have any, and that he relied on a spreadsheet for portion sizes, thinking he had used an 8 oz ladle for regular stew and a #10 (3.2 oz) disher scoop for pureed stew, and that he had been told to always use the #10 scoop. The Regional Dietary Services Consultant, the Registered Dietitian, and the Administrator each stated their expectation that staff follow menus, recipes, and specified portion sizes to meet residents’ nutritional needs and maintain weight, underscoring that the observed practices did not align with facility policies or expectations.
Food Storage, Sanitization, and Hot Holding Temperature Failures in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage practices based on observations, interviews, and policy review. The facility’s undated Food Storage policy required that cooked foods be stored above raw foods, raw animal foods be separated and stored on lower shelves in drip-proof containers, and all foods be covered, labeled, and dated. During a kitchen observation, surveyors found prepared sandwiches in a reach-in cooler that were not dated, lunch meat and cut cantaloupe in the walk-in cooler with no dates, and raw pork breakfast meat stored on a shelf above eggs and lettuce. In the walk-in freezer, frozen waffles were found open to the air and frozen chicken was stored in an unlabeled bag. The Regional Dietary Services Consultant acknowledged that the raw meat should not be stored above lettuce due to cross contamination risk and commented that she had not seen the kitchen look that bad in a long time. A second deficiency involved failure to ensure proper dish machine sanitization and staff competency in monitoring it. The facility’s Cleaning Dishes/Dish Machine policy required dish machines to be checked prior to meals to ensure proper functioning and appropriate temperatures for cleaning and sanitizing. During observation, two dietary aides were washing dishes and reported that they believed the manager checked the dish machine temperature and sanitizer, and that they had never been trained to do so. When a Dietary Director from a sister facility checked the dish machine, no sanitizer was being dispensed, and the dish machine log showed no temperature or sanitizer levels recorded that morning. The manufacturer’s guidelines required a minimum sanitizer concentration of 50 ppm. Later, another Dietary Director checked the sanitizer level in the three-compartment sink and found the concentration appropriate, but stated that dishes needed to soak for 15 seconds, while the posted manufacturer’s guidelines required immersion for 1 to 2 minutes, or a minimum of 60 seconds, prompting recognition that the stated contact time was incorrect. A third deficiency involved improper hot holding temperature monitoring for food being served. The FDA 2022 Food Code requires hot-held food to have an internal temperature of at least 135°F when removed from hot holding temperature control. During a meal service observation, a staff member responsible for cooking and serving took temperatures of certain hot foods on the steam table, including beef stew, pureed beef stew, and pureed carrots, but did not check the temperature of the carrots or mechanical soft beef stew because those items were not listed on the temperature log sheet. The staff member stated that he only checked temperatures of items listed on the log. A Dietary Director later checked the remaining food items and found the carrots were not hot enough, returning them to the stove to be reheated. The Regional Dietary Services Consultant later stated that training of dietary staff was the responsibility of the Dietary Director, that staff working with the dish machine should be checking temperature and sanitizer levels, and that the staff member who had been cooking had only recently transitioned from a dietary aide role.
Unlocked and Unattended Medication and Treatment Carts
Penalty
Summary
The deficiency involves the facility’s failure to keep medication and treatment carts locked when not under the direct observation of the assigned nurse, contrary to facility policy requiring all drugs and biologicals to be stored in locked compartments and secured when not in use. Surveyors observed an unlocked and unattended medication cart on one hall early in the morning, with the assigned LPN acknowledging that the cart should have been locked, stocked, and secured when she left it to go down another hall approximately 64 feet away. Additional observations showed two medication carts and a treatment cart unlocked and unattended near the nurses’ station for two halls, with one cart’s narcotic box door open (though the narcotic box itself was locked). The drawers of these carts contained OTC medications, insulin pens and vials, inhalers, nebulizer medications, and multiple resident bubble packs of prescription drugs including anticoagulants, antipsychotics, antihypertensives, analgesics, diuretics, and potassium chloride. Surveyors further observed another unlocked and unattended medication cart on a different hall, and staff interviews confirmed that nurses had been off the floor and out of sight of their assigned carts for approximately 10–15 minutes while the carts remained unlocked. One agency LPN stated she and another nurse were assigned to the treatment cart and that the carts should not have been left unlocked, acknowledging she had been trained by both the agency and the facility on the importance of locking carts when out of sight. Later that morning, another medication cart on a hall was found unlocked while the assigned LPN was approximately 35 feet away in a resident’s room; the LPN stated she left the cart unlocked to respond to a yelling resident but recognized it should have been locked when not in her line of sight. The DON and the Administrator both stated their expectation that medication and treatment carts be locked when nurses are away and out of sight of the carts, confirming that the observed practices did not meet facility expectations or policy.
Failure to Honor Resident's Right to Refuse Medication
Penalty
Summary
A deficiency occurred when facility staff failed to respect a resident's right to refuse medication. The resident, who had intact cognition and a medical history including anxiety disorder, conversion disorder, rheumatoid arthritis, and depression, was on a bowel protocol due to concerns about constipation. Despite the resident reporting to the nurse that they had already had a bowel movement earlier in the day and refusing the suppository, the nurse continued to attempt administration and ultimately gave the medication with the resident's nighttime medications after repeated requests. Documentation showed that the resident had a large and a medium bowel movement on the day in question, which was not recognized by the nurse at the time of medication administration. The nurse stated he was unaware of any documentation of the resident's bowel movements and relied on a printed list indicating the resident had not had a bowel movement in three days. The nurse did not verify the resident's report by checking the electronic health record or consulting with the assigned CNA, as outlined in facility policy and as described by supervisory staff during interviews. Interviews with supervisory staff, including the LPN Supervisor, ADON, Quality Assurance nurse, DON, and Administrator, confirmed that the expected protocol was to verify a resident's report of a bowel movement by reviewing documentation and consulting with staff before proceeding with further interventions. In this case, the nurse did not follow these steps, resulting in the administration of a suppository against the resident's expressed wishes and without proper verification, thereby failing to honor the resident's right to self-determination and choice.
Failure to Timely Report Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report allegations of abuse and injuries of unknown origin to the state survey agency within the required timeframes for three residents. According to facility policy, all alleged violations involving abuse or serious bodily injury must be reported immediately, but not later than two hours after the allegation is made. In the case of one resident with severe cognitive impairment and a history of behavioral issues, a CNA witnessed an LPN strike and verbally abuse the resident during care. The CNA delayed reporting the incident until after her shift, and the RN Supervisor also waited until the LPN had left the building before notifying the DON. The DON subsequently reported the incident to the state agency over four hours after the alleged abuse occurred. Another resident, who had intact cognition and a history of a recent hip fracture, was found to have a dislocated femur following a routine X-ray. The injury was of unknown origin, and the resident denied any trauma or falls. The injury was not reported to the state survey agency until 26 hours after it was identified, despite facility expectations that such incidents be reported immediately to allow for prompt investigation. The LPN responsible for reporting could not explain the delay. A third incident involved an altercation between two residents, where one resident entered another's room and pulled their hair. Staff intervened and separated the residents, and law enforcement and responsible parties were notified. However, the incident was not reported to the state survey agency until more than three hours after it occurred. Interviews with facility leadership confirmed that these reports were not made within the required timeframes, as outlined in facility policy.
Failure to Thoroughly Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident physical and verbal abuse involving one resident with severe cognitive impairment. The incident involved a resident with a history of type two diabetes mellitus, cirrhosis of the liver, and aphasia, who was admitted with a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The resident was known to refuse care and exhibit combative behaviors. On the date of the incident, a CNA reported that an LPN called the resident derogatory names and struck the resident on the hand and face during care. The CNA did not intervene at the time, stating she was in shock, and delayed reporting the incident until after the LPN had left the building. The facility's investigation included statements from the involved staff, assessment by the Medical Director, and notification of the police, who found no evidence of criminal activity. The resident was assessed and found to have no injuries, and interviews with other cognitively intact residents assigned to the LPN revealed no concerns. However, the investigation did not include assessment of other cognitively impaired residents under the LPN's care for possible signs of abuse. The facility unsubstantiated the allegation based on the lack of physical evidence and the LPN's history, and the LPN was allowed to return to work after a suspension. Despite the steps taken, the facility's investigation was incomplete as it failed to assess all potentially affected residents, particularly those with cognitive impairment who may not be able to report abuse. The deficiency was further highlighted by the fact that the CNA did not intervene or immediately report the incident, and the facility did not ensure that all residents were protected from potential harm during and after the investigation, as required by their own policy.
Failure to Ensure Safe Mechanical Lift Transfer Procedures
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards related to the improper use of a mechanical lift, as required by facility policy. The policy specified that two staff members must assist with mechanical lift transfers to ensure resident safety, dignity, and comfort. Despite this, a certified nursing assistant (CNA) attempted to transfer a resident with significant mobility impairments using a mechanical lift without the required second staff member. The resident's care plan and Kardex clearly indicated the need for two-person assistance during transfers. The incident involved a resident with a history of stroke, hemiplegia, and impaired mobility, who was dependent on staff for transfers. During the transfer from a chair to a bed, the CNA was unable to find another staff member to assist and accepted help from the resident's family member instead. The mechanical lift did not clear the bed properly, and as the CNA attempted to maneuver the resident onto the bed, the lift made contact with the base of the geriatric chair. This caused the resident's weight to shift, resulting in the lift tilting and the resident being lowered to the floor by the CNA and family member. Following the incident, the resident complained of pain and was sent to the emergency department, where imaging showed no fractures or acute injuries. Interviews with staff and the family member confirmed that the transfer was performed by only one staff member, contrary to facility policy and training. The CNA admitted to acting impatiently and not following the required procedure for mechanical lift transfers.
Failure to Maintain Resident Bed in Safe Operating Condition
Penalty
Summary
The facility failed to maintain a resident’s bed in safe operating condition, resulting in a persistently uneven, left-tilting bed over multiple days. Facility policy on providing a safe and homelike environment required staff to report any furniture in disrepair to maintenance promptly. Resident #142, admitted with diagnoses including unspecified dementia, osteoarthritis, and intervertebral disc displacement of the lumbar region, had a care plan identifying potential for falls with injury related to non-compliance with safety measures and specifying use of a concave mattress and other safety interventions. Despite this, surveyors observed on four separate dates that the resident’s bed was visibly uneven with a noticeable left-sided downward tilt. Resident #142 reported that the bed had been broken for a long time, had informed family and facility staff, and expressed fear of falling because the bed was lopsided, although no fall had occurred. When an LPN acting as unit manager operated the bed controls, he confirmed the bed was not even, with the right side higher and tilting to the left, and stated it was the first time he was aware of the issue. The Maintenance Director later examined the bed, stated the bed frame was broken, and could not recall the last time an audit had been done for the resident’s room. The Administrator stated that the expectation was for the Maintenance Director to follow policy and perform routine maintenance, and reported having no prior knowledge that the bed was broken.
Failure to Initiate Bowel Protocol Leads to Hospitalization
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident, identified as R159, who was admitted with diagnoses including Parkinson's Disease, muscle weakness, and dementia. The resident's care plan highlighted a potential for constipation due to decreased motility, with specific interventions to monitor and document bowel movements. Despite these orders, the facility did not initiate the bowel protocol as required when the resident did not have a bowel movement for several days. This oversight occurred on two separate occasions, each lasting five days, during which the bowel protocol was not followed, and the physician was not notified of the lack of bowel movements. As a result of the facility's failure to monitor and initiate the bowel protocol, the resident experienced abdominal pain and was hospitalized for fecal disimpaction. The hospital records indicated a large stool burden in the rectum, and the resident's condition improved after treatment for constipation. Interviews with facility staff confirmed that the bowel protocol should have been initiated after three days without a bowel movement, but this was not done, leading to the resident's hospitalization.
Inadequate Pain Management for Resident with Severe Wounds
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R157, who was admitted for wound care and physical therapy following a hospital stay for septic shock due to an infection in her left lower leg. Despite the hospital discharge summary indicating the need for Oxycodone 10 mg to be administered 30 minutes before dressing changes, the facility did not consistently follow this directive. The resident's pain was not adequately assessed or managed, particularly during dressing changes, leading to the resident experiencing pain during these procedures. R157 had multiple diagnoses, including cellulitis, open wounds, a fractured spine, arthritis, and dementia, which made her a vulnerable resident with significant cognitive impairment. The facility's records lacked evidence of using alternative pain assessment tools for cognitively impaired residents, except for one instance. The resident's daughter, who was actively involved in her care, expressed concerns about her mother's pain management, specifically noting that pain medication was not administered consistently before dressing changes. The facility's inaction in adjusting pain management despite the resident's deteriorating condition and the daughter's expressed concerns resulted in harm to the resident. The resident's wounds showed signs of infection, and her pain management remained unchanged even as her condition worsened. The facility did not document any reasons for not making changes to the pain management plan, and the resident was eventually hospitalized again for treatment of a wound infection.
Inadequate Staffing and Meal Service Delays in Facility
Penalty
Summary
The facility failed to ensure that a qualified person was in charge during kitchen operations, as evidenced by the absence of food service members with valid Food Protection Manager certificates on multiple dates. This was confirmed through interviews and a review of dietary time cards. Additionally, there were significant delays in meal delivery, with breakfast trays not being provided to residents within 45 minutes of the scheduled time. Observations and interviews revealed that breakfast was often delivered late, sometimes close to lunchtime, particularly in the B unit. Further issues were noted with meal delivery on specific dates, where lunch and dinner meals were late and lacked reasonable portions or selection. The facility's dietary time cards confirmed that no qualified food service member was present during these times. These findings were corroborated through interviews with staff and a review of facility records, highlighting a consistent pattern of inadequate staffing and meal service management in the facility's food and nutrition service.
Facility Fails to Maintain Sanitary Environment and Adequate Linen Supply
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment for residents, as observed in multiple rooms across different hallways. In the B hallway, several rooms had dirty floors with stains and dust, and some had additional issues such as exposed nails, rusted bathroom fixtures, and disrepair of windowsills and heating systems. The F hallway had a resident's bed rail improperly placed on a dresser for two weeks, indicating a lack of timely maintenance. The environmental tour confirmed these issues, and it was noted that the facility had experienced frequent changes in maintenance directors, contributing to the lack of consistent oversight. In the shower rooms, there were significant cleanliness issues, including broken tiles, discolored grout, and evidence of insect debris. The shower chairs and floors were dirty, and there was clutter in the form of shoes and wheelchair parts scattered on the floor. Despite claims that the shower rooms were cleaned daily, there was no evidence of housekeeping audits being conducted, and the maintenance director was unable to provide records of monthly maintenance audits. Additionally, there was a shortage of clean linens in the facility, with minimal supplies observed in the linen closets of the E and D wings. Staff confirmed the lack of linens, which affected their ability to provide proper care to residents. The absence of an overnight laundry shift contributed to delays in restocking clean linens, as the morning shift had to manage the backlog from the previous night. These deficiencies were confirmed during interviews with various staff members and reviewed with facility leadership and a representative from the Ombudsman's office.
Failure to Implement Individualized Care Plans for Seizure Disorder and Bed Rail Usage
Penalty
Summary
The facility failed to develop and implement individualized care plans for residents with specific needs related to seizure disorders and bed rail usage. For one resident with a seizure disorder, the clinical record showed an active physician's order for Levetiracem, yet the comprehensive care plan lacked evidence of an individualized seizure disorder care plan. This deficiency was confirmed during an interview with the Director of Nursing and a Licensed Practical Nurse. Additionally, the facility did not have a person-centered care plan for another resident's use of a left-sided quarter-length bed rail, as observed during incontinence care. The absence of a care plan was confirmed during an interview with the Director of Nursing and a Resident Care Coordinator. Furthermore, the facility failed to develop and implement care plans for two other residents regarding their use of bed rails. One resident was observed with bilateral grab bars, but the facility lacked evidence of a person-centered care plan for these bed rails. Another resident, admitted to the facility in 2023, was observed with a left-sided quarter bed rail, yet the care plan did not focus on this aspect. These findings were confirmed during interviews with facility staff, including the Director of Nursing, a Licensed Practical Nurse, and a representative from the Ombudsman's office.
Deficiencies in Care Plan Updates and Infection Control
Penalty
Summary
The facility failed to review and revise the comprehensive care plans for several residents, leading to deficiencies in individualized and person-centered care. For one resident with dementia, the activity care plan was not updated to reflect the resident's preferences and capabilities, despite documented refusals to participate in various activities. The care plan also lacked input from the resident's family, which was noted as important in the admission assessment. Two residents were observed with bilateral quarter-length bed rails, but their care plans did not reflect this current use. The care plans were outdated and did not include person-centered goals or measurable outcomes related to the use of bed rails. This oversight was acknowledged during interviews with facility staff, indicating a failure to ensure that care plans were current and reflective of the residents' needs. Additionally, the care plans for three residents with specific medical conditions, such as dysphagia and dialysis, lacked a focus on infection control precautions. Despite the presence of feeding tubes and dialysis ports, the care plans did not address enhanced barrier precautions, which are critical for preventing infections. This deficiency was confirmed by a registered nurse during an interview, highlighting a gap in the facility's infection control practices.
Improper Delegation of Nursing Assessments
Penalty
Summary
The facility failed to adhere to the Delaware Nursing Scope of Practice by allowing Licensed Practical Nurses (LPNs) to perform assessments that should have been completed by Registered Nurses (RNs). Specifically, for five residents, the facility did not ensure that RNs conducted the necessary admission and post-fall assessments. For one resident, an LPN completed the post-fall assessment, which included vital signs, pain assessment, and neurological checks, instead of an RN as required. Interviews with the Director of Nursing (DON) and Quality Assurance (QA) staff confirmed that the initial post-fall assessment should have been conducted by an RN. Additionally, for four other residents, LPNs completed various admission assessments, including medical history, sensory orientation, pain, musculoskeletal evaluations, and other health-related assessments. These actions were in violation of the state regulations that mandate RNs to perform such assessments. Interviews with the involved LPNs revealed a lack of awareness regarding the scope of practice limitations, and the DON confirmed the facility's requirement for RNs to conduct these assessments. The findings were reviewed with facility leadership and a representative from the Ombudsman office.
Deficiency in Bed Rail Assessment and Documentation
Penalty
Summary
The facility failed to implement a comprehensive system for assessing and documenting the use of bed rails for residents, leading to deficiencies in compliance with federal requirements. For seven residents reviewed, there was a lack of evidence regarding the specific date of bed rail installation, the medical necessity for their use, and attempts to use appropriate alternatives before installation. Additionally, there was no documentation of assessments for risks such as entrapment, nor was there evidence of informed consent being obtained from residents or their representatives. The facility's policy requires a person-centered approach to bed rail use, including a comprehensive assessment of the resident's medical conditions, cognition, mobility, and risk of falling. However, the records for residents R6, R14, R16, R60, R67, R76, and R119 lacked documentation of these assessments. Observations revealed that bed rails were installed without proper evaluation of their necessity or safety, and in some cases, the bed rails were stationary and could not be lowered, posing potential risks to the residents. Interviews with facility staff, including the Rehab Director, revealed that the rehabilitation team evaluates residents for bed rail use but does not specify the size of the bed rails when communicating with maintenance. Despite requests from surveyors, the facility failed to provide the necessary documentation and evidence to support compliance with federal requirements for bed rail use. This lack of documentation and assessment highlights a significant deficiency in the facility's processes for ensuring resident safety and informed decision-making regarding bed rail use.
Failure to Provide Consistent Hydration and Beverage Preferences
Penalty
Summary
The facility failed to provide drinks consistent with the needs and preferences of 10 out of 13 residents reviewed for food. One resident, R6, reported that fluids were not always offered during the day, and they had to request them. An observation confirmed that R6 had not been offered fresh water for two shifts, as evidenced by a dated Styrofoam cup on their bedside table. This issue was discussed with the Nursing Home Administrator, Director of Nursing, and other staff members. Additionally, an observation on the B unit revealed that nine residents did not receive coffee or tea with their breakfast meal trays, despite these beverages being indicated on their meal tickets. Interviews with CNAs confirmed the absence of these beverages, and it was noted that this was a recurring issue. The Dietary Supervisor was unaware of the problem, indicating a breakdown in the kitchen system. The Regional Dietary Consultant confirmed that residents should receive the beverages listed on their meal tickets. This deficiency was also discussed with the facility's administrative and clinical staff.
Unsanitary Food Storage and Preparation Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in its food storage and preparation areas, as observed during an initial tour of the kitchen. The walk-in freezer was found to contain bread, ice cream, and debris on the floor. The standard refrigerator had a pink and orange substance spilled inside at the base. In the dry food storage room, bags of onions, a bag of potatoes, and a container of icing were stored on the floor. Additionally, a pan with meat was left uncovered and unattended on a table, and a prepared salad inside the refrigerator was undated. In the ware washing room, the table where clean dishes come out of the ware washing machine was covered in food debris, and clean plastic mugs were stored in a wet location with visible white spots on them. Furthermore, paper towels were not available at the hand washing sink. A follow-up visit to the kitchen revealed further unsanitary conditions, including small containers of ice cream and muffins turned over on the floor of the walk-in freezer, and a box of muffins left partially uncovered. The ware washing room's dish area table still contained visible food debris. Additionally, a snack/nourishment refrigerator serving multiple units contained a personal lunch bag and food items in Styrofoam inside an undated and unlabeled plastic bag. These findings were confirmed by a registered nurse and discussed with the Nursing Home Administrator, Director of Nursing, and Regional Clinical Consultant.
Deficiencies in Medical Record Keeping and Medication Orders
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for several residents. For instance, the urine culture results for multiple residents were not properly documented in their electronic medical records (EMR). The contracted laboratory did not upload the final culture results to the residents' EMR, and the facility relied on sending these results via email to providers, which led to the absence of these critical results in the residents' records. This issue was confirmed during interviews with facility staff, and the surveyor was provided with copies of the results only upon request. Additionally, the facility did not provide adequate medical diagnoses for the prescription of anticoagulant medications for several residents. The orders for medications such as rivaroxaban, warfarin, and apixaban were documented with indications like 'anticoagulation' or 'blood thinner,' which are not considered valid medical diagnoses. The residents had underlying conditions such as atrial fibrillation and pulmonary embolism, which were the actual medical indications for these medications, but these were not properly documented in the orders. Furthermore, there were discrepancies in the documentation of enteral feed water flushes for residents with feeding tubes. The medication administration records showed inaccuracies in the recorded amounts of water flushes, either being undocumented or incorrectly documented, which was confirmed by facility staff. Additionally, there was a failure to ensure that a resident's care plan accurately reflected their incontinence care needs, as there was a mismatch between the care plan and the CNA Kardex regarding the resident's toileting program.
Inadequate Infection Control and Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of implementation of enhanced barrier precautions for several residents with indwelling medical devices. For instance, a resident with a suprapubic catheter did not have enhanced barrier precautions ordered or implemented for 46 days, despite meeting the criteria for such precautions. During this period, staff provided high-contact care without donning the appropriate personal protective equipment (PPE), such as gowns, which is a requirement for handling indwelling devices. Another resident with a cholecystostomy tube also did not have enhanced barrier precautions ordered or implemented for 103 days. The facility's failure to order and implement these precautions was consistent across multiple residents, including those with PICC lines, Foley catheters, and wounds. The lack of appropriate orders and PPE usage was observed during direct care activities, such as dressing changes and incontinence care, where staff either did not wear the required PPE or were unaware of the need for enhanced precautions. Additionally, an environmental tour revealed infection control issues, such as uncleanable materials on bed frames and uncovered wash bins on dusty floors. These findings were confirmed by facility staff, indicating a broader issue with maintaining a sanitary environment. The facility's policies on infection prevention and enhanced barrier precautions were not effectively implemented, leading to multiple deficiencies in infection control practices.
Deficiencies in Antibiotic Stewardship and Infection Control
Penalty
Summary
The facility failed to ensure antibiotics were prescribed in accordance with recognized standards for three residents. For one resident, antibiotics were prescribed without evidence of a urine culture specimen order or results, despite the resident being treated for a urinary tract infection (UTI). The nurse practitioner ordered two different antibiotics, Cephalexin and Levaquin, without a documented reason or supporting laboratory evidence. The facility's Infection Preventionist was unaware of the rationale behind the antibiotic prescriptions, indicating a lack of communication and adherence to the facility's infection prevention and control program policy. Another resident was readmitted to the facility with a history of a catheter-associated UTI. Although a urine culture was ordered, the facility could not provide the final microbiology report with sensitivity results, which is necessary to meet the McGeer's Criteria for Infection Surveillance. Additionally, a third resident received a one-time dose of an antibiotic for a COPD exacerbation without documentation on the facility's line list or supporting laboratory or radiology reports to confirm the infection. These deficiencies highlight a failure in the facility's antibiotic stewardship program and infection control practices.
Failure to Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to maintain accurate and complete documentation of pneumococcal vaccinations for four residents, R15, R33, R102, and R138, as required by their Infection Prevention and Control Program. For R15, although there was a medical order for a pneumococcal vaccine upon admission, the vaccine was not offered, and there was no documentation of its administration. R33's electronic medical record lacked evidence of an up-to-date pneumococcal vaccine, despite the DELVAX website showing a complete vaccination schedule. Similarly, R102's record did not document the pneumococcal vaccine, even though DELVAX confirmed the administration of PCV20. R138's record also failed to document the administration or refusal of the pneumococcal vaccine, although DELVAX indicated a previous PCV13 vaccination, and the resident was due for PCV20 upon admission. The facility's failure to document these vaccinations was confirmed during an interview with the Infection Preventionist, who acknowledged that the facility had not conducted a vaccine clinic the previous year and that the previous Infection Preventionist had not maintained the vaccination records. The current Infection Preventionist confirmed that the residents' vaccination statuses were documented in the DELVAX system but not in the facility's electronic medical records. This lack of documentation was reviewed with the Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, Resident Care Coordinator, Regional Director of Operations, and a representative from the Ombudsman office.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by two main observations. In the first instance, a resident with a suprapubic catheter had their catheter bag and tubing visibly positioned from the hallway, contrary to the care plan instructions. The CNA responsible for the resident's care was unaware of the proper positioning, and the LPN was not familiar with the care plan details. This oversight was confirmed by the Director of Nursing and other staff members during the survey. In the second instance, a CNA was observed sitting in an armchair with her legs over the armrest and using her cellphone while positioned between two residents eating lunch in the dining room. The CNA was not facing or assisting the residents, indicating a lack of engagement and respect for the residents' dining experience. This behavior was immediately reviewed with a Registered Nurse/Unit Manager and later discussed with the Nursing Home Administrator and other staff members.
Failure to Support Resident Self-Determination in Outdoor Activities
Penalty
Summary
The facility failed to honor the rights of three cognitively intact residents to self-determination and choice regarding outdoor activities. Despite having care plans that included preferences for outdoor activities, residents reported being unable to go outside independently. One resident expressed that new management policies restricted access to an enclosed courtyard unless accompanied by staff, which was not always available. Another resident confirmed the inability to go outside without staff supervision, and the Activities Director corroborated that staff supervision was mandatory for safety reasons, even in the enclosed courtyard. Additionally, a third resident was unable to access the facility lobby or courtyard independently due to locked doors, requiring staff assistance to unlock them. This resident also faced scheduling conflicts between late lunch tray deliveries and afternoon activities, forcing a choice between eating and participating in activities. The facility's meal delivery logs confirmed delays in lunch tray deliveries, which sometimes extended past the scheduled end time, further impacting the resident's ability to engage in preferred activities.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the Ombudsman of a resident's transfer to the hospital, which was a requirement. The resident was admitted to the facility on August 20, 2023, and was transferred to the hospital on April 27, 2024. Upon review of the resident's electronic medical record and the facility's Ombudsman Transfer log for April 2024, there was no evidence that the Office of the State Long-Term Care Ombudsman was notified of this transfer. During an interview, the Nursing Home Administrator (E1) confirmed that the resident was sent to the hospital on the specified date and acknowledged that the resident's name was not on the Ombudsman Transfer log. Additionally, there was no documentation available to prove that the Ombudsman's Office had been notified. These findings were reviewed with several facility staff members and a representative from the Ombudsman office.
Failure to Notify State PASARR Authority of New Mental Disorder Diagnoses
Penalty
Summary
The facility failed to notify the appropriate state-designated authority for two residents when new diagnoses of mental disorders were identified, which is a requirement under the PASARR program. For one resident, R141, the clinical record showed that a PASARR Level I Screen Outcome indicated no Level II was required upon admission. However, after being diagnosed with adjustment disorder with depressed mood and prescribed citalopram for depression, the facility did not inform the state PASARR authority until it was pointed out by a surveyor. This oversight was confirmed by the Nursing Home Administrator (NHA) during an interview. Similarly, for another resident, R125, the facility did not refer the resident for a PASARR Level II screening after being diagnosed with a delusional disorder and prescribed Risperdal, an atypical antipsychotic medication. The resident's PASARR application was also incorrectly filled out by the hospital, stating the medication was for major depression disorder instead of the actual delusional disorder. The facility failed to recognize and correct this error, which was acknowledged by the NHA during an interview.
Failure to Provide Outdoor Activities for Residents
Penalty
Summary
The facility failed to provide outdoor activities for two residents, R20 and R80, during appropriate weather, as outlined in their comprehensive assessments and care plans. R20, who was admitted with an amputation of the left leg above the knee, had an activity care plan that included community outings and outdoor activities during suitable weather. Despite being cognitively intact and self-propelling with a manual wheelchair, R20 expressed that under new management, residents were not allowed to go outside unless accompanied by staff. A review of R20's Daily Activities Log showed minimal participation in outdoor activities over several months, with no outdoor activity recorded in October 2024. Similarly, R80, admitted with muscle weakness and lack of coordination, had a care plan emphasizing the importance of outdoor activities. R80, who used a rolling walker for mobility, also reported being unable to go outside without staff supervision, which was often unavailable. The Daily Activities Log for R80 mirrored that of R20, with limited outdoor activity participation and none in October 2024. The Activities Director confirmed that residents required staff supervision to access the courtyard, and the deficiency was acknowledged by the Regional Clinical Consultant and discussed with the Nursing Home Administrator and Director of Nursing.
Failure to Maintain Bladder Continence for a Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R92, received appropriate services and assistance to maintain bladder continence. Upon admission, R92 was documented as continent of bladder and bowel, but the care plan inaccurately noted incontinence. Despite a three-day voiding diary showing no episodes of incontinence, the care plan interventions included assistance to the toilet as requested and application of barrier cream after incontinent episodes. Over time, R92's records indicated occasional bladder incontinence, but there was no evidence of interventions to restore continence. Interviews with staff revealed a lack of communication and understanding regarding R92's toileting needs. A CNA stated they were not informed about assisting R92 to the toilet, and the resident expressed a desire to use the toilet independently but feared falling. The RNAC explained the facility's process for creating a toileting plan based on voiding diary results, but there was no evidence of a person-centered plan to promote continence for R92. The facility's failure to provide adequate services and assistance to maintain R92's bladder continence was confirmed by the Nursing Home Administrator and Director of Nursing.
Failure to Provide Appropriate Food Texture for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R141, received food prepared in a form that met his individual needs and care plan. R141 was admitted to the facility with a care plan addressing nutrition and hydration risks due to poor food intake and potential weight changes. Despite having a physician's order for a regular texture diet for comfort feeding, R141 was observed receiving a mechanical soft texture meal. During an interview, R141 expressed that he had repeatedly informed the nursing staff of his preference for regular texture food, yet continued to receive chopped and ground food. An LPN confirmed the discrepancy, stating she was unaware of R141's dietary allowance for regular texture food. The deficiency was confirmed by a Regional Clinical Consultant and discussed with the Nursing Home Administrator, Director of Nursing, and the Regional Clinical Consultant.
Failure to Accommodate Resident Meal Preferences
Penalty
Summary
The facility failed to accommodate food preferences for two residents, leading to deficiencies in meal service. One resident expressed a desire for an alternative meal option, specifically requesting a tuna sandwich instead of the primary menu of fried chicken with gravy, mashed potatoes, seasoned spinach, and a dinner roll. Despite communicating this preference to a staff member, the resident received the primary menu items on their lunch tray. The LPN on duty was unaware of the resident's request and confirmed the incorrect meal was served. The Dietary Supervisor acknowledged that alternative menu requests sometimes do not reach the kitchen due to communication lapses, such as staff not placing the request forms in the designated bin outside the kitchen. Another resident reported that the facility does not offer alternative meal choices for breakfast, and there are no breakfast items listed on the always available menu. This was confirmed by the Food Service Director, who admitted the absence of an alternative breakfast menu. These findings were discussed with the Nursing Home Administrator, Director of Nursing, Regional Clinical Consultant, and other relevant staff, highlighting a systemic issue in accommodating resident meal preferences and ensuring effective communication between staff and the kitchen.
Failure to Provide Evening Snacks to Residents
Penalty
Summary
The facility failed to ensure that two residents, R23 and R78, received their evening snacks as per their needs and preferences. R23, who was admitted to the facility on August 3, 2021, reported to a surveyor on October 28, 2024, that she was not receiving her bedtime or evening snacks. She mentioned having to request food from the nursing staff, who informed her that the kitchen had no more snacks available. A review of R23's CNA flowsheet from September to October 2024 showed no evidence of evening snacks being provided. Interviews with CNAs E42 and E43 revealed that there were instances when evening snacks were insufficient or unavailable, and backup snacks stored in the Unit Manager's office were inaccessible after 3:00 PM due to the room being locked. Similarly, R78 reported that the facility did not consistently provide evening snacks, leading residents to store food in their rooms due to the unpredictability of meal times and the lack of timely provision of bedtime snacks. These findings were discussed with the Nursing Home Administrator (E1), Director of Nursing (E2), Resident Care Coordinator (E47), Regional Director of Operations (E58), and a representative from the Ombudsman's office on November 13, 2024.
Failure to Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to properly document the COVID-19 vaccination status of two residents, R25 and R33, in their electronic medical records (EMR). For R25, the clinical record showed no documentation of COVID-19 vaccines administered, despite the DELVAX website indicating that R25 had received vaccines on four separate occasions. Similarly, R33's EMR lacked documentation of COVID-19 vaccines, although DELVAX confirmed that R33 had received vaccines on three different dates. Additionally, the facility could not provide evidence of education or declination of the COVID vaccine for either resident. During an interview, the Infection Preventionist (E4) acknowledged that the facility had not conducted a vaccine clinic in the previous year and that the previous Infection Preventionist had not maintained the vaccination records. E4 confirmed that both R25 and R33 had received COVID-19 vaccines as documented in DELVAX but not in the facility's EMR. These findings were reviewed with the Nursing Home Administrator (E1), Director of Nursing (E2), Assistant Director of Nursing (E27), Resident Care Coordinator (E47), Regional Director of Operations (E58), and a representative from the Ombudsman office.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to make the survey results from the past three years readily accessible to residents, family members, and legal representatives. During a random observation in the facility lobby, it was noted that the survey results were not visible. Upon request by the surveyor, the receptionist retrieved the survey results binder, which was kept behind the reception desk. An interview with the receptionist confirmed that the binder was always stored in this location. These findings were reviewed with the Nursing Home Administrator, Director of Nursing, Resident Care Coordinator, Regional Director of Operations, and a representative from the Ombudsman's office.
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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