Gilpin Hall
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, Delaware.
- Location
- 1101 Gilpin Avenue, Wilmington, Delaware 19806
- CMS Provider Number
- 085047
- Inspections on file
- 20
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Gilpin Hall during CMS and state inspections, most recent first.
A resident with severe cognitive impairment had a motion-activated camera in their room, permitted and monitored by their representative. Despite staff being aware of the camera and instructed not to touch it, a CNA was observed on multiple occasions turning the camera to face the wall, interfering with its intended use by the resident's representative.
A resident with severe dementia and a history of care resistance was subjected to physical and mental abuse by a CNA and an RN, as captured on video. The CNA forcefully handled the resident during toileting and dressing, causing distress, while the RN attempted to forcibly retrieve medication from the resident's hand and verbally reprimanded her after being struck. Staff failed to follow the care plan and did not properly document or report incidents, resulting in psychosocial harm to the resident.
The facility did not maintain a surety bond in an amount sufficient to cover all residents’ personal funds held in trust. Documentation showed that the surety bond in place was for $20,000, while a current account summary listed forty-five residents with a combined trust account balance of $28,733.79. During an interview, the Executive Director confirmed the bond amount, demonstrating that the bond did not fully cover the total resident trust funds managed by the facility.
The facility did not report allegations of abuse and an injury of unknown origin within the required two-hour timeframe for two residents. In one case, a hand fracture was reported to authorities about three days after discovery, and in another, a resident-to-resident abuse incident was reported approximately four hours after it occurred.
Surveyors found that controlled substances storage boxes in two medication rooms were either placed on top of the refrigerator or inside the refrigerator without being permanently affixed, as required. Staff confirmed that these medications were kept in the refrigerators and counted every shift, but the required permanent affixation was not in place. Facility leadership was informed of these findings.
A resident with DM2 and normal cognition had a weekly Ozempic order. An LPN signed for delivery of multiple Ozempic pens and stored them in a locked medication room refrigerator accessible only to nursing staff. Days later, another LPN could not locate the medication when it was needed for administration. The resident reported not giving anyone permission to take any medications. The facility’s failure to safeguard the medication and ensure it was available for use resulted in misappropriation of the resident’s property.
A resident was discharged home to live with family, as documented in a nurse progress note, but the facility failed to notify the Ombudsman of this discharge as required. Review of the transfer log showed no evidence of Ombudsman notification for the community discharge, and the NHA later confirmed in an interview that the Ombudsman had not been informed when the monthly list of discharges was submitted. The omission was identified during surveyor record review and discussed with facility leadership, including the NHA, DON, and ADON.
Two residents experienced significant changes in mental health status, including new diagnoses of MDD, delusional disorder, unspecified psychosis, and psychotic disorder, along with initiation or continuation of antipsychotic medications such as Risperdal and Seroquel. One resident’s record evolved from a primary dementia diagnosis with anxiety treated by Lexapro and Zyprexa to multiple additional psychiatric diagnoses and documented psychosis, while another progressed from dementia with anxiety and depression and no problematic behaviors to documented aggressiveness, physical altercations with staff, and poor impulse control. Despite these changes and confirmation from the State PASRR Authority that a new assessment was needed for at least one resident, the facility did not complete updated PASRR screenings or coordinate reassessments after the status changes, as confirmed by the DON.
A resident with heart failure had a physician order for daily weights at a specific time, with instructions to notify the MD for certain weight gains. Review of the eMAR showed that staff did not obtain or document the ordered daily weights on multiple days and did not record any reasons for the missed weights. An RN reported that nurses were responsible for weighing the resident and stated the resident sometimes refused, but the clinical record contained no documentation of such refusals, resulting in a failure to follow and document the ordered daily weight regimen.
Surveyors found that the facility’s written abuse policy did not meet CMS requirements, as it lacked coordination with the QAPI program, did not specify required training on recognizing signs and types of abuse, and omitted language prohibiting and preventing retaliation for reporting abuse. During interview, the NHA reported that extensive abuse training is conducted but acknowledged unawareness that the policy itself was missing these elements, which was later reviewed with the NHA, DON, and ADON at exit.
Surveyors found that the facility’s medication regimen review policy did not include defined time frames for the steps in the monthly drug regimen review process or specify what actions a pharmacist must take when an urgent medication irregularity is identified. Review of the written policy and interview with the DON confirmed that, although the consultant pharmacist conducts MRRs, the policy lacks these required procedural details, and this was acknowledged by facility leadership during the survey exit conference.
The facility failed to protect residents from abuse, including physical and verbal aggression. Incidents involved a resident being physically assaulted, inappropriate sexual behavior by a male resident, and verbal abuse by a staff member. The facility's interventions were insufficient to prevent these occurrences.
The facility failed to ensure proper infection control during resident care. CNAs did not change gloves or perform hand hygiene during incontinence care for a resident, and an LPN did not disinfect an overbed table or perform hand hygiene during wound care for another resident. Additionally, an LPN did not follow the recommended drying times for a glucometer, using a tissue to dry it instead. These actions were against the facility's policies and increased the risk of cross-contamination.
A resident with severe cognitive impairment fell and sustained injuries, but the facility failed to notify the Resident Representative (RR) as required by policy. The resident was sent to the hospital, and the RR was informed by a third party, not the facility. Attempts to contact the RR were reportedly unsuccessful, and documentation of the notification was missing.
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two residents, preventing them from making informed decisions about the costs of continued therapy services. The Admission Coordinator and Administrator confirmed the oversight, citing concerns about potential confusion for residents and families when Medicaid was the payment source.
A facility failed to follow its grievance procedures for a resident who did not receive a dinner tray. A family member filed a grievance, but the Administrator did not provide a written response or resolution, as required by the facility's policy. This oversight increased the potential for unresolved grievances.
The facility failed to thoroughly investigate abuse allegations involving three residents. One resident felt humiliated by a CNA, leading to the CNA's termination, but the investigation lacked interviews with other potential witnesses. Another resident reported being punched by a fellow resident, yet the investigation did not include witness interviews. The ADON and Administrator acknowledged the lack of comprehensive investigative documentation.
A resident with cognitive impairment and arthritis experienced a delay in receiving an x-ray for a swollen knee, resulting in a three-day wait before discovering an acute fracture. The facility failed to notify the physician of the delay or seek alternative x-ray services, leading to inadequate pain management and delayed treatment.
A facility failed to follow transfer protocols for a resident requiring a Hoyer lift with two staff, as a CNA used a stand-up lift alone, contrary to the care plan. The resident, with cognitive impairments, was dependent on staff for transfers. Additionally, another resident had a Keurig coffee maker in their room without a documented safety assessment, despite being cognitively intact and independent in some activities.
A resident with cognitive impairment and arthritis experienced inadequate pain management due to delayed x-ray and lack of pain assessments. The resident received Tylenol for knee swelling and pain over three days without proper documentation or assessment, leading to the discovery of a femur fracture. The facility adjusted pain management only after the x-ray confirmed the fracture.
Failure to Honor Resident Representative's Rights Regarding Room Camera
Penalty
Summary
Staff failed to honor the rights of a resident's representative, who was designated as power of attorney for care, by not following the established permission for a motion-activated camera in the resident's room. The resident, who was severely cognitively impaired due to dementia, had a camera installed and monitored by the representative, with the facility and nursing staff aware of its presence and purpose. On multiple occasions, a CNA was observed on video turning the camera to face the wall and away from the resident, despite being educated not to touch the resident's personal property, including the camera. The CNA later confirmed in a written statement and interview that she had turned the camera because she did not consent to being recorded.
Failure to Protect Resident from Physical and Mental Abuse by Staff
Penalty
Summary
A resident with severe dementia, depression, and anxiety disorder was admitted to the facility and care planned for significant assistance with activities of daily living (ADLs), including toileting and dressing. The resident was known to be frequently resistive to care and required staff to use specific approaches such as encouragement, clear explanations, and providing choices. Despite these care plan directives, video evidence captured multiple incidents where a CNA physically forced the resident into the bathroom and handled her roughly during care, resulting in the resident screaming and expressing distress. In one incident, the CNA forcefully grabbed and pushed the resident into the bathroom while she was screaming, and in another, the CNA pulled the resident up from the bed and pushed her from behind without verbal communication, despite the resident's vocal protests. Additionally, a separate incident involving an RN was captured on video, where the nurse attempted to administer medication to the same resident. The resident resisted by holding the medication in her hand and verbally expressing her refusal. The RN attempted to retrieve the medication from the resident's closed fist, during which the resident screamed and accused the nurse of breaking her fingers. The resident then struck the nurse, who responded by pointing a finger at the resident's face and verbally reprimanding her. There was no documentation in the clinical record of the medication refusal or the altercation, and the nurse did not report the incident to a supervisor as required. These incidents demonstrate that the facility failed to protect the resident from physical and mental abuse by staff. The staff did not follow the resident's care plan for managing resistive behaviors and did not adhere to protocols for reporting and documenting refusals of care or incidents of abuse. The actions of the staff resulted in dehumanization and psychosocial harm to the resident, as evidenced by the resident's distress and the nature of the interactions captured on video.
Insufficient Surety Bond Coverage for Residents’ Trust Funds
Penalty
Summary
The facility failed to assure the security of all personal funds of residents deposited with the facility by not maintaining a surety bond in an amount sufficient to cover the total balance of residents’ trust accounts. On review of documents, the surveyor was provided a surety bond from the facility’s insurance company in the amount of $20,000, effective from 12/08/24 to 12/08/25. The facility also provided a list labeled “Trust- Current Account Balance as of 8/27/25,” which identified forty-five residents with personal funds accounts managed by the facility and showed a current total balance of $28,733.79. In an interview, the Executive Director confirmed that the surety bond amount was $20,000, which was less than the total amount of residents’ funds held in trust, resulting in the deficiency. No additional resident-specific medical history or clinical conditions were described in the report, and the deficiency pertained solely to the financial protection of residents’ personal funds.
Failure to Timely Report Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report allegations of abuse and injury of unknown origin within the required two-hour timeframe for two out of six residents reviewed. For one resident, an x-ray report indicating an acute hand fracture was received, but the injury of unknown origin was not reported to the State Agency until approximately three days later. In another case, an incident report documented an allegation of resident-to-resident abuse, but the facility reported the incident to the State Agency about four hours after the altercation. These delays in reporting were confirmed through record review and staff interview.
Controlled Substances Storage Boxes Not Permanently Affixed in Medication Rooms
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage of controlled substances in two medication rooms. On multiple occasions, the storage box for controlled substances on the second floor was found placed on top of the refrigerator rather than being secured inside and permanently affixed. In the third-floor medication room, the controlled substances box was inside the refrigerator but was not permanently affixed as required. These findings were consistent over several days of observation. During an interview, a registered nurse confirmed that controlled substances requiring refrigeration were kept in the refrigerators and counted every shift, but did not address the lack of permanent affixation. The findings were reviewed with facility leadership during the exit conference. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Protect Resident Medication from Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident’s personal property, specifically a prescribed medication, and ensure it was available for use. The resident was admitted with diabetes and had an active order for weekly Ozempic injections for DM2. According to the facility’s abuse policy, misappropriation of resident property includes intentional theft or mishandling of a resident’s money or property by personnel authorized to handle it. The resident’s quarterly MDS showed normal cognition, and there is no indication that the resident gave anyone permission to take any of their medications. On the morning of 6/8/25, an LPN signed for delivery of three Ozempic pens for the resident and placed them in the refrigerator in the locked medication room on the third floor. On the morning of 6/13/25, another LPN was unable to locate the Ozempic in that refrigerator. The medication, which had been properly delivered and stored in a secure area accessible only to nurses, was missing when needed for administration. As a result, the facility did not have the resident’s ordered Ozempic dose available at the scheduled time, constituting a failure to protect the resident’s property and ensure its availability for the resident’s use.
Failure to Notify Ombudsman of Resident Discharge to the Community
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to notify the Ombudsman of a resident’s discharge to the community. Record review showed that on 7/3/25 at 2:30 PM, a nurse progress note documented that the resident’s daughter arrived at the facility to pick up the resident, who was discharging home to live with her daughter. Review of the facility’s April 2025 Transfer Log on 8/28/25 at 1:15 PM lacked any evidence that the Ombudsman was notified of this discharge to the community on 7/3/25. In an email dated 8/28/25 at 4:09 AM, the Nursing Home Administrator (E1) documented that the Ombudsman was notified that day of the resident’s discharge home, and in a follow-up interview on 8/29/25 at 8:39 AM, E1 confirmed that the Ombudsman had not been notified of the resident’s discharge when the July 2025 list was submitted to the Ombudsman on 8/15/25. Findings were subsequently reviewed with the Nursing Home Administrator (E1) and Director of Nursing (E2) on 8/29/25 at 1:33 PM, and again during the exit conference on 8/29/25 at 2:30 PM with E1, E2, and the Assistant Director of Nursing (E5).
Failure to Coordinate PASRR Reassessments After Significant Mental Health Changes
Penalty
Summary
The deficiency involves the facility’s failure to coordinate with the PASRR program and submit updated assessments when residents experienced significant mental health status changes. For one resident, a Level I PASRR completed at admission documented a primary neurocognitive disorder/dementia and use of Lexapro and Zyprexa for anxiety. Subsequently, the resident was care planned for antipsychotic use (Risperdal) related to frontotemporal dementia, delusions, and a history of psychosis. Over time, multiple new psychiatric diagnoses were added to the record, including major depressive disorder (MDD), delusional disorder with psychosis, unspecified dementia with psychosis, other specified behavioral and emotional disorders with onset in childhood/adolescence, and pseudobulbar affect. A quarterly MDS later documented active anxiety disorder, depression, psychotic disorder, and pseudobulbar affect. The State PASRR Authority later confirmed by email that the facility should submit a new PASRR assessment for a status change to include MDD as a new major diagnosis and to update the resident’s current mental status and diagnoses, but this had not been done. For a second resident, the clinical record showed admission with dementia, peripheral vascular disease, and diabetes mellitus, and a Level I PASRR that listed dementia, anxiety, and major depressive disorder, with trazodone and lorazepam prescribed and no known problematic behaviors. Later nursing documentation described increased issues evidenced by aggressiveness and physical altercations with staff. The resident was then diagnosed with delusional disorder and unspecified psychosis, and an antipsychotic (Seroquel) was ordered. A subsequent psychiatric note described the resident as difficult to manage, with no impulse control, poor response to redirection, and requiring medications, and a quarterly MDS documented anxiety, depression, and psychotic disorder. During interview, the DON stated that the last PASRR screening in the chart was the earlier Level I and confirmed there was no PASRR screening after that date, indicating the facility did not coordinate with PASRR for reassessment after the significant change in mental health status and diagnoses.
Failure to Complete and Document Ordered Daily Weights for Heart Failure Management
Penalty
Summary
A resident with a diagnosis of heart failure was admitted to the facility and later had a physician’s order dated 10/24/24 for a daily weight at 8:00 AM, with instructions to notify the MD for specified weight gains related to heart failure management. Review of the resident’s electronic MAR for June 1–24, 2025, showed that daily weights were not obtained or documented on 7 of 24 ordered days, and there was no documented reason for the missed weights. During interview, an RN stated it was the nurse’s responsibility to weigh the resident and acknowledged that the resident sometimes refused, but the clinical record contained no evidence that the resident had refused the ordered weights. The deficiency centers on the facility’s failure to provide and document ordered daily weights and any refusals, as required by the physician’s order for heart failure monitoring.
Failure to Include Required Elements in Abuse Prevention Policy
Penalty
Summary
Surveyors determined that the facility failed to develop and implement an abuse policy that met CMS requirements. The Resident Abuse Policy/Procedure provided for review did not show evidence of coordination with the facility’s QAPI program, did not include required training content regarding recognizing signs of abuse and identifying different types of abuse, and did not contain language prohibiting and preventing retaliation against individuals who report abuse. During interview, the NHA stated that the facility conducts extensive abuse training throughout the year but was not aware that the written abuse policy lacked these specific CMS-required elements, including training on signs and types of abuse, anti-retaliation provisions, and QAPI involvement. These findings were discussed with the NHA, DON, and ADON during the exit conference. No residents or specific patient conditions were mentioned in the report.
Incomplete Medication Regimen Review Policy Lacking Time Frames and Urgent Action Steps
Penalty
Summary
The facility failed to ensure that its monthly drug regimen review (MRR) policy contained required elements, specifically time frames for the different steps in the MRR process and directions for actions the pharmacist must take when an irregularity requiring urgent action is identified. Review of the facility document titled “Medication Regimen Review,” revised on multiple dates, showed that while it stated medications are reviewed in multiple ways, including the MRR conducted by the consultant pharmacist, it lacked evidence of defined time frames for each step of the process and did not specify the steps the pharmacist must take when an irregularity is identified. During an interview, the DON confirmed that the policy does not include time frames for the different steps in the medication review process. These findings were discussed with the NHA, DON, and ADON during the exit conference. No specific residents, medical histories, or clinical conditions were identified in the report in relation to this deficiency.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect several residents from abuse, including resident-to-resident abuse, as evidenced by multiple incidents involving physical and verbal aggression. One incident involved a resident with cognitive impairment who wandered into another resident's room and was physically assaulted, resulting in a subconjunctival hemorrhage and corneal abrasion. The assaulted resident was on anticoagulant medication, which increased the risk of excessive bleeding. Despite the altercation, the facility did not implement adequate measures to prevent further incidents between these residents. Another incident involved a cognitively impaired resident who was observed engaging in inappropriate sexual behavior with a female resident who was non-ambulatory and dependent on staff for activities of daily living. The male resident had a history of sexually inappropriate behavior, yet the facility's interventions were insufficient to prevent the incident. The dietary aide who witnessed the event intervened, but the lack of staff presence in the area allowed the incident to occur. Additional incidents included verbal abuse by a staff member towards a resident, resulting in the resident feeling humiliated and manipulated. The staff member was terminated following the investigation. Other incidents involved physical aggression between residents, with one resident attempting to hit another with a walker. These events highlight the facility's failure to adequately supervise and protect residents from abuse, as well as to implement effective interventions to prevent such occurrences.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during incontinence care for a resident with cognitive impairment and incontinence issues. Certified Nursing Assistants (CNAs) did not change gloves or perform hand hygiene after cleaning the resident's soiled areas and before adjusting the resident's clothing and bed. The CNAs also did not follow the correct cleaning technique, as they cleaned the resident's perineal area in a back-to-front motion, which is against the facility's policy. During wound care for a resident with a stage III pressure sore, the Licensed Practical Nurse (LPN) did not disinfect the overbed table after a wash basin left a wet spot. The LPN also failed to perform hand hygiene between changing gloves while conducting the dressing change. These actions were contrary to the facility's policy, which requires creating a clean field and washing hands between glove changes to prevent contamination. The facility also failed to follow the recommended disinfectant drying times for a multi-use glucometer. An LPN used a tissue to dry the glucometer immediately after wiping it with a disinfectant, instead of allowing it to air dry for the required time. This practice was not in line with the facility's policy and the manufacturer's guidelines, which specify a drying time to ensure effective disinfection.
Failure to Notify Resident Representative After Fall
Penalty
Summary
The facility failed to notify the Resident Representative (RR) following a fall with injuries for one of the residents, identified as R94. This failure resulted in a delay for the RR to reach the hospital before the resident's condition worsened. The facility's policy required that the responsible party, physician, and Director of Nursing be contacted and documented in the progress notes and incident report. However, the documentation and communication were inadequate in this case. R94 was admitted with diagnoses including dementia, gait abnormalities, and seizures, and had a history of wandering and falls. The resident was part of a safety program and had interventions such as safety checks and non-slip footwear. On the day of the incident, R94 was witnessed by dietary staff getting up from a wheelchair and falling, resulting in facial lacerations and bleeding. The primary care physician was notified, and the resident was sent to the hospital, but attempts to notify the RR were unsuccessful. Interviews revealed that the RR was informed of the incident by a third party and not by the facility. The RR stated that the facility never called, and by the time they reached the hospital, R94 was intubated and later placed on hospice care. The LPN involved claimed to have attempted to contact the RR but was unsuccessful. The hospital transfer form, which should have documented the notification, was not found in the electronic medical record, and the facility's administration was unable to provide it upon request.
Failure to Provide SNFABN to Residents
Penalty
Summary
The facility failed to provide the required Form CMS-10055, also known as the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), to two residents, identified as R10 and R77, who were reviewed for liability notices. This form is essential for informing residents or their representatives about potential financial liabilities for services not covered by Medicare or Medicaid. The absence of this notice prevented these residents or their responsible parties from making informed decisions regarding the costs associated with continued therapy services after the end of their skilled services. The deficiency was identified through interviews and record reviews. R10 and R77 continued to reside in the facility after their skilled services ended, but they were not provided with the SNFABN. The Admission Coordinator confirmed during an interview that the ABN letter was not given alongside the Notice of Medicare Non-Coverage (NOMNC). The facility's Administrator acknowledged that the ABN notice was never provided, citing concerns that it might confuse residents and their families, especially when Medicaid was the payment source. This oversight highlights a failure in the facility's process to ensure residents are adequately informed about their financial responsibilities.
Failure to Follow Grievance Procedures for Resident
Penalty
Summary
The facility failed to adhere to its grievance procedures for a resident, identified as R79, who was part of a sample of 34 residents reviewed for grievances. The facility's policy, dated 03/11/22, mandates that residents have the right to voice grievances without fear of discrimination or reprisal, and the facility must make prompt efforts to resolve these grievances. However, a review of the grievance log dated 01/16/24 revealed that a family member of R79 filed a grievance regarding the resident not receiving a dinner tray the previous night. The log indicated a delay in staff delivery, but there was no further information provided by the Administrator, who handles all grievances. During interviews conducted on 10/16/24, the Administrator confirmed that she did not provide residents or family members with a written response to grievances, including the resolution. This lack of documentation and communication regarding the resolution of grievances indicates a failure to follow the established grievance procedures, potentially leaving resident grievances unresolved.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse involving three residents. In the first case, a resident with a history of depression and anxiety reported feeling humiliated and manipulated by a CNA during care. The CNA was suspended and later terminated based on the resident's statement and the CNA's own account. However, the investigation lacked documentation of interviews with other residents or staff who may have interacted with the CNA, which could have provided additional context or corroboration. In another incident, a resident reported being punched by another resident. The facility's investigation did not include interviews with potential witnesses, such as other staff or residents who might have observed the altercation. The ADON confirmed the absence of such interviews in the investigative file, and the Administrator noted that witness interviews are collected based on the situation, indicating inconsistency in the investigative process.
Delay in X-ray Leads to Untreated Fracture
Penalty
Summary
The facility failed to ensure timely treatment for a resident who experienced swelling in the right knee, leading to a delay in obtaining a necessary x-ray. The resident, who was cognitively impaired and dependent on staff for mobility and activities of daily living, was admitted with diagnoses including arthritis, dementia, and Alzheimer's disease. On the day the swelling was noted, the physician ordered a 2-view x-ray of the right knee. However, the x-ray was not obtained until three days later, during which time the resident was administered non-narcotic pain medication and experienced continued swelling and pain. Throughout the three-day period, there was no documentation indicating that the physician was notified of the delay in obtaining the x-ray, nor were there attempts to contact another mobile x-ray company or seek further physician guidance regarding the resident's pain management. The x-ray, when finally completed, revealed an acute fracture of the distal femur. The delay in obtaining the x-ray and notifying the physician resulted in a delay in appropriate treatment for the resident's condition.
Failure to Follow Transfer Protocols and Assess Environmental Hazards
Penalty
Summary
The facility failed to ensure that a resident, identified as R30, was transferred using the appropriate mechanical lift and the required number of staff as per the resident's care plan. R30, who was admitted with diagnoses including arthritis, dementia, and Alzheimer's disease, was assessed as cognitively impaired and dependent on staff for transfers and activities of daily living. The care plan specified that R30 required a Hoyer lift with two staff members for transfers. However, video evidence and interviews revealed that CNA9 used a stand-up lift instead of the Hoyer lift and performed the transfer alone, contrary to the care plan and facility policy. The facility's EZ Lift Policy and Procedures, revised on 08/01/24, mandated that two staff members be present when using the EZ Way Lift or EZ Way stand-up lift to prevent injury. Despite this, CNA9 was observed on video using the stand-up lift alone to transfer R30, and later, after lunch, taking the resident into the spa room without assistance. The Director of Nursing confirmed that CNA9 was aware of the requirement for two staff members during transfers and had access to the resident's care information through the facility's electronic medical record system. Additionally, the report mentions another resident, R38, who had a Keurig coffee maker in their room. Although R38 was cognitively intact and independent in certain activities, there was no documented assessment for the safe use of the coffee maker. The Assistant Director of Nursing was unaware if the resident had been assessed for its use and stated that staff typically made coffee for the resident. This lack of assessment for potential hazards in the resident's environment was noted during the survey.
Inadequate Pain Management and Delayed X-ray for Resident with Fracture
Penalty
Summary
The facility failed to provide adequate pain management for a resident who experienced swelling in the right knee and was later found to have a fracture in the right distal femur. The resident, who was cognitively impaired and dependent on staff for mobility and activities of daily living, was administered Tylenol for pain relief over a period of three days while awaiting an x-ray. During this time, the facility did not assess the resident's pain before or after administering the medication, nor did they document the reason for administering Tylenol. The x-ray, which was delayed, eventually revealed a fracture, and the resident was sent to the Emergency Department for further evaluation. The resident's medical records indicated that Tylenol was administered multiple times without proper pain assessments, and the x-ray was not completed until three days after it was ordered. Upon receiving the x-ray results, the facility adjusted the resident's pain management to include stronger medications such as Oxycodone and Morphine. The Director of Nursing confirmed the delay in obtaining the x-ray, which contributed to the inadequate pain management for the resident.
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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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