Delaware Veterans Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Milford, Delaware.
- Location
- 100 Delaware Veterans Blvd, Milford, Delaware 19963
- CMS Provider Number
- 085051
- Inspections on file
- 21
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Delaware Veterans Home during CMS and state inspections, most recent first.
Multiple cognitively impaired residents with known behavioral issues, including wandering, agitation, and physical aggression, were not adequately protected from resident‑to‑resident abuse. In one case, a resident with dementia and PTSD was pushed to the floor by another resident who had a history of combative behavior, resulting in multiple fractures and facial lacerations after staff initially documented the event as an unwitnessed fall. In another case, two residents with dementia and psychotic features engaged in a physical altercation in a dayroom after one placed his hand on the other’s chest, leading to mutual punching. A separate incident occurred when a resident with dementia and behavioral disturbances entered another resident’s room, pulled at the bedcovers, yelled that the room was his house, and allegedly struck the other resident, who was later noted with puffiness around one eye. In all incidents, the involved residents had documented behavioral care plans and significant cognitive impairment, yet physical confrontations still occurred.
Dirty and wet kitchen equipment was found stored after use, including stacked pans with food debris still present and a can opener blade with a black substance on it. The FSD acknowledged the pans should have been dry, clean, and free of food residue before storage, and the facility policy required equipment to be cleaned after use and pots and pans to be air dried.
A resident with dementia, spinal stenosis, and total dependence for transfers, care-planned for Hoyer lift use with two-person assist, was being transferred from a shower bed to a Geri-chair when the Hoyer lift tipped sideways. Staff reported the lift’s legs had been widened and that one CNA manually pushed the feet apart instead of using the control, and straps may have been unevenly positioned. The resident was lowered to the floor while still in the sling and sustained a small skin tear to the elbow; imaging later showed no fractures. The DON stated that three CNAs were involved, including one on light duty who was not supposed to be using the lift, and that no mechanical defect was found with the lift.
A resident with severe dementia and a BIMS score of 0 had a care plan that was not revised when he developed new wounds to the buttock and penis and when derma sleeves and biker gloves were added for protection. The EMR showed the resident’s existing care plan addressed other skin issues, but it did not include the new wounds or the protective devices, and staff confirmed the care plan had not been updated.
A resident with CHF, renal insufficiency, AFib, atherosclerotic heart disease, and edema had a physician order for daily weights, with instructions to notify the cardiologist for weight gain over three pounds. The care plan also included daily weights for fluid imbalance related to CHF, but the EMR showed multiple missed weight entries across several months, and staff confirmed the order and documentation process.
Bed rail assessments and consents were not completed for three residents. One resident with severe dementia, one resident with a femur fracture, and one resident with hemiplegia were observed with 1/4 side rails in place, but the EMR lacked evidence of risk/benefit review or signed consent for two residents, and one resident had a blank assessment despite rails being on the bed. The DON stated she believed 1/4 side rails did not require consent or explanation of risks and benefits.
Two residents with prior PPSV23 immunizations were not offered updated PCV options, and the IP confirmed awareness of the CDC update was lacking. The facility’s pneumococcal immunization policy had not been revised to match current CDC guidance for adults 50 years and older who previously received PPSV23 only.
Multiple residents did not receive timely treatment for UTIs, with delays in reviewing lab results and initiating antibiotics, and two residents were administered antihypertensive medications despite vital signs being outside physician-ordered parameters. Staff interviews and documentation confirmed lapses in monitoring, communication, and adherence to professional standards.
The facility did not document physician input during care plan meetings for several residents, despite regular provider assessments and completed MDS evaluations. This deficiency was confirmed through record review and staff interviews, which revealed that the charting system failed to capture direct provider involvement at the time of care plan meetings.
A resident who was hospitalized for altered mental status and later medically cleared for discharge experienced a delay in returning to the facility due to concerns about behavior and a preference for weekday readmissions. Facility staff acknowledged these concerns and the delay, but there was no evidence that the resident was allowed to return promptly after being cleared.
Staff failed to use the required Hoyer lift for a resident with significant mobility impairments and a high risk for falls, instead performing a sit-to-stand transfer that resulted in the resident slipping from the sling and being lowered to the floor without injury. Staff interviews confirmed the transfer method used was not appropriate for the resident’s documented needs.
Two residents with positive urine cultures indicating UTIs did not have their abnormal lab results promptly communicated to the ordering practitioner. In both cases, there was either a documented delay or no evidence of provider notification, despite facility procedures requiring immediate notification for positive results.
The facility failed to notify residents and their representatives of the location and reason for discharge at the time of transfer. This deficiency was identified in four residents, whose records lacked necessary details in bed hold notices. Interviews confirmed the missing information, and the facility's policy did not include the required details.
The facility failed to protect two residents from abuse. In one case, a CNA used profanity towards a resident with severe cognitive deficits. In another case, a resident with severe cognitive deficits was found pressing down on another resident's chest. Both incidents were investigated, and the offending CNA was terminated, while the aggressive resident was placed on one-to-one supervision and transferred to a psychiatric facility.
A facility failed to follow infection control procedures during a dressing change for a resident with severe cognitive impairment. The RN did not clean the overbed table or perform hand hygiene after obtaining a dressing from the treatment cart, contrary to the facility's wound care policy.
Failure to Prevent Resident‑to‑Resident Physical Abuse Among Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from resident‑to‑resident physical abuse. One resident with dementia, agitation, depression, anxiety, and PTSD, and a BIMS score indicating moderate cognitive impairment, was pushed to the floor by another resident after that resident entered his room and followed him into the hallway. Staff initially documented the event as an unwitnessed fall after hearing loud screaming and finding the resident on the floor with complaints of right shoulder and left wrist pain, active bleeding from facial lacerations, and clamminess. Subsequent review of surveillance footage showed that another resident walked into the victim’s room, then followed him out and pushed him, causing the fall that resulted in multiple fractures, including a closed left distal radius fracture, a closed, displaced comminuted right proximal humerus fracture, and a closed, displaced distal clavicle fracture. The resident who pushed him had dementia with mood disturbances, bipolar disorder with psychotic features, PTSD, insomnia, and depression, and a BIMS score indicating severe cognitive impairment. His care plan identified a behavior problem related to bipolar disorder and dementia, including wandering, refusal of care, and physical aggression toward staff and others, such as biting a CNA and swinging a walker at a CNA. The care plan directed staff to anticipate and meet his needs, divert him with alternative objects or activities, intervene to protect the rights and safety of others, and conduct safety checks. Despite these identified risks and interventions, he was able to enter another resident’s room and subsequently push that resident in the hallway, resulting in serious injury. Another incident involved two residents with significant cognitive impairment and behavioral symptoms, including delusions, physical behaviors toward others, agitation, and a tendency to invade others’ personal space. One resident, who was described as aggressive toward others, easily agitated, and prone to getting into others’ personal space, walked next to another resident sitting in a dayroom chair and placed his hand on that resident’s chest. The seated resident responded by punching him in the face with the back of his fist, and the first resident then punched back. Staff and psychiatric documentation noted this altercation and ongoing behavioral concerns such as combativeness with care, agitation, and wandering, but the record contained no additional progress notes describing the incident itself beyond the brief psychiatric follow‑up entry. A further incident occurred when a resident with anxiety, major depressive disorder, dementia with behavioral disturbances, agitation, and severe cognitive impairment entered another resident’s room on the memory care unit. The resident in the room, who had depression, anxiety, dementia without behavioral disturbances, PTSD, insomnia, hallucinations, verbal behaviors toward others, other behavioral symptoms, and wandering, reported that he was hit in the face. Staff heard yelling and found the intruding resident pulling covers at the foot of the bed and yelling that the room was his house, while the other resident sat on the side of the bed and stated that he had been hit and told staff to get a gun and shoot the other resident. Slight puffiness was noted around the reporting resident’s left eye. The intruding resident’s care plan documented compulsiveness, invading others’ personal space, yelling, restlessness, physical aggression, and attempts to assist other residents he believed needed help, with interventions to divert him, familiarize him with his surroundings, and intervene to protect the rights and safety of others. Despite these identified behaviors and interventions, he was able to enter another resident’s room, engage in a confrontation, and allegedly strike the resident.
Dirty and Wet Kitchen Equipment Stored After Use
Penalty
Summary
The facility failed to ensure kitchen staff thoroughly cleaned and air-dried pots and pans and failed to ensure one of two can openers had been cleaned. During an observation on 03/09/26 at 10:30 AM, three 6x6x6 stainless steel pans and six 6x24x6 stainless steel pans were stacked on a storage rack and were wet inside with some food debris remaining. During an interview on 03/09/26 at 10:50 AM, the Food Service Director stated the pans were wet, should not have been, and should have been dry, clean, and free of remaining food before being put away. During an observation on 03/09/26 at 11:00 AM, one of two can openers bolted to a preparation table had a black substance on the blade, and the Food Service Director stated the blade was dirty and should be clean. The facility policy titled Food Preparation Area stated that all machines and equipment requiring cleaning shall be cleaned after use and that pots and pans should be washed thoroughly, rinsed to remove all traces of food and detergent, and inverted on an open shelving rack for air drying.
Resident Injury from Improper Hoyer Lift Operation During Transfer
Penalty
Summary
The deficiency involves the facility’s failure to prevent an accident during a Hoyer lift transfer, resulting in a fall and skin tear injury to a resident. The resident had diagnoses including spinal stenosis, Alzheimer’s disease, vascular dementia with behavioral disturbance, bipolar disorder, and pain, and was documented on the MDS as dependent on staff for transfers from bed to chair. The care plan and physician orders specified that the resident required a Hoyer lift with assistance of two staff for transfers. On the day of the incident, the resident was being transferred via Hoyer lift after a shower, from a shower bed back to a Geri-chair. Progress notes and the post-fall evaluation documented that the fall occurred in the bathroom during a Hoyer transfer with staff assistance of two, and that the Hoyer lift tipped sideways. The resident was found on the floor in the sling, with staff reporting that the Hoyer lift’s legs were widened and that as the resident was being positioned over the chair, the lift tipped to the side. Staff held the sling on each side of the resident’s head and lowered the resident to the floor, after which a skin tear measuring 1.0 cm x 0.1 cm was noted on the elbow. The facility’s investigation determined that the Hoyer tipped because one CNA pushed the lift’s feet apart manually instead of using the designated button to open the legs. Interviews indicated that the manual mechanical lift used at the time was considered less steady and required manual operation of a foot pedal to open the legs, and that the straps may have been more to one side than the other. The DON reported that three CNAs were involved with operating the lift at the time of the incident, including one CNA on light duty who was not supposed to be using the Hoyer lift, and that the lift itself was later found to have no mechanical problems. As a result of the tipping incident, the resident sustained a skin tear to the elbow and required diagnostic imaging to rule out fractures.
Care plan not updated for new wounds and protective devices
Penalty
Summary
The facility failed to ensure R19’s comprehensive care plan was revised and updated when his condition changed. R19 was admitted with Alzheimer’s disease and severe dementia with behavioral disturbances, and his quarterly MDS showed a BIMS score of 0 out of 15, indicating severe cognitive impairment. The care plan in the EMR included a focus on excoriation to the left buttock and a separate focus for risk of skin impairment related to fragile skin, bowel incontinence, and limited mobility, but it was not updated to reflect new care needs that developed during the stay. Record review showed R19 developed a new wound to the right buttock on 02/12/26, which worsened by 02/26/26, and also had a wound to the penis with an order for bacitracin ointment twice daily. The Tasks List also showed derma sleeves to both upper extremities when out of bed and biker gloves to the hands, but the list did not indicate when the gloves were to be applied or removed. During observations, R19 was seen wearing derma sleeves and biker gloves while up in a geri-chair. RN1 stated the sleeves and gloves were used to protect the backs of his hands and arms because he tended to flail his arms and hit staff or bed rails. The nursing supervisor and the Administrator both confirmed the care plan was not revised to reflect the new wounds or the protective devices.
Failure to Document Ordered Daily Weights for Resident With CHF
Penalty
Summary
The facility failed to provide quality care for one resident reviewed for physician orders by not performing daily weights as ordered. The resident was admitted with diagnoses including acute kidney failure, heart failure, atrial fibrillation, atherosclerotic heart disease, and edema, and the quarterly MDS documented heart failure and renal insufficiency. The care plan identified fluid imbalances and kidney insufficiency due to congestive heart failure, with a goal for the resident to remain free of fluid imbalance and an intervention for daily weights to be obtained. The EMR order summary documented a physician order for daily weights for congestive heart failure, with instructions to call the cardiologist if daily weight gain was greater than three pounds. Review of the weights and vitals summary showed multiple dates with no weights documented, including several dates across August 2025 through February 2026. During interview, an RN stated the resident was to have daily weights due to congestive heart failure, and the nursing supervisor confirmed the physician order and stated staff were to enter the weights in the EMR under the Wts/Vitals tab.
Bed Rail Assessments and Consents Not Completed
Penalty
Summary
The facility failed to assess the entrapment risk of bed rails used for mobility assistance and failed to obtain consents for three residents reviewed for accident hazards: R19, R24, and R37. The report states that the facility also did not have a policy for bed rails. During review of R19, who had diagnoses of Alzheimer's disease with late onset and severe dementia with behavioral disturbances and a BIMS score of 0, the resident was observed in bed with 1/4 side rails up on both sides, but there was no evidence in the EMR of any bed rail assessment, discussion of risks and benefits, or signed consent from the resident's representative. RN1 later observed that R19 could not grab or use the side rails for mobility or during care and stated the resident had never been able to use them. For R24, who was admitted with a left femur fracture and had BIMS scores of 13 and later 15, one bed rail assessment stated the resident did not need bed rails and was signed by the resident, but a later assessment was blank. Despite the earlier assessment indicating bed rails were not indicated, the resident was observed with 1/4 side rails up on both sides of the bed and said he used them for positioning, but could not remember being informed of the risks and benefits. For R37, who had hemiplegia and hemiparesis following a stroke and a BIMS score of 15, the bed rail assessment was blank, yet the resident was observed with bilateral 1/4 side rails up and stated he used them for positioning and mobility, but could not remember if anyone had reviewed the risks and benefits or when the rails were placed on the bed. The Administrator stated she thought 1/4 side rails did not require consent or explanation of risks and benefits, and confirmed there were no signed consents or evidence that R19, R24, or R37 or their representatives were provided the risks and benefits.
Failure to Offer Updated Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure two residents reviewed for pneumococcal vaccination, R5 and R13, were offered an updated pneumococcal vaccine. R5’s EMR showed admission to the facility and an immunization record documenting receipt of PPSV23 on 11/11/21, but there was no evidence that R5 was offered PCV15, PCV20, or PCV21. R13’s EMR showed admission to the facility and an immunization record documenting receipt of PPSV23 on 10/16/23, but there was no evidence that R13 was offered PCV15, PCV20, or PCV21. During interview on 03/12/26 at 10:15 AM, the Infection Preventionist confirmed that R5 and R13 were not offered PCV15, PCV20, or PCV21 and stated they were unaware of the updated CDC guidance. Review of the facility’s pneumococcal immunization policy showed it had not been revised to reflect the updated CDC recommendations, despite stating it would be reviewed annually and revised according to new CDC guidance. Review of CDC guidance dated 01/08/25 showed adults 50 years and older who previously received PPSV23 only should receive a single dose of PCV21, PCV20, or PCV15 after one year from the last PPSV23 dose.
Failure to Provide Timely UTI Treatment and Adhere to Medication Parameters
Penalty
Summary
The facility failed to provide timely and appropriate treatment for urinary tract infections (UTIs) and did not follow physician orders for medication administration, resulting in deficiencies in care for multiple residents. In one case, a resident with a history of stroke, Parkinson's disease, and dementia exhibited confusion and lethargy, prompting a physician to order a urinalysis and urine culture. Although the lab results confirmed a UTI, there was no evidence in the clinical record that the infection was addressed for several days. The resident's condition deteriorated, leading to hospitalization for altered mental status, where the UTI was treated with IV antibiotics. Interviews confirmed that the provider was not notified of the critical lab results, and no antibiotics were ordered prior to the resident's transfer to the hospital. Another resident experienced a delay in treatment for a UTI. After reporting hallucinations, a urinalysis and culture were ordered and collected, with results confirming a UTI. However, there was a two-day delay before the results were reviewed and antibiotics were prescribed. Staff interviews revealed that lab results are supposed to be monitored and communicated to providers promptly, but this process was not followed, resulting in delayed care. Additionally, two residents received antihypertensive medications despite their vital signs being outside the parameters specified in physician orders. Medication administration records showed that the medications were given even when blood pressure or heart rate readings were below the hold parameters. Pharmacist reviews noted these discrepancies, and staff interviews confirmed that medications should have been held and providers notified if an ongoing pattern was observed. These failures demonstrate a lack of adherence to professional standards of practice and physician orders.
Lack of Physician Input in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that all required interdisciplinary team (IDT) members, specifically the physician, provided input during care plan meetings for five out of nineteen sampled residents. Record reviews showed that for multiple care plan meetings following comprehensive assessments, there was no documented evidence of physician input. This occurred repeatedly for several residents at both quarterly and annual care plan meetings, despite the completion of Minimum Data Set (MDS) assessments as required. Interviews with facility staff confirmed that the current charting system did not reflect direct provider input at the time of care plan meetings, even though residents were regularly seen and assessed by providers. The lack of documented physician participation was consistent across several care plan meetings for the affected residents, as noted in the care plan meeting notes.
Failure to Permit Timely Return of Hospitalized Resident
Penalty
Summary
A deficiency was identified when a resident who had been admitted to the facility was hospitalized for altered mental status and a psychiatric evaluation. The resident was medically cleared for discharge from the hospital, but there was a delay in their return to the facility. Hospital records indicated that the facility was not accepting the resident back on weekends, and there were ongoing placement issues, with the facility expressing concerns about the resident's behaviors and safety for both the resident and staff. Despite being medically stable and not requiring inpatient psychiatric care, the resident remained in the hospital for several days after being cleared for discharge due to the facility's reluctance to readmit him. Interviews with facility staff confirmed that there was a preference for weekday readmissions, although they stated that weekend returns were not refused. Staff also acknowledged concerns about the resident's behavior and safety, which contributed to the delay. There was no documentation or evidence provided to support that the resident was allowed to return to the facility in a timely manner after being medically cleared, resulting in a failure to permit the resident's prompt return following hospitalization.
Failure to Use Correct Transfer Device for High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to use the correct assistive device for transferring a resident who was at high risk for falls. The resident, who had diagnoses including peripheral autonomic neuropathy, lack of coordination, generalized muscle weakness, and unsteadiness, was care planned as a total assist for transfers and required a Hoyer lift with two staff. Despite this, staff used a sit-to-stand transfer method instead of the Hoyer lift, which was not appropriate for the resident’s condition. During the transfer, the resident began to slip out of the sling and was gradually lowered to the floor by staff. The resident did not sustain any injuries during this incident. Interviews with staff confirmed that the sit-to-stand transfer was used in error, and that the resident was supposed to be transferred with a Hoyer lift due to his inability to safely participate in a sit-to-stand transfer. The staff involved did not verify the correct transfer method before proceeding, despite the resident’s documented need for a Hoyer lift and his history of not being able to hold on during transfers. The incident was witnessed and documented, and the error was attributed to not following the resident’s transfer requirements as outlined in his care plan and physician orders.
Failure to Promptly Notify Provider of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify the ordering medical practitioner of abnormal laboratory results for two residents. In one case, a resident was admitted and had a physician's order for a urinalysis with culture and sensitivity. The urine sample was collected and sent to the lab, and the results revealed a urinary tract infection with significant bacterial growth. However, there was a two-day delay before the provider was notified and reviewed the results, after which an antibiotic was ordered. Interviews with nursing staff indicated that lab results are supposed to be tracked by the unit manager or supervisor, and positive results are faxed and monitored each shift, with the expectation that providers are notified immediately for positive cultures. In another case, a resident with Parkinson's disease, a history of stroke, and dementia had a physician's order for a urinalysis with culture and sensitivity. The results, which indicated a urinary tract infection, were faxed to the supervisor's office, but there was no evidence in the clinical record of provider notification or documentation of the results. The DON and the physician confirmed that the provider was not notified of the positive results. These findings demonstrate a failure to ensure timely communication of abnormal laboratory results to the ordering practitioner.
Failure to Notify Residents and Representatives of Transfer Details
Penalty
Summary
The facility failed to ensure that residents and their representatives were notified at the time of discharge about the location and reason for the discharge. This deficiency was identified in four residents who were hospitalized. For Resident 13, the electronic medical record lacked information about the reason or destination of the transfer, and the bed hold notices did not document where the resident was transferred to or why the transfer was needed. Similarly, Resident 19's records did not indicate the location of the transfer, and the bed hold notices sent to the resident's power of attorney also lacked this information. Social services progress notes confirmed that the necessary details were not provided in the notifications. Resident 12's records showed that the resident was hospitalized twice, but there was no written evidence that a bed hold notification with the location or reason for the transfer was provided to the resident or their representative. For Resident 39, who was transferred to an inpatient psychiatric facility after a physical altercation with another resident, the bed hold notice did not include the name of the facility or the reason for the transfer. Interviews with the Social Work Consultant and the Administrator confirmed that the bed hold information sent out lacked the required details about the reason and location of the discharge. The facility's policy on bed holds, dated January 4, 2024, stated that written notice specifying the duration of the bed-hold policy and information explaining the return of the resident to the next available bed should be provided at the time of transfer. However, the policy did not include information about the reason or location of the transfer, which was a key factor in the deficiency. The Administrator confirmed that the information was missing on the forms sent to the residents or their representatives.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse. In the first incident, a Certified Nurse Aide (CNA) used profanity towards a resident during care. The resident, who had severe cognitive deficits due to dementia and anxiety, was not compliant with care, which led the CNA to become frustrated and use inappropriate language. This incident was witnessed by another CNA, who reported it to the Assistant Director of Nurses (ADON). The offending CNA was subsequently removed from the unit, suspended, and terminated following an investigation. The resident did not exhibit any behavior changes or recall the incident when questioned by the Social Worker. In the second incident, another resident with severe cognitive deficits due to Alzheimer's and other mental health conditions was found kneeling on another resident's bed and pressing down on the resident's chest. The resident being pressed down had severe cognitive deficits due to neurocognitive disorder with Lewy bodies and PTSD. Staff intervened and redirected the aggressive resident, who was later placed on one-to-one supervision and transferred to an inpatient psychiatric facility. The aggressive resident believed the bed was his own and did not realize he was in another resident's room. Both incidents highlight the facility's failure to protect residents from abuse, as required by their policies. The facility's policy on abuse and neglect mandates that incidents of abuse be investigated, reported, and that staff be educated and trained. Despite these policies, the facility did not prevent these incidents of abuse from occurring, resulting in potential harm to the residents involved.
Infection Control Lapses During Wound Care
Penalty
Summary
The facility failed to follow infection control procedures during a dressing change for a resident with severe cognitive impairment. Specifically, the Registered Nurse (RN) did not clean the overbed table or place a barrier on it before placing clean wound supplies on the table. Additionally, the RN did not perform hand hygiene after returning to the room from obtaining a dressing from the treatment cart. These actions were observed during a dressing change for a resident with chronic atrial fibrillation, post-traumatic stress disorder, idiopathic progressive neuropathy, and acute neurologic conditions, who had two open areas behind the left knee requiring wound care. The facility's policy and procedure for wound care were not followed, as the RN failed to clean the overbed table, perform hand hygiene upon returning to the room, and date the dressing as per protocol. During an interview, the RN confirmed these lapses in procedure, and the Unit Manager stated that the expectation was to clean the overbed table and wash hands again when returning to the room. The Administrator also confirmed that retraining on handwashing and wound care criteria had been conducted after the incident.
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Three residents who were dependent on staff for bed mobility and transfers did not receive adequate supervision and safe handling during care and transfers, resulting in serious injuries. A resident who was totally dependent for bed mobility slid from the bed to the floor while a CNA focused on gathering supplies during care, later being found to have an ankle fracture. Another resident with a prior brain bleed, craniotomy, and left-sided paralysis, requiring a mechanical lift with two staff, sustained a head injury when a Hoyer lift was improperly positioned or controlled during transfer from a shower bed to a wheelchair, causing the lift bar to strike the top of the head and leading to ongoing head and neck pain. A third resident needing extensive assistance fell between a shower bed and her regular bed when a CNA attempted to transfer her without locking the shower bed wheels, resulting in acute L2–L3 compression fractures confirmed by CT.
A resident who required set-up assistance for eating spilled coffee onto bare upper thighs while being prepared for morning care, initially resulting in nonblanchable redness with intact skin and no reported pain. During later incontinence care, staff identified a broken blister on the resident’s right upper thigh, cleansed the area, and applied skin prep, but did not notify the MD until more than a day after the blister was first noted. An NP confirmed that although she had been informed of the coffee spill itself, there was no documentation that the subsequent change in skin condition had been communicated to a provider, resulting in a failure to promptly notify the on-call provider of the new skin alteration.
A resident with significant neurologic impairment and multiple contractures slid from bed and was assisted to the floor during the night shift, but an RN did not complete the initial post-fall assessment until the following day shift. An LPN documented that the resident was seated after the event, denied pain, had ROM and VS assessed, and was assisted back to bed with a CNA. The DON later reported that the CNA and LPN did not report the event as a fall because the resident was assisted down, and the LPN stated she relied on the CNA’s account when completing the incident report and was unsure if the RN had been notified.
A resident reported an allegation of physical abuse by a CNA during the night shift, which was documented in the clinical record. Facility policy required that all alleged violations be reported to the Administrator, state agency, APS, and other required agencies immediately but no later than two hours after the allegation. Instead, the allegation was reported to the state agency approximately nine hours after it was made. An RN acknowledged not reporting the allegation right away and waiting for the day shift, and the DON confirmed that the reporting timeframe was not followed.
A resident with dementia and a care plan for false accusations alleged physical abuse by a CNA. Facility policy required staffing or room changes to protect residents from an alleged perpetrator, but the CNA remained on duty providing care to other residents for the rest of the shift. An LPN and an RN confirmed that the CNA continued working with residents, with the CNA only being stopped from caring for the accusing resident’s room, resulting in a failure to fully implement the abuse protection policy.
A resident with CHF and kidney disease requiring dialysis was admitted and assessed as having congestive heart failure, but the baseline care plan lacked CHF-related interventions and there was no timely physician order for fluid restriction despite a nutrition assessment referencing a 1500 mL limit. A physician note identified the resident as high risk for rehospitalization and called for strict I&O and daily weights, yet a formal fluid restriction order was not entered until several days later, only after the responsible party requested it. The next day, the resident was sent to the hospital from dialysis for chest pain and shortness of breath. In interviews, the MD, RN, and DON all confirmed the resident should have been placed on fluid restriction and monitoring upon admission and that this was not done in a timely manner.
Surveyors found that dietary staff repeatedly failed to wear required hair and beard restraints while preparing food, washing dishes, and serving meals, and the Dietary Manager acknowledged that restraints should be worn at all times but that the facility had run out of them. These unsanitary practices occurred during routine kitchen operations and affected nearly all residents who received meals from the kitchen, with only two residents receiving nutrition via feeding tubes.
Surveyors found that medication carts were left unlocked and unattended in two separate locations. One cart on a hall outside a resident room was left unlocked while an LPN was inside the room with the privacy curtain pulled and unable to see the cart, with only a CNA present further down the hall. Another cart at the nurses’ station, shared by nurses on two halls, remained unlocked while the ADON walked past it twice and then left the area, leaving no one at the station until returning several minutes later to lock it. Facility policy required all medication and treatment carts to be locked when not in use and not left unattended while unlocked.
The facility did not provide required written information on advance directives and the right to accept or refuse medical and surgical treatment to two residents, one cognitively intact and one with moderately impaired cognition, as confirmed by EMR review showing no such documentation. The SSD reported having no written materials explaining types of advance directives or any signature page confirming verbal explanations or resident understanding. The AD stated the admission packet only asked whether a resident had or wanted an advance directive and did not include written definitions or explanations. The Administrator acknowledged being unaware of regulatory requirements and of the facility policy, which states that residents have the right to formulate an advance directive and to accept or refuse treatment, and that written information must be provided in an easily understood manner.
A cognitively intact resident with mild cognitive impairment reported to her son that a male CNA entered her room at night to provide incontinent care, which she refused, and that he returned and made an inappropriate sexualized remark when she again refused care. The son called the facility to report the concern, and the Admissions Director stated she immediately informed the DON, in line with protocol to notify leadership of abuse-related grievances. However, the DON reported she did not recall receiving the grievance and only became aware of the allegation when law enforcement arrived several days later after receiving a family complaint. The DON confirmed that the SSA was not notified of the abuse allegation until four days after the initial grievance, despite facility policy and leadership acknowledging that alleged abuse must be reported to the SSA within two hours.
Failure to Provide Adequate Supervision and Safe Transfers Resulting in Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate assistance and supervision to prevent accidents for three residents who were dependent on staff for mobility and transfers. One resident with anoxic brain injury, multiple contractures, abnormal posture, and idiopathic progressive neuropathy was documented on multiple MDS assessments as requiring substantial/maximal assistance for bed mobility and was described by nursing and therapy staff as totally dependent and unable to move or roll in bed without physical assistance. During nighttime care, a CNA entered the room in response to a call light, found that the resident had vomited, and focused on looking for towels while standing on one side of the bed. The CNA reported that the resident then began sliding off the opposite side of the bed; the CNA ran around the bed but was unable to prevent the resident from sliding off, and instead lowered the resident to the floor in a seated position. Subsequent imaging confirmed a stable right ankle fracture, and interviews with the NP, OT, LPN, and other CNAs confirmed that the resident was dependent for bed mobility and could not independently roll or slide out of bed, indicating that the resident did not receive the level of hands-on assistance and supervision consistent with their documented needs. A second resident with a history of brain bleed, seizure disorder, craniotomy, and left-sided paralysis had a care plan and therapy determination requiring a mechanical (Hoyer) lift with two staff for all transfers and was completely dependent on staff for bathing and transfers. During a transfer from a shower bed back to a wheelchair using a mechanical lift, the resident reported that the hooks of the lift were not properly attached to the bars, causing the front of the lift to become unbalanced and tilt backward, dropping the resident into the chair and allowing the lift bars to strike the top of the resident’s head at the craniotomy site. The resident stated that the lift was not moving when staff attempted to place him in the chair and that this type of incident had not occurred during prior showers, when he was typically returned to his room on the shower bed and transferred in bed. One CNA described that while assisting with the transfer, the lift appeared stuck and positioned sideways over the wheelchair; when she voiced concern and attempted to correct the position, the lift rose and the bar hit the resident’s head. The other CNA involved stated that as she operated the lift controls, the resident’s weight shifted, the lift tipped back, and the bar struck the top of his head. The physician documented a head strike from the Hoyer lift with subsequent head and neck pain, and the resident required repeated PRN pain medication for ongoing head and neck pain. A third resident with cerebral infarction and rheumatoid arthritis had orders and MDS documentation indicating a need for extensive to maximal assistance with bed mobility and dressing. After receiving a shower, this resident was brought back to the room on a shower bed. The facility’s incident report documented that the CNA lowered the side rail of the shower bed, pushed the shower bed against the resident’s bed, turned the resident on her side, removed the bath sheet, and began pushing the Hoyer pad underneath. During this process, the resident rolled and fell between the two beds to the floor, becoming very anxious and crying. A subsequent CT scan at the hospital revealed acute L2 and L3 vertebral compression fractures. In a later interview, the CNA acknowledged that she must have forgotten to lock the wheels on the shower bed before attempting the transfer, and described that when she rolled the resident to place the Hoyer pad, the shower bed separated from the resident’s bed, allowing the resident to fall between them. These events demonstrate that the resident did not receive adequate supervision and safe handling during the transfer process, despite her documented need for extensive assistance with mobility.
Failure to Timely Notify Provider of New Skin Blister After Coffee Spill
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a provider of a change in a resident’s skin condition following a coffee spill incident. The resident was admitted earlier in the month, and the admission MDS documented that the resident required set-up assistance for eating. On the morning of 3/30/26, a nurse documented that the resident placed a cup of coffee on the bed railing, and when he let go, the cup fell onto his lap, spilling hot coffee onto his bilateral upper thighs while he was not wearing pants and was about to receive morning care. At that time, the nurse documented nonblanchable redness on both upper thighs with all skin intact, and later that day a wound care RN documented that there was no scalded skin present and the resident denied pain. A late entry nurse’s note documented that during incontinence care on 3/31/26, a broken blister on the resident’s right upper thigh was identified, cleansed with saline, patted dry, and skin prep applied. Review of incident documentation showed that the physician was not notified of this blister until 4/1/26 at 8:38 AM, more than 24 hours after the blister was first identified. During interview, the NP stated she had been notified of the coffee spill on 3/30/26 but, upon reviewing the physician binder, confirmed there was no evidence that the change in skin condition noted on 3/31/26 had been communicated to a provider at that time. The facility therefore failed to notify the on-call provider when the resident experienced a change in skin condition after the coffee spill incident.
Failure to Obtain Timely RN Post-Fall Assessment After Assisted Descent to Floor
Penalty
Summary
The facility failed to ensure that an RN performed and documented an initial post-fall assessment for a resident who slid off the bed and was lowered to the floor during the 11 PM–7 AM shift. The resident had significant medical conditions including anoxic brain injury, abnormal posture, multiple contractures of the upper and lower limbs, and idiopathic progressive neuropathy. A facility-reported incident documented that the resident sustained a fall with later complaint of ankle pain, with an X-ray obtained and results unclear, and a repeat film obtained two days later. The clinical record showed that the initial post-fall assessment was not completed by an RN until 8:34 AM on the 7 AM–3 PM shift by the ADON, and there was no evidence of an RN assessment during the overnight shift when the fall occurred. A witness summary completed by an LPN documented that the resident was in a seated position after the fall, denied pain, had range of motion assessed, denied pain again, had vital signs taken, and was assisted by a CNA back to bed. During interviews, the DON stated that the fall was not reported by the CNA and the LPN because they did not consider it a fall since the resident was assisted to the floor. In a phone interview, the LPN confirmed being called by the CNA about the fall, stated that care and an assessment were provided, and indicated uncertainty about whether the RN was notified, noting that the written incident report was based on what the CNA reported and that the LPN was not present at the time of the fall.
Failure to Timely Report Allegation of Staff-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure immediate reporting of an allegation of staff-to-resident physical abuse in accordance with its abuse policy and regulatory time frames. The facility’s abuse policy, last updated January 2026, required that all alleged violations be reported to the Administrator, state agency, adult protective services, and other required agencies immediately but no later than two hours after the allegation is made. On 6/12/25 at 3:31 AM, an incident note in the clinical record documented that resident R83 alleged physical abuse by a CNA (E8). However, the allegation was not reported to the State Agency until 11:21 AM the same day, approximately nine hours after the allegation was made, exceeding the required reporting timeframe. During an interview on 4/23/26 at 11:06 AM, an RN (E6) confirmed that the allegation was not immediately reported and stated that the DON later informed her it should have been reported right away rather than waiting for day shift. In a separate interview at 11:14 AM, the DON (E2) confirmed these findings. The deficiency centers on the delayed reporting of the abuse allegation to the State Agency despite clear policy requirements for immediate notification. The survey findings were reviewed with the Nursing Home Administrator (E1), the DON (E2), and others at the exit conference on 4/23/26 at 3:00 PM.
Failure to Remove Accused Staff From Resident Care After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from further potential abuse by not immediately removing an accused staff member from resident care following an allegation of physical abuse. The facility’s abuse policy, updated January 2026, states that room or staffing changes are to be made as necessary to protect residents from the alleged perpetrator. On 6/12/25 at 11:21 AM, the facility reported an allegation of staff-to-resident physical abuse involving resident R83 and CNA E8. Record review of E8’s timesheet showed that after this allegation, E8 remained in the facility working with residents until 7:05 AM. During interview, LPN E7, who was assigned to R83’s unit at the time, confirmed that E8 continued caring for residents after R83’s accusation and stated that R83 had dementia and a care plan for false accusations, and that E8 was only stopped from caring for R83’s room for the rest of the shift. RN E6 also confirmed that E8 continued caring for residents after the allegation and stated that she instructed E8 to care for other patients. These findings were reviewed with the NHA (E1) and DON (E2) during the exit conference. The resident involved, R83, had dementia and a documented care plan for false accusations, which influenced staff’s decision to limit E8’s contact only with R83 rather than removing E8 from all resident care. Despite the facility’s written policy requiring protective staffing or room changes to safeguard residents from an alleged perpetrator, E8 remained on duty providing care to other residents for the remainder of the shift after the allegation of physical abuse was made.
Failure to Implement Timely Fluid Restriction and Monitoring for Resident With CHF and Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and monitoring consistent with professional standards of practice for a resident admitted with congestive heart failure and kidney disease requiring dialysis. The resident was hospitalized for multiple conditions, including heart failure, and then admitted to the facility with diagnoses of congestive heart failure and kidney disease. An admission assessment by an RN documented congestive heart failure, but the baseline care plan did not include any interventions related to this diagnosis. A nutrition assessment documented that the resident was on a therapeutic meal plan with a 1500 mL fluid restriction and indicated ongoing monitoring of oral intake, weight, skin integrity, and labs, yet the physician’s orders and dietary intake records did not contain an order for fluid restriction. A physician progress note documented that the resident had multiple complex comorbidities, including heart failure, and was at high risk for rehospitalization without proper care, specifying a plan for strict intake and output and daily weights. An admission MDS later confirmed that the resident was cognitively intact, experiencing shortness of breath, and had an active diagnosis of heart failure. A physician’s order for a 1500 mL fluid restriction was not written until several days after admission, at the request of the resident’s responsible party. The following day, nursing documentation showed the resident was sent to the hospital from dialysis for chest pain and shortness of breath. In interviews, the MD, the admitting RN, and the DON all confirmed that the resident should have been placed on a fluid restriction and monitoring upon admission, and the DON acknowledged that the fluid restriction order was not implemented in a timely manner.
Failure to Ensure Dietary Staff Used Required Hair and Beard Restraints During Food Service
Penalty
Summary
The deficiency involves failure to maintain sanitary conditions in the kitchen, specifically related to staff not using required hair and beard restraints during food service activities. During an observation and interview with the Dietary Manager (DM) on 03/29/26 from 9:25 AM to 10:28 AM, two Dietary Aides (DA1 and DA2) were seen engaged in food preparation and dishwashing without wearing beard or hair restraints, which the DM confirmed. In a subsequent observation and interview with the DM on 03/31/26 from 8:55 AM to 11:36 AM during the meal serving line, DA1 and DA3 were again observed not wearing beard or hair restraints, and the DM stated that such restraints should be worn at all times and acknowledged the facility was out of beard/hair restraints. These conditions affected 78 residents who received meals from the kitchen, out of a total census of 80 residents, with 2 residents receiving nutrition via feeding tubes. The observations document that multiple dietary staff members repeatedly failed to use required protective restraints while handling food and dishes, and that the facility lacked an adequate supply of beard/hair restraints, as confirmed by the DM. The report specifies that this failure occurred during both food preparation and meal service times and applied to nearly all residents receiving meals from the kitchen.
Unattended, Unlocked Medication Carts Left Accessible in Two Locations
Penalty
Summary
The deficiency involves the facility’s failure to keep medication carts locked and secured when not in use, as required by facility policy and professional standards. During an early morning observation on 04/01/26 at 4:53 AM, a medication cart on the [NAME] Hall in front of room W102 was found unlocked while an LPN was inside the resident’s room with the privacy curtain pulled. The medication cart was not visible from inside the room, and the only other staff member in the area, a CNA, was further down the hall delivering linen to another room. At 4:59 AM, the LPN returned to the cart and locked it, confirming that it had been left unlocked and out of her line of sight. A second unsecured cart was observed on 04/01/26 at 5:56 AM at the nurses’ station, where the medication cart shared by nurses on the [NAME] and East Halls was left unlocked. The ADON walked past this unlocked cart twice and then left the nurses’ station to go down the East Hall at 6:00 AM, leaving the cart unattended and still unlocked. At 6:05 AM, the ADON returned and locked the cart. In an interview at that time, the ADON stated that it was the expectation that all medication and treatment carts be kept locked when not in use. Review of the facility’s “Storage of Medication” policy, revised November 2020, confirmed that compartments containing drugs and biologicals are to be locked when not in use and that unlocked carts should not be left unattended.
Failure to Provide Required Written Information on Advance Directives and Treatment Rights
Penalty
Summary
The facility failed to provide written information regarding advance directives and the right to accept or refuse medical and surgical treatment to two residents reviewed for advance directives. One resident was admitted with hemiplegia and hemiparesis following cerebrovascular disease and major depressive disorder and had a BIMS score of 15/15, indicating intact cognition. Review of this resident’s EMR, including the admission record and MDS, showed no evidence that written information on advance directives had been provided. A second resident was re-admitted with heart failure, stage three chronic kidney disease, malignant neoplasm of the upper lobe of the left bronchus, and pain, and had a BIMS score of 12/15, indicating moderately impaired cognition. Review of this resident’s EMR also revealed no evidence that written information regarding advance directives had been provided. During interviews, the SSD stated she did not have any written information to provide residents about the distinct types of advance directives and that there was no signature page to indicate a verbal explanation was provided or that residents understood their right to accept or refuse medical and surgical treatments. The AD reported that the admission packet contained only one page asking if a resident had an advance directive or wished to formulate one, and that she did not have written information defining the types of advance directives to give residents on admission. The Administrator stated she was not aware of the regulatory guidance requiring written information on advance directives and the right to accept or refuse medical and surgical treatment, and was unaware that the facility’s own policy required this. The facility’s “Advanced Directives” policy, revised November 2025, stated that residents have the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment, and that written information must be provided in a manner easily understood by the resident or representative.
Failure to Timely Report Allegation of Sexual Abuse to SSA
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of sexual abuse to the State Survey Agency (SSA) within the required two-hour timeframe. A cognitively intact resident, admitted with cognitive communication deficit and mild cognitive impairment and having a BIMS score of 15/15, was the subject of an allegation reported by her son. On a grievance/concern form dated 09/18/25, the son reported that a male aide entered the resident’s room in the middle of the night stating he needed to check if she was wet; the resident refused, and the aide returned later, at which time the resident again refused. The facility’s investigation report dated 09/22/25 documented that the assigned CNA made an inappropriate verbal remark to the resident, stating, “you don’t know what you are missing,” when she refused incontinent care. An incident tracking form dated 09/22/25 at 8:21 PM showed that a police officer came to the facility and informed staff that they had received a complaint from the resident’s family alleging the resident had been spoken to in a manner that made her uncomfortable, and that the male staff assigned to her care made the same remark when she refused care. The Admissions Director stated she received the telephone call from the resident’s son on 09/18/25 describing the male staff entering the room, the resident’s refusals of care, and the uncomfortable comment, and that she immediately informed the DON of the concern, consistent with facility protocol to notify the Administrator and DON of all grievance and abuse concerns. The DON stated she did not remember receiving the grievance/concern form and reported that she first learned of the alleged abuse on 09/22/25 when a police officer came to the facility after receiving an allegation of abuse. The DON confirmed that the SSA was notified of the abuse allegation on 09/22/25, four days after the son’s grievance, and acknowledged that the SSA should have been notified on 09/18/25. The Administrator/Abuse Coordinator, who was out on leave at the time and unaware of the grievance, confirmed that alleged violations involving abuse should be reported to the SSA within two hours after the allegation is made. The facility’s written policy on abuse, neglect, exploitation, mistreatment, and misappropriation of property, dated 06/15/25, states that alleged violations involving abuse are to be reported to the SSA within two hours after the allegation is made, which did not occur in this case.
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