Kutz Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, Delaware.
- Location
- 704 River Road, Wilmington, Delaware 19809
- CMS Provider Number
- 085043
- Inspections on file
- 20
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Kutz Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with rectal cancer and intact cognition reported that an RN on night shift confronted him when he returned from smoking off campus, spoke to him loudly about his smoking, used profanity, and threatened to have staff refuse to buzz him back into the building. A CNA corroborated that the RN was upset about being called in to work and used curse words toward the resident, but did not report the incident at the time because the RN was the night supervisor. The resident reported the event to the Social Services Director the next day, yet the facility initially treated it as a grievance rather than abuse and delayed submitting a report to the State Survey Agency until weeks later, after determining it was a reportable abuse incident.
Two residents did not receive required ADL and hygiene care as care planned. One resident with dementia and osteoarthritis, dependent for toileting and personal hygiene, was not toileted during an evening shift, with CNA documentation showing no toileting and the oncoming CNA finding the resident’s clothing, linens, and mattress saturated with urine; the assigned CNA reported care resistance but did not notify an RN or LPN. Another resident with dementia and stroke, requiring assistance with dressing and personal hygiene, remained in bed in pajamas into the afternoon without having received morning care, despite CNA documentation indicating dressing was completed; the CNA later confirmed that care was only provided after being questioned by an RN supervisor following a family complaint.
A resident with left-sided weakness after a stroke, high fall risk, and total dependence for ADLs and bed mobility was being turned onto their side for peri care by an aide when they fell from the bed to the floor, sustaining head trauma and a scalp laceration while on blood thinners. The care plan required extensive to total assistance with two-person support for bed mobility, but the fall occurred during care without documentation of the required level of assistance, indicating the facility did not provide adequate supervision and assistance to prevent accidents as outlined in its own fall prevention practices.
The facility did not ensure that hospice care plans matched the medications administered to three residents, leading to discrepancies that could delay symptom management. Additionally, a resident experienced a delay in care after a fall due to lack of vital sign monitoring, missed lab work, and failure to notify the provider of a low heart rate, resulting in hospitalization for phenytoin toxicity and hyponatremia. Other issues included inaccurate documentation of vital signs after falls and failure to assess skin discoloration in a resident at risk for bleeding.
Two residents identified as high fall risks were not provided care according to their individualized care plans, resulting in preventable accidents. One resident was transferred by a single CNA instead of two staff with a Hoyer lift, leading to a leg laceration requiring sutures. Another resident, dependent for bed mobility, rolled off the bed during incontinence care when only one staff was present, resulting in a fall and hospital evaluation. In both cases, care plans and fall risk protocols were not followed, leading to resident harm.
Two residents with significant physical impairments were subjected to verbal abuse and neglect by CNAs, including refusal to provide necessary assistance with toileting and transfers, rude and punitive language, and falsified care documentation. These actions caused distress to the residents and were confirmed by interviews and video surveillance.
The facility did not report several allegations of abuse, neglect, and injuries of unknown source to the State Agency within the required timeframes. In multiple cases, incidents involving residents with cognitive and physical impairments were reported days after the facility became aware, rather than immediately or within the specified reporting periods as required by policy and state law.
Multiple residents with significant mobility and medical issues were found to have bedrails or enablers installed without documented assessments or informed consent. Staff interviews confirmed that no evaluations or consents had been completed prior to installation, and there was a lack of awareness among staff regarding the need for these procedures.
The facility did not ensure that nurses and nurse aides had the required competencies for medication administration and clinical assessment. An LPN repeatedly documented medications as given when they were not, without evidence of completed competency checks. Two nurses failed to recognize and respond to a resident's prolonged bradycardia, with incomplete or missing documentation of their competency in vital sign assessment. Another LPN administered IV antibiotics without proper training or skills verification, resulting in a medication error.
Multiple residents did not receive their prescribed medications as ordered, including missed doses of antiviral, COPD, and critical chronic disease medications, as well as an instance of an antibiotic being administered incorrectly. These errors were due to medication unavailability, pharmacy delays, lack of prior authorization, and staff unfamiliarity with medication administration procedures, resulting in significant medication errors.
The QAPI program did not effectively address ongoing issues with staff-to-resident abuse, repeated medication errors by nursing staff, and persistent problems with medication availability from the pharmacy. Although these issues were discussed in meetings and some staff education was provided, there was no evidence of measurable goals, systemic changes, or sustained monitoring. Additionally, there was no current performance improvement plan for abuse incidents.
A new LPN was assigned to administer IV antibiotics to a resident without having received training or a skills checkoff in IV medication administration, as the facility lacked an effective training program for this skill. Despite a prior facility assessment identifying insufficient staff competency in IV medication, no evidence of a training process or action plan was provided.
A resident with a large body habitus and multiple medical conditions fell from a standard-sized bed during incontinence care due to insufficient space for safe movement. Despite expressing ongoing fear and discomfort and requesting a larger bed, the facility did not provide one, citing that the resident did not meet criteria for a larger bed. Staff confirmed the resident's concerns and the facility's decision, resulting in a failure to accommodate the resident's needs and preferences.
The facility's abuse policy did not provide staff with clear procedures for identifying abuse based on resident outcomes, such as suspicious injuries or behavioral changes, and failed to specify required reporting timeframes under federal and state regulations.
A resident with Parkinson's disease and dementia was involved in an alleged neglect incident, and although the initial report was made, the required five-day follow-up investigation report was submitted to the State Agency eighteen days late, contrary to facility policy.
Two residents did not have comprehensive, person-centered care plans that addressed their specific needs. One resident with a dialysis fistula did not have clear care plan instructions to avoid blood pressure measurements on the affected arm, and another resident who received bed enabler bars after a fall did not have this intervention added to the care plan. Staff were aware of some requirements, but documentation and care plan updates were lacking.
A resident with a right hand contracture did not receive a physician-ordered palm guard for over 10 months because the order was incorrectly entered into the EMR, omitting the frequency and causing it to be absent from nursing task lists. Staff were unaware of the active order, and the device was never applied, as confirmed by observations and staff interviews.
Two residents with complex medical needs did not receive multiple doses of their prescribed medications due to pharmacy delivery issues, insurance coverage problems, and lack of stock. Nursing staff documented the unavailability of medications, and both the physician and family were notified. The facility's policy required immediate action for unavailable medications, but the necessary steps were not effectively carried out, resulting in missed doses and affected resident conditions.
A medication cart was found to contain an open insulin aspart pen without an open date label. An LPN confirmed the missing label during an interview, and the issue was discussed with facility leadership and department representatives.
Two residents' medical records contained inaccurate fall risk assessments, with one resident's assessments failing to document all predisposing diseases, recent falls, and incontinence, and another resident's assessment omitting two prior falls. These inaccuracies were confirmed by facility staff during interviews.
A resident with an indwelling Foley catheter and multiple diagnoses, including neurogenic bladder and obstructive uropathy, did not have Enhanced Barrier Precautions (EBP) ordered or implemented during their stay, despite facility policy and ongoing high-contact catheter care. Staff interviews and record review confirmed the absence of EBP, and leadership acknowledged the deficiency during the survey.
A resident who was completely dependent for care and admitted with end stage renal disease was observed multiple times without access to a functioning call bell system. Staff confirmed the previous call bell was removed due to malfunction and had not been replaced, leaving the resident unable to request assistance.
A resident with severe cognitive impairment and unsteadiness fell and suffered a concussion due to a CNA's failure to follow the care plan, which required extensive assistance and the use of a gait belt. The CNA stood the resident up without the gait belt and attempted to pull up her pants from behind, leading to the fall. The facility's policy on fall prevention was not adhered to, and training for nursing assistants on fall prevention had not yet been implemented.
A resident experienced a decline in urinary continence after losing the ability to use a walker, but the facility failed to complete required assessments or implement a toileting program. The resident was placed in incontinence briefs and remained in bed, dependent on staff for changes, without attempts to maintain continence. Staff interviews and record reviews confirmed the lack of appropriate care and adherence to the facility's Bladder Management Program policy.
The facility failed to address and resolve resident grievances discussed in monthly resident council meetings, including issues with CNAs using phones during care, long call light response times, and staff rudeness. Despite recurring complaints, no documented actions or thorough investigations were conducted.
The facility failed to thoroughly investigate and document abuse allegations for three residents. One resident reported a male staff member disconnected her call light, another reported rough treatment and yelling by staff, and a third mentioned rude staff behavior. Investigations were incomplete, lacking interviews with involved staff and verification of claims.
The facility failed to maintain the kitchen in a sanitary condition, affecting 79 out of 82 residents. Issues included food residue on clean items, improper storage of utensils and food, and discolored residue in the dish room. The Dietary Manager and Registered Dietitian confirmed these findings, which were against the facility's policies.
A resident with hemiplegia and hemiparesis refused to wear her left resting hand splint for most of a two-week period, but the physician was not notified. Interviews and records confirmed the lack of communication, leading to a deficiency identified by surveyors.
A resident with anxiety disorder, weakness, and chronic kidney disease reported multiple instances of staff not answering call lights or changing soiled briefs timely. The facility failed to document sufficient findings or provide written responses to these grievances, as confirmed by the Social Service Director and Administrator.
A CNA left the facility without informing staff, resulting in eight residents not receiving care. One severely cognitively impaired resident fell and was found with her head on the floor and pelvis on the bed. The resident was sent to the ED for evaluation and returned after a CT scan showed no injuries. The CNA was suspended and later terminated for job abandonment and misconduct.
The facility failed to report potential abuse and neglect involving nine residents in a timely manner. One incident involved a CNA unplugging a resident's call light, and another involved a CNA abandoning eight residents, leading to a fall. The facility did not follow its own policies or state regulations for reporting these incidents.
The facility failed to provide written transfer notices to two residents who were hospitalized. Although family members were notified, the residents themselves did not receive the required written notices. The Social Service Director and Administrator were unaware of the federal requirement to notify residents in writing.
The facility failed to provide bed hold notices within 24 hours to two residents during their emergent transfers to the hospital. Both the Social Service Director and the Administrator were unaware of the requirement to notify both the resident and the family member in writing.
The facility failed to update the care plan for a resident who experienced a significant decline in her ability to ambulate, transfer, use the toilet, and maintain continence. Despite the resident's increased need for assistance and use of a Hoyer lift, the care plan was not revised to reflect these changes.
A resident developed a coccyx wound upon admission, but the facility failed to notify the wound nurse practitioner, resulting in a six-day delay in treatment. The wound was not assessed or treated by the nurse practitioner until ten days after admission, leading to worsening of the wound.
A resident with hemiplegia and hemiparesis following a stroke did not receive consistent application of a left-hand resting splint as ordered by the physician. Documentation revealed inconsistencies, and staff interviews confirmed the splint was not applied regularly. The care plan did not include the splint, and there was no documentation of the resident's refusals in the nursing notes.
Failure to Protect Resident From Verbal Abuse and Delay in Reporting Incident
Penalty
Summary
The facility failed to protect a cognitively intact resident from verbal abuse by a staff member. The resident, admitted with rectal cancer and independently ambulatory with a rolling walker, reported that during an overnight shift he left the campus to smoke and, upon returning and walking toward the nursing station, was confronted by an RN. According to the resident’s report, the RN told him that when she was on the night shift he was not allowed to go outside, using profanity toward him, and further stated that if he went out the door she would instruct staff not to buzz him back into the building. A CNA later confirmed that the RN had been upset about being called in to work, spoke loudly to the resident about his smoking, and used curse words when he responded to her. The incident was not promptly reported to facility administration despite occurring during the night shift, with the CNA stating that the RN involved was the supervisor at the time. The resident reported the incident the following day to the Social Services Director, but the facility did not immediately recognize or treat the allegation as reportable abuse. Instead, the administration initially considered it a grievance and investigated it in that manner. The incident report was not submitted to the State Survey Agency until several weeks after the resident’s report, and only after the facility later determined that the event constituted a reportable abuse incident.
Failure to Provide Required ADL and Hygiene Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL assistance to maintain grooming and personal hygiene for two dependent residents. One resident with dementia, osteoarthritis, and moderately impaired cognition was care planned to receive partial to substantial assistance with personal and oral care, scheduled toileting every two hours, and assistance with toilet transfers. CNA documentation for an evening shift showed “N/A” for all scheduled toileting times, and a facility incident report stated that the CNA assigned to this resident failed to provide incontinence care during that shift. The oncoming night-shift CNA later found the resident’s clothing, linens, and mattress saturated and soaked with urine and provided the needed care, with the prior-shift LPN confirming the condition when notified. The assigned CNA reported the resident was resistant to care but did not notify the LPN or RN for assistance or document the issue. The second resident, with dementia, stroke, weakness, and moderately impaired cognition, was care planned for an ADL self-care deficit requiring setup or cleanup assistance with eating, partial to substantial assistance with personal hygiene and oral care, and substantial assistance with toileting, showering/bathing, and lower body dressing. On a morning shift, the resident’s daughter-in-law reported to the LSW that she did not believe the resident had received morning care because he was still in bed wearing pajamas and had not yet received his lunch tray. A CNA statement indicated the resident had eaten breakfast and was later found asleep in bed, and CNA documentation for that shift showed the dressing task as completed. However, the facility’s follow-up summary documented that the CNA confirmed care had not been provided to the resident prior to being questioned by the RN supervisor, and the LSW confirmed that the CNA changed the resident only after the family reported the concern and nursing was notified.
Failure to Provide Adequate Supervision and Assistance During Bed Mobility for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for a resident with significant functional and cognitive impairments. The resident was admitted with left-sided weakness after a stroke and was care planned as extensively to totally dependent for bed mobility, requiring the support of two persons. A fall risk evaluation documented a score of 10, indicating high fall risk, and a quarterly MDS assessment showed the resident was unable to participate in a cognitive assessment and was completely dependent on staff for all ADLs. Despite these identified needs and risks, the resident was being turned onto their side for peri care by an aide when they fell from the bed to the floor. During this incident, the resident sustained head trauma and a small scalp laceration, and was on blood thinners at the time of the fall. The fall occurred while the aide was providing peri care and turning the resident, but the report does not document the presence of a second staff member, despite the care plan indicating the need for two-person assistance for bed mobility. The facility’s own policy on falls emphasized instituting individualized practices to minimize fall risk and maximize safety for residents identified as high risk, but the resident’s documented high fall risk and total dependence were not adequately addressed in the supervision and assistance provided at the time of the fall.
Failure to Coordinate Hospice Care and Monitor Resident Conditions
Penalty
Summary
The facility failed to ensure that the most recent hospice plan of care included the services furnished by the facility for several residents. For three residents under hospice care, there were discrepancies between the medications listed on the hospice plan of care and those being administered by the facility. For example, certain medications ordered by hospice were not present on the facility's medication list, and vice versa. These discrepancies were confirmed by facility staff and could lead to delays in symptom treatment for the affected residents. Additionally, the facility did not provide care in accordance with professional standards of practice for multiple residents. One resident experienced a significant delay in care after a fall, as the facility failed to monitor and document vital signs appropriately, did not notify the provider of a low heart rate, and did not complete ordered lab work to monitor phenytoin levels. This resident was later hospitalized with phenytoin toxicity and hyponatremia, conditions that were not identified or managed in a timely manner by the facility. Other deficiencies included the failure to monitor and document vital signs after unwitnessed falls, as well as the failure to identify and assess skin discoloration in a resident at risk for bleeding. In one case, vital signs were either not documented or the same values were copied across multiple shifts, and skin assessments did not include observed discoloration. These failures were confirmed by interviews with facility staff and through review of clinical records and facility policies.
Failure to Follow Care Plans Results in Resident Falls and Injuries
Penalty
Summary
The facility failed to ensure that residents' care plans were followed to prevent accidents for two residents identified as high fall risks. One resident, with diagnoses including dementia, aphasia, and a history of falls, had a physician's order for Hoyer lift transfers with two staff. Despite this, the resident was transferred by a single CNA using a stand and pivot method, resulting in a laceration to the lower leg that required sutures in the emergency room. The incident was not reported to the State Agency as required. Another resident, who had a large body habitus, muscle weakness, and was cognitively intact, required substantial assistance for bed mobility and was identified as high risk for falls. During incontinence care, a CNA asked the resident to turn in bed, leading to the resident rolling off the bed onto the floor. The resident was sent to the emergency room for evaluation and returned with no acute findings. At the time of the fall, the care plan only required one staff for turning and repositioning, and it was not updated to require two-person assistance until several months after the incident. In both cases, the facility did not implement or follow individualized interventions as outlined in the residents' care plans and fall risk assessments. The lack of adherence to prescribed transfer and repositioning protocols directly contributed to the residents' injuries and hospitalizations.
Failure to Protect Residents from Abuse and Neglect by Staff
Penalty
Summary
Two residents experienced abuse and neglect by staff members, as documented through interviews, record reviews, and video surveillance. One resident, who had a history of stroke, cerebral palsy, and muscle weakness, and required substantial assistance with toileting, reported being verbally abused by a CNA. The CNA responded rudely and angrily when the resident requested to use the bathroom, telling the resident it was too late and scolding him for attempting to wipe himself. Another CNA corroborated the resident's account, stating that the staff member spoke very rudely and that the resident was visibly upset. The resident later described feeling punished and yelled at by the staff member during the incident. A second resident, admitted with a left knee fracture and requiring partial moderate assistance for transfers, reported that a CNA refused to assist with transferring out of bed, telling the resident to do it herself and speaking in a nasty manner. Video footage confirmed that the CNA spent minimal time in the resident's room and did not provide the care documented in the resident's chart, including assistance with toileting and repositioning. The resident's social worker confirmed that the resident was very upset by the staff member's refusal to help, and the facility's documentation showed discrepancies between the care provided and what was recorded.
Failure to Timely Report Alleged Abuse, Neglect, and Injuries of Unknown Source
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and injuries of unknown source to the State Agency within the required timeframes for four out of fourteen residents reviewed. In one case, a resident with a history of stroke and cognitive impairment was found with a facial skin tear, and the incident was reported to the State Agency thirty-five hours after it was first noted, exceeding the required reporting window. Another resident reported being blocked from leaving the bathroom by a CNA, and this alleged mistreatment was reported eighteen days after the incident and fifteen days after the facility became aware of it. Additionally, a resident reported that staff delayed responding to another resident who was vomiting, and this alleged neglect was reported twenty days after the incident and fifteen days after the facility was informed. In a separate case, a resident's allegation of verbal abuse by a CNA was reported six days after the facility was notified, rather than within the required two-hour timeframe. The facility's own policies, consistent with Delaware State Law, require immediate reporting of suspected abuse, neglect, or misappropriation of funds, with specific timeframes for reporting incidents involving serious bodily injury or other events. The records and interviews reviewed indicate that the facility did not adhere to these requirements, resulting in delayed reporting of multiple incidents involving potential abuse, neglect, or injury of unknown source. These delays were documented through clinical records, grievance reviews, and interviews with residents and staff.
Failure to Assess and Obtain Consent for Bedrail Use
Penalty
Summary
The facility failed to assess residents for the use of bedrails or enablers and did not obtain informed consent prior to their installation for four residents. Observations revealed that bedrails or enablers were present on the beds of these residents, but reviews of their clinical records showed no documentation of bedrail use assessments, consideration of alternatives, risk versus benefit analysis, or informed consent. Interviews with staff, including the contracted Director of Rehabilitation (DOR), confirmed that no assessments or consents had been completed for any residents using bedrails or enablers at the time of the survey. The DOR also stated that efforts to obtain assessments were only just beginning, and the therapy company did not have access to previous therapy provider records. The residents involved had significant medical histories, including stroke with hemiplegia, hemiparesis, large body habitus, muscle weakness, and osteoporosis, which could impact their mobility and safety needs. Despite these conditions, there was no evidence that the facility evaluated the appropriateness of bedrail use or discussed the associated risks and benefits with the residents or their representatives. Staff interviews further confirmed the lack of awareness regarding the need for assessments and consent, and no documentation was provided to the surveyor to demonstrate compliance with these requirements.
Failure to Ensure Nursing Staff Competency in Medication Administration and Clinical Assessment
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the appropriate competencies to care for residents, specifically in the areas of medication administration and clinical assessment. One LPN was found to have repeatedly documented the administration of medications that were not actually given, with multiple prior incidents of medication errors and falsification of medical records. Despite these occurrences, there was no evidence that this LPN had completed a medication administration competency since her hire date. Additionally, the facility's orientation policy required documentation of training and competency evaluations, but this was not maintained in the employee's educational file as required. In another instance, the facility failed to ensure that two nurses had the specific competencies to recognize and respond to a resident's bradycardia. The resident, who had a history of seizure disorder and hypopituitarism, experienced a low heart rate for nearly 24 hours, which was documented in the medical record but not addressed by staff. Review of the nurses' skills checkoff forms revealed incomplete or missing documentation of competency in vital sign assessment, and the facility was unable to provide evidence that these nurses were competent in recognizing abnormal heart rates. Additionally, a newly hired LPN administered intravenous antibiotics to a resident without having received training or a skills checkoff for IV medication administration. The nurse reported that she had not been trained on IV antibiotics during orientation, and the facility could not provide documentation of her competency in this area. This resulted in a medication administration error, as the antibiotic was given at incorrect times and not properly documented.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple instances where ordered medications were not administered as prescribed. One resident with HIV and COPD did not receive several doses of Dovato, an antiviral, and Formoterol, a COPD medication, on multiple occasions. The MAR confirmed these omissions, and a registered nurse acknowledged the missing doses during an interview. The facility's medication administration policy requires that medications be administered as ordered and that the six rights of medication administration are followed, but these requirements were not met in this case. Another resident with Parkinson's disease, diabetes, and osteomyelitis received three doses of Zosyn, an IV antibiotic, within a six-hour period, instead of the prescribed two doses. This error occurred due to a new nurse being unfamiliar with the unit and the medication administration process, resulting in improper documentation and failure to check the MAR before administering the medication. The error was identified during a shift change, and the nurse supervisor was notified after the fact. Additional deficiencies included a resident with hypopituitarism missing nine doses of Cortef (hydrocortisone) due to the medication not being available from the pharmacy, as documented in the MAR and progress notes. The pharmacy required prior authorization, which delayed delivery, and the resident's family ultimately paid out of pocket to obtain the medication. Another resident dependent on dialysis missed thirty-two out of seventy-three scheduled doses of Sevelamer due to ongoing issues with pharmacy supply, insurance coverage, and lack of timely communication with the dialysis center. These failures to provide ordered medications as prescribed directly contravened the facility's own policies and resulted in significant medication errors for multiple residents.
QAPI Program Fails to Address Ongoing Medication and Abuse Deficiencies
Penalty
Summary
The facility's Quality Assessment and Assurance (QAPI) program failed to effectively address ongoing quality of care issues, specifically related to staff-to-resident abuse, repeated medication errors by nursing staff, and the continued lack of medication availability from the pharmacy for multiple residents. Despite routine discussions of medication errors in QAPI meetings and periodic staff education, documentation lacked evidence of measurable goals, systemic changes, and ongoing monitoring to ensure sustained improvement. Medication audits were limited and infrequent, and the facility lacked a consistent Staff Development nurse, resulting in the inability to conduct a skills fair for staff. Additionally, the facility experienced ongoing issues with medication availability since October, with management relying on nursing staff to report when medications were not available. There were also two incidents of staff-to-resident abuse identified, but no current performance improvement plan (PIP) was in place for abuse, despite the topic being discussed at QAPI meetings. These deficiencies were confirmed through interviews and record reviews during the survey.
Failure to Train New LPNs in IV Medication Administration
Penalty
Summary
The facility failed to implement and maintain an effective training program for new LPN staff regarding intravenous (IV) medication administration. A new LPN, hired in July, was assigned to independently administer an IVSS antibiotic to a resident in February, despite having never received training on IV antibiotics during orientation. The LPN stated that there was no training provided because there were no residents in the facility requiring IV antibiotics at the time of orientation. Review of the resident's clinical record and staff interviews confirmed that the LPN had not completed a skills checkoff for IV medication administration prior to being assigned this responsibility. The facility's own assessment, completed seven months prior to the incident, had already identified insufficient staff skills and training in IV medication administration and documented an action plan to address this gap. However, the facility was unable to provide evidence of a training process or skills checkoff for new staff in IV medication administration, nor any documentation regarding the referenced action plan. The deficiency was confirmed during interviews and review of facility records, and findings were discussed with facility leadership and department managers.
Failure to Provide Appropriate Bed Size for Resident with Special Needs
Penalty
Summary
A resident with a large body habitus and multiple medical conditions, including anxiety, compressed lower back nerves, muscle weakness, nerve pain, and osteoporosis, was admitted to the facility. The resident experienced a fall from a standard-sized bed during incontinence care when a CNA did not ensure proper positioning safety before providing care. The resident was transported to the emergency room for evaluation and returned after 24 hours with no acute findings. Documentation and interviews revealed that the resident had little room to move side to side in the standard bed and expressed fear of falling, stating that the bed was not wide enough and she was always on the edge during turns and repositioning. Despite the resident's ongoing discomfort and expressed need for a larger bed, the facility did not provide one, citing that she did not meet the classification for a larger bed. The care plan was updated three months after the fall to require a two-person assist for all turns and repositioning, but the resident continued to express fear and discomfort related to the bed size. Staff interviews confirmed the resident's concerns and the facility's decision not to accommodate her request for a larger bed, resulting in a failure to reasonably accommodate her needs and preferences.
Deficient Abuse Policy Lacks Identification and Reporting Guidance
Penalty
Summary
The facility failed to develop a comprehensive written policy and procedure addressing the identification and reporting of abuse, neglect, and theft. Specifically, while the policy defined various types of abuse, neglect, and exploitation, it did not provide clear guidance in the identification section on how staff should recognize different forms of abuse based on resident outcomes, such as unwitnessed suspicious injuries, multiple injuries over time, or unexplained changes in resident behavior or activities. Additionally, the reporting section of the policy did not clearly specify the required reporting timeframes for abuse, neglect, or mistreatment in accordance with federal and state regulations, whichever is more stringent. These deficiencies were identified during a review of the facility's Resident Abuse Policies and Procedures and discussed with facility leadership and department representatives.
Late Submission of Abuse Investigation Follow-Up Report
Penalty
Summary
The facility failed to report the results of an abuse investigation to the State Agency within the required five working days for one resident. According to the facility's policy, a follow-up State Incident Report indicating the results of the investigation must be completed and sent electronically within five days. A resident with Parkinson's disease and dementia was involved in an alleged neglect incident, where it was reported that the resident had to wait an hour to be changed by a CNA. The incident was reported to the facility and subsequently to the State Agency, but the required five-day follow-up report was not submitted until eighteen days after the deadline. This delay was confirmed by facility leadership during the survey exit conference.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
For one resident with end stage renal disease and a dialysis fistula in the left arm, the facility failed to develop and implement a comprehensive, person-centered care plan that included specific instructions to avoid taking blood pressure on the left arm. Although the resident's orders required vital signs to be checked pre- and post-dialysis on certain days and monthly, the care plan only stated to monitor vital signs as ordered and did not specify the need to avoid the left arm. An LPN interviewed was aware of the requirement but there was no documentation of this order in the resident's electronic chart. For another resident with multiple diagnoses including large body habitus, anxiety, and osteoporosis, who experienced a fall and was subsequently provided with bed enabler bars for repositioning assistance, the facility failed to update the care plan to include this intervention. The care plan after the fall only documented bed mobility evaluation and continuation of at-risk interventions, omitting the addition of bed enabler bars, despite this being documented in a follow-up incident report. The DON confirmed that the care plan had not been revised to reflect the use of enablers after the fall.
Failure to Provide Ordered Palm Guard Due to EMR Entry Error
Penalty
Summary
A deficiency was identified when a resident with a right hand contracture did not receive a right-hand palm guard as ordered by a physician. The order for the palm guard was written in the electronic medical record (EMR) with instructions for application after morning care and removal before bedtime. However, observations on multiple occasions revealed that the resident was not wearing the palm guard, and the resident's right hand remained contracted with fingers pressed into the palm. Interviews with staff confirmed that the palm guard had never been applied, and the task was not listed on the Medication Administration Record (MAR), Treatment Administration Record (TAR), or CNA task list. Further investigation revealed that the order for the palm guard was entered incorrectly into the EMR, omitting the frequency for application and removal, which prevented it from appearing on any nursing task lists. Despite a daily 24-hour chart check process intended to verify new orders, the error was not detected, and the palm guard was not provided for over 10 months. Staff were unaware of the active order, and the resident did not receive the prescribed intervention to maintain or improve range of motion.
Failure to Ensure Timely Availability and Administration of Resident Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents by not ensuring the timely availability and administration of prescribed medications. One resident, with complex medical conditions including seizure disorder, diabetes insipidus, central blindness, and hypopituitarism, was readmitted to the facility with an order for hydrocortisone (Cortef). Despite the physician's order, the medication was not available for several days due to issues with pharmacy delivery and insurance coverage, resulting in the resident missing nine doses. Documentation shows repeated notations by nursing staff that the medication was not available, and lab results indicated an elevated serum sodium level during this period. Communication with the physician and family confirmed the ongoing unavailability of the medication, and the resident's condition was affected, as evidenced by lethargy and the need for further medical evaluation. Another resident, admitted with diagnoses including HIV and COPD, experienced multiple missed doses of critical medications, specifically Dovato (an antiviral) and Formoterol (a bronchodilator). The Medication Administration Records and progress notes documented several instances where these medications were not administered due to unavailability, with staff noting delays in pharmacy delivery, back orders, and lack of stock at both the primary and backup pharmacies. Nursing staff and the pharmacy were aware of the ongoing issues, and the physician was notified of the inability to obtain the medications on several occasions. The facility's own policy required immediate action when medications were unavailable, including determining the reason, notifying the physician, and escalating the issue to nursing supervisors. Despite these requirements, the facility did not ensure that the necessary medications were available and administered as ordered, resulting in multiple missed doses for both residents. Interviews with staff and pharmacy representatives confirmed the lack of communication and follow-through in resolving the medication availability issues.
Insulin Pen Lacking Open Date Label on Medication Cart
Penalty
Summary
During a survey, it was observed that one of three medication carts did not comply with proper labeling and storage practices for insulin pens. Specifically, an insulin aspart pen that was open and in use for a resident was found without an open date labeled on it. This observation was confirmed through an interview with an LPN, who acknowledged the absence of the required open date on the insulin pen. The findings were reviewed with facility leadership and department representatives during the exit conference. No additional information about the resident's medical history or condition at the time of the deficiency was provided in the report.
Inaccurate Fall Risk Assessments and Incomplete Medical Records
Penalty
Summary
The facility failed to ensure that complete and accurate medical records were maintained for two residents reviewed for falls. For one resident with a history of falls, fractures, osteoporosis, and arthritis, post-fall risk assessments conducted on two occasions did not accurately document all predisposing diseases that increased her fall risk. Additionally, the assessments failed to record a recent fall and the resident's frequent incontinence, despite this information being present in other parts of the clinical record. These inaccuracies were confirmed by a registered nurse during an interview. For another resident, clinical records showed two separate falls, including one that resulted in a transfer to the emergency room. However, a subsequent fall risk evaluation incorrectly documented that the resident had no falls in the previous three months. This discrepancy was confirmed during an interview with the Director of Nursing, and no further information was provided to clarify the inaccuracy. The facility did not ensure that fall risk assessments accurately reflected the residents' clinical histories and fall events.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
A deficiency was identified when the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident who had an indwelling urinary catheter during their stay. According to the facility's own policy, EBP should be initiated for residents with indwelling medical devices, such as urinary catheters, to reduce the transmission of multidrug-resistant organisms (MDROs). The resident in question was admitted with diagnoses including emphysema, neurogenic bladder, and obstructive uropathy, and had a Foley catheter in place. Orders were present in the electronic medical record for Foley catheter care and regular flushing with sterile water, which are considered high-contact care activities requiring EBP. Despite these requirements, a review of the resident's medical record and interviews with facility staff revealed that no order for EBP was ever placed during the resident's admission. Staff interviews confirmed that the resident was not placed on any type of precautions related to the catheter, and the facility did not begin implementing EBP until after the relevant period. The deficiency was confirmed during the survey exit conference with facility leadership and department representatives.
Failure to Provide Functioning Call Bell System for Dependent Resident
Penalty
Summary
A resident admitted with end stage renal disease and completely dependent for activities of daily living was found to be without a functioning call bell system in their room during three separate surveyor observations. The resident's clinical record confirmed their total dependence on staff for care. Staff interviews revealed that the resident previously had a touch call bell, which was removed due to malfunction and not replaced prior to the surveyor's observations. The absence of a call bell system meant the resident was unable to request staff assistance as needed during this period.
Failure to Prevent Fall for High-Risk Resident
Penalty
Summary
The facility failed to prevent a fall for a resident (R30) who was at high risk for falls due to severe cognitive impairment and unsteadiness. The resident required extensive assistance for various activities of daily living, including dressing and toileting. On the day of the incident, a CNA was dressing R30 in her room. The CNA stood R30 up from a recliner without a gait belt and attempted to pull up her pants from behind. R30, who was known to be impulsive and unsteady, walked away and fell face down, resulting in a concussion and an abrasion to her forehead. The resident was hospitalized for eight days following the fall. The investigation revealed that the CNA did not follow the care plan, which required extensive assistance and the use of a gait belt for transfers and ambulation. Multiple staff members, including the RN who investigated the fall, confirmed that R30 was impulsive and had a history of trying to walk away during care. The CNA admitted to removing the gait belt after seating R30 in the recliner and standing her up without it, which led to the fall. The facility's policy on fall prevention was not adhered to, as the CNA did not ensure the resident's safety by requesting assistance or standing in front of her while dressing. Interviews with other staff members, including LPNs, CNAs, and the Staff Development Coordinator, corroborated that R30 was a high fall risk and required careful supervision during care. The Staff Development Coordinator acknowledged that training for nursing assistants on fall prevention had not yet been implemented. The Medical Director confirmed that R30 was a high fall risk due to her severe dementia and unsteadiness. The facility's failure to follow the care plan and ensure adequate supervision directly led to the resident's fall and subsequent hospitalization.
Failure to Assess and Implement Care for Decline in Urinary Continence
Penalty
Summary
The facility failed to ensure that a resident (R8) was properly assessed and provided with appropriate care following a decline in urinary continence. Initially, R8 was continent of urine and able to use a walker to go to the toilet with assistance. However, after losing the ability to use the walker due to a loss of function in her hand, R8 became incontinent and was placed in incontinence briefs. Despite this significant change, the facility did not complete the required assessments or implement a toileting program to maintain as much continence as possible for R8. The quarterly Bowel and Bladder Program Screener and the Elimination Pattern Evaluation tool were not completed as required by the facility's Bladder Management Program policy. Interviews with staff revealed that R8 was previously able to walk to the toilet and required assistance with toileting hygiene. However, after the decline in her physical abilities, R8 was no longer taken to the toilet and remained in bed, dependent on staff to change her incontinence brief. Staff confirmed that R8 was on a check and change program, where her brief was changed after it was wet, but no attempts were made to implement a toileting program. The care plan for R8 was not updated to reflect her current needs, and the facility failed to provide the necessary interventions following her decline in continence. The facility's failure to complete the required assessments and implement appropriate care for R8 was further confirmed by the MDS Coordinator and the Administrator. The MDS Coordinator acknowledged that the quarterly Bowel and Bladder Program Screener was not completed, and no toileting program was attempted despite R8 being identified as a good candidate. The Administrator verified that the voiding pattern form was not completed and attributed this to recent changes in the software used by the facility. The facility's Bladder Management Program policy clearly outlined the procedures for assessing and providing care for residents with continence issues, but these procedures were not followed in R8's case.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to provide feedback and/or resolutions to resident complaints and/or grievances discussed in the monthly resident council meetings in 12 of 13 meetings. The issues raised by residents included CNAs using their phones during care, long call light response times, and staff being rude or unresponsive. Despite these recurring complaints, there was no documented action taken by staff to resolve these issues, nor was there a thorough investigation or resolution provided to the group as noted in the resident council minutes. In several instances, residents reported specific grievances such as CNAs stopping care to answer their phones, taking 25-30 minutes to respond to call lights, and being rushed during showers. Additionally, there were complaints about staff talking loudly, slamming doors, and using ear buds, making it difficult for residents to communicate with them. These issues persisted over several months without any effective resolution or documented follow-up actions by the facility. Interviews with the Activities Director and the Social Services Director revealed that while the concerns were noted and communicated to the Administrator and the Director of Nursing, there was no formal process in place to elevate these grievances to a reportable incident or investigation. Residents expressed that their concerns were only resolved 60-70% of the time, indicating a significant gap in addressing and resolving resident grievances effectively.
Failure to Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate and document abuse allegations for three residents. One resident reported that a male staff member disconnected her call light after she had a bowel movement and waited over two hours to be changed. The investigation revealed that the assigned CNA had left early without notifying the RN Supervisor, leading to a delay in care. However, the investigation lacked interviews with the involved CNA, other staff members, and did not verify if the call light was disconnected as alleged. The grievance was deemed unsubstantiated without thorough evidence collection. Another resident reported that staff had been rough during care and one CNA yelled at her when she soiled her bed. The resident did not provide specific details but mentioned informing her nurse. The facility's investigation into this allegation was not comprehensive, lacking statements from all staff present at the time or other residents who might have witnessed the incident. A third resident mentioned that some staff were very rude, and his wife confirmed an incident a few weeks prior. The Social Services Director handled the grievance but did not conduct a thorough investigation, missing statements from all involved staff and other potential witnesses. The facility's policy required a thorough investigation, including interviews and documentation, which was not followed in these cases.
Sanitation Issues in Kitchen
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary condition, affecting 79 out of 82 residents. During an initial inspection, it was observed that three lids covering plates for meal service had food residue and crumbs, and a large tray stored as clean had scattered food crumbs. In the dry food storeroom, two spoodles were stored on top of five-gallon buckets with bulk foods, and a box of cornstarch was torn open, exposing its contents. Additionally, a resealable plastic bag with unidentified food was not labeled. The dish room had numerous food crumbs and particles on the counter, discolored residue along the walls and floor under the dish machine, and brown residue on the stainless-steel wall adjacent to the clean dishes. Several plastic cups stored as clean had food residue on the interior drinking surface. Further observations with the Dietary Manager revealed similar issues, including food crumbs and particles on the dish room counter, discolored residue along the walls and floor under the dish machine, and brown residue on the stainless-steel wall. Two bowls on the shelf for clean dishes had food residue, and an opened box of cornstarch was improperly stored. In the walk-in freezer, large bags of ice were stored directly on the floor, and the walk-in refrigerator had improperly labeled food items. The Registered Dietitian confirmed that foods should be completely covered when stored, clean scoops should be stored in holders, and bags of ice should not be stored directly on the floor. The facility's policies on food storage and warewashing were not adhered to, leading to these deficiencies.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure that a resident's physician was notified of a change in condition. The resident, who had hemiplegia and hemiparesis following a stroke, was documented as refusing to wear her left resting hand splint most of the time over a two-week period. Despite this, the physician was not informed, which could have led to a lack of necessary treatment modifications. The resident's refusal to wear the splint was noted in the Treatment Administration Record (TAR) for January and February 2024, but there was no documentation of physician notification in the physician notification book or any other evidence provided by the facility. Interviews with the resident, staff, and the physician confirmed that the physician had not been notified of the resident's refusal to wear the splint. The Director of Nursing (DON) and the Administrator acknowledged that the staff should have informed the physician. The facility's policy required the licensed nurse to notify the physician when there was a need to significantly alter treatment, but this procedure was not followed in this case. The lack of communication and documentation led to the deficiency identified by the surveyors.
Failure to Resolve and Document Grievances Promptly
Penalty
Summary
The facility failed to make prompt efforts to resolve grievances and report the findings in writing to the resident or family for one of the sampled residents. Resident 8, who had diagnoses including anxiety disorder, weakness, and chronic kidney disease, reported numerous instances of staff not answering her call light timely, not toileting her, or changing her soiled incontinence brief in a timely manner. These grievances were reported by the resident and her family members, but the facility did not document sufficient findings or provide written responses at the conclusion of the investigations. Specific grievances included incidents where the resident was left on the toilet for extended periods, did not receive requested medication, and experienced delays in being changed after soiling herself. In several cases, the facility's grievance files lacked staff statements, and there was no evidence of written responses being provided to the resident or her family. For example, one grievance reported that a CNA argued with the resident about whether her brief was wet, and another grievance noted that the resident's call light was not answered for over an hour. The Social Service Director, who was the Grievance Official, confirmed that there were no staff statements or written documentation following the grievances. The Administrator acknowledged that the grievance process had been updated recently, but the more recent grievances still lacked witness statements. The facility's policy required prompt efforts to resolve grievances and written decisions to be provided to the resident or representative, but this was not consistently followed in the cases reviewed.
Neglect Due to CNA Abandonment
Penalty
Summary
The facility failed to protect the residents' right to be free from neglect when a CNA left the facility without informing staff, resulting in eight residents not receiving care. One resident, who was severely cognitively impaired and required extensive assistance, sustained a fall during this period. The resident was found with her head on the floor and her pelvis on the bed by restorative CNAs, and she was subsequently sent to the emergency department for evaluation due to complaints of headache and neck soreness. The resident was treated with Eliquis, a blood thinner, and returned to the facility after a CT scan showed no injuries. The incident occurred when CNA1, who was assigned to care for eight residents on the 100 B Unit, left the facility without notifying any staff. The CNA had initially come to work for a special assignment but was reassigned to patient care due to another CNA testing positive for COVID-19. Despite being informed of the reassignment, CNA1 clocked out and left the building without informing anyone, leading to the neglect of the assigned residents. The fall of the resident was discovered by other CNAs during their rounds. Interviews with the facility staff revealed that the CNA did not communicate his refusal to take the new assignment and left the building shortly after being informed of the change. The facility's policy on resident abuse prevention and neglect was reviewed, indicating that the facility prohibits and does not tolerate neglect. The CNA was suspended and later terminated for job abandonment and misconduct. The facility's failure to ensure that the CNA fulfilled his duties led to the neglect of the residents and the subsequent fall of one resident.
Failure to Report Abuse and Neglect
Penalty
Summary
The facility failed to implement policies and procedures for ensuring the reporting of potential neglect and abuse within two hours for two allegations involving nine residents. One incident involved a resident who reported that her certified nursing assistant (CNA) unplugged her call light after she had waited over two hours to be changed following a bowel movement. The resident's family member confirmed the incident, and the Social Services Director (SSD) handled it as a grievance rather than reporting it to the State Survey Agency (SSA). The Administrator and Director of Nursing (DON) acknowledged that the incident could be considered abuse or neglect, but it was not reported to the SSA as required by facility policy and state regulations. Another incident involved a CNA who did not provide care for eight assigned residents for an hour and left the facility without informing anyone. This resulted in one resident falling and being transported to the hospital. The former DON did not report the neglect and abandonment of the eight residents to the SSA, as she was on leave at the time. The Administrator confirmed that the staff did not follow the abuse reporting policy and that the neglect should have been reported to the SSA. The facility's policy requires immediate reporting of alleged violations involving mistreatment, neglect, or abuse to the Administrator and the SSA, but this was not followed in these cases. The facility's failure to report these incidents in a timely manner highlights a significant deficiency in their abuse and neglect reporting procedures. The SSD and nursing staff did not recognize the incidents as reportable, and the facility lacked an abuse coordinator to ensure proper reporting. The Administrator and DON acknowledged the deficiencies in their interviews, confirming that the facility did not adhere to its own policies or state regulations regarding the reporting of potential abuse and neglect.
Failure to Provide Written Transfer Notices to Hospitalized Residents
Penalty
Summary
The facility failed to ensure that two residents, who were hospitalized, received written transfer notices upon their emergent transfer to the hospital. Resident 35, who had diagnoses including Parkinson's disease and feeding tube complications, was transferred to the hospital due to a clogged GJ tube. Although the resident's family member was notified in writing, the resident himself was not provided with a written notice. The Social Service Director (SSD) and the Administrator both confirmed that they were unaware of the requirement to notify the resident in writing, and the facility's policy did not include this requirement either. Similarly, Resident 51, who had a diagnosis of hemiplegia and gastrointestinal hemorrhage, was sent to the emergency room for evaluation of bleeding. While the resident's family member received a written transfer notice, the resident did not. The SSD confirmed that the resident, who was cognitively intact, was not provided with a copy of the transfer notice. The Administrator also stated that the facility's practice was to notify the resident's representative and not the resident, as they were unaware of the federal requirement to do so.
Failure to Provide Bed Hold Notices to Hospitalized Residents
Penalty
Summary
The facility failed to ensure that two residents, R35 and R51, were provided with bed hold notices within 24 hours of their emergent transfers to the hospital. For R35, who was admitted with diagnoses including Parkinson's disease and feeding tube complications, there was no documentation showing that a written bed hold notice was provided during a hospitalization for a clogged feeding tube. The Social Service Director (SSD) and the Administrator both confirmed that they were not aware of the requirement to notify both the resident and the family member in writing at the time of hospitalization. Similarly, R51, who was admitted with a diagnosis of hemiplegia and later readmitted with a gastrointestinal hemorrhage, did not receive a bed hold notice in writing during a hospitalization for bleeding. Although the bed hold policy was mailed to R51's family member, R51, who was cognitively intact, confirmed that he did not receive a copy. The SSD and the Administrator both acknowledged that the bed hold policy was only mailed to the resident's representative and not provided to the resident because they were in the hospital.
Failure to Update Care Plan Following Resident's Change in Condition
Penalty
Summary
The facility failed to update the care plan for one resident following a significant change in her ability to ambulate, transfer, use the toilet, and maintain continence. The resident, who was admitted with diagnoses including anxiety disorder, weakness, and chronic kidney disease, was initially able to walk with assistance and was continent of urine. However, a subsequent assessment revealed that the resident had become incontinent, no longer used the toilet, and required a Hoyer lift and two staff members for transfers. Despite these changes, the care plan was not updated to reflect the resident's current needs and condition. Interviews with the resident and staff confirmed that the resident's condition had deteriorated over the past few months, necessitating increased assistance and a change in her care routine. The resident reported that she no longer walked and was dependent on staff for changing her incontinence brief. Staff members corroborated that the resident was now on a check and change program and no longer used the toilet. The MDS Coordinator also verified that the care plan had not been updated to reflect these significant changes, despite the facility's policy requiring care plans to be revised when there is a change in the resident's condition.
Failure to Notify Wound Nurse Practitioner of New Wound
Penalty
Summary
The facility failed to notify the wound nurse practitioner when an alteration in skin was identified for a resident, leading to a delay in wound treatment. The resident, who was admitted with diagnoses including heart failure, Parkinson's disease, and vascular dementia, developed a coccyx wound upon admission. The wound was documented by the admitting nurse, but the necessary information was not entered into the wound logbook to alert the nurse practitioner, resulting in the wound not being assessed or treated by the nurse practitioner until several days later. The resident's wound was initially documented on the day of admission, and a one-day treatment order was entered. However, there was no documented evidence of wound treatment from the day after admission until six days later when a family member brought the wound to the attention of a nurse. The nurse then assessed the wound, applied a dressing, and entered a treatment order. The nurse practitioner was not aware of the wound until ten days after the resident's admission, at which point the wound had worsened. Interviews with staff revealed that the process for notifying the wound nurse practitioner was not followed. The Director of Nursing confirmed that the admitting nurse did not enter the wound information into the logbook, which was necessary for the nurse practitioner to be aware of and assess the wound. The facility's policies on pressure ulcer treatment and skin alteration management were not adhered to, leading to a significant delay in wound care for the resident.
Failure to Apply Hand Splint as Ordered
Penalty
Summary
The facility failed to ensure that a resident with hemiplegia and hemiparesis following a stroke received appropriate care to maintain range of motion (ROM) as prescribed. The resident had a physician's order for a left-hand resting splint to be applied in the morning and removed before bedtime. However, documentation revealed inconsistencies in the application of the splint, with several days showing no record of the splint being applied or the resident refusing it. Additionally, there was no documentation in the nursing progress notes regarding the resident's refusal to wear the splint, and the care plan did not include the use of the splint as an intervention despite the resident's condition and physician's orders. Observations during the survey confirmed that the resident was not wearing the left-hand splint on multiple occasions. Interviews with the resident and staff indicated that the splint had not been applied consistently, and some staff members were unaware of the order for the splint. The Director of Rehabilitation confirmed that the resident should be wearing the splint for contracture management, and the Director of Nursing acknowledged that refusals should be documented in the nursing notes. The Administrator noted that the resident's recent move within the facility might have contributed to the oversight. The facility's policy on the use of assistive devices emphasized the importance of a reliable process for the proper and consistent use of such devices. However, the failure to apply the left-hand splint as ordered and the lack of documentation regarding refusals or application in the care plan and progress notes indicate a lapse in adherence to this policy. This deficiency highlights the need for improved communication and documentation practices to ensure residents receive the care necessary to maintain their ROM and prevent complications such as contractures.
Latest citations in Delaware
Three residents who were dependent on staff for bed mobility and transfers did not receive adequate supervision and safe handling during care and transfers, resulting in serious injuries. A resident who was totally dependent for bed mobility slid from the bed to the floor while a CNA focused on gathering supplies during care, later being found to have an ankle fracture. Another resident with a prior brain bleed, craniotomy, and left-sided paralysis, requiring a mechanical lift with two staff, sustained a head injury when a Hoyer lift was improperly positioned or controlled during transfer from a shower bed to a wheelchair, causing the lift bar to strike the top of the head and leading to ongoing head and neck pain. A third resident needing extensive assistance fell between a shower bed and her regular bed when a CNA attempted to transfer her without locking the shower bed wheels, resulting in acute L2–L3 compression fractures confirmed by CT.
A resident who required set-up assistance for eating spilled coffee onto bare upper thighs while being prepared for morning care, initially resulting in nonblanchable redness with intact skin and no reported pain. During later incontinence care, staff identified a broken blister on the resident’s right upper thigh, cleansed the area, and applied skin prep, but did not notify the MD until more than a day after the blister was first noted. An NP confirmed that although she had been informed of the coffee spill itself, there was no documentation that the subsequent change in skin condition had been communicated to a provider, resulting in a failure to promptly notify the on-call provider of the new skin alteration.
A resident with significant neurologic impairment and multiple contractures slid from bed and was assisted to the floor during the night shift, but an RN did not complete the initial post-fall assessment until the following day shift. An LPN documented that the resident was seated after the event, denied pain, had ROM and VS assessed, and was assisted back to bed with a CNA. The DON later reported that the CNA and LPN did not report the event as a fall because the resident was assisted down, and the LPN stated she relied on the CNA’s account when completing the incident report and was unsure if the RN had been notified.
A resident reported an allegation of physical abuse by a CNA during the night shift, which was documented in the clinical record. Facility policy required that all alleged violations be reported to the Administrator, state agency, APS, and other required agencies immediately but no later than two hours after the allegation. Instead, the allegation was reported to the state agency approximately nine hours after it was made. An RN acknowledged not reporting the allegation right away and waiting for the day shift, and the DON confirmed that the reporting timeframe was not followed.
A resident with dementia and a care plan for false accusations alleged physical abuse by a CNA. Facility policy required staffing or room changes to protect residents from an alleged perpetrator, but the CNA remained on duty providing care to other residents for the rest of the shift. An LPN and an RN confirmed that the CNA continued working with residents, with the CNA only being stopped from caring for the accusing resident’s room, resulting in a failure to fully implement the abuse protection policy.
A resident with CHF and kidney disease requiring dialysis was admitted and assessed as having congestive heart failure, but the baseline care plan lacked CHF-related interventions and there was no timely physician order for fluid restriction despite a nutrition assessment referencing a 1500 mL limit. A physician note identified the resident as high risk for rehospitalization and called for strict I&O and daily weights, yet a formal fluid restriction order was not entered until several days later, only after the responsible party requested it. The next day, the resident was sent to the hospital from dialysis for chest pain and shortness of breath. In interviews, the MD, RN, and DON all confirmed the resident should have been placed on fluid restriction and monitoring upon admission and that this was not done in a timely manner.
Surveyors found that dietary staff repeatedly failed to wear required hair and beard restraints while preparing food, washing dishes, and serving meals, and the Dietary Manager acknowledged that restraints should be worn at all times but that the facility had run out of them. These unsanitary practices occurred during routine kitchen operations and affected nearly all residents who received meals from the kitchen, with only two residents receiving nutrition via feeding tubes.
Surveyors found that medication carts were left unlocked and unattended in two separate locations. One cart on a hall outside a resident room was left unlocked while an LPN was inside the room with the privacy curtain pulled and unable to see the cart, with only a CNA present further down the hall. Another cart at the nurses’ station, shared by nurses on two halls, remained unlocked while the ADON walked past it twice and then left the area, leaving no one at the station until returning several minutes later to lock it. Facility policy required all medication and treatment carts to be locked when not in use and not left unattended while unlocked.
The facility did not provide required written information on advance directives and the right to accept or refuse medical and surgical treatment to two residents, one cognitively intact and one with moderately impaired cognition, as confirmed by EMR review showing no such documentation. The SSD reported having no written materials explaining types of advance directives or any signature page confirming verbal explanations or resident understanding. The AD stated the admission packet only asked whether a resident had or wanted an advance directive and did not include written definitions or explanations. The Administrator acknowledged being unaware of regulatory requirements and of the facility policy, which states that residents have the right to formulate an advance directive and to accept or refuse treatment, and that written information must be provided in an easily understood manner.
A cognitively intact resident with mild cognitive impairment reported to her son that a male CNA entered her room at night to provide incontinent care, which she refused, and that he returned and made an inappropriate sexualized remark when she again refused care. The son called the facility to report the concern, and the Admissions Director stated she immediately informed the DON, in line with protocol to notify leadership of abuse-related grievances. However, the DON reported she did not recall receiving the grievance and only became aware of the allegation when law enforcement arrived several days later after receiving a family complaint. The DON confirmed that the SSA was not notified of the abuse allegation until four days after the initial grievance, despite facility policy and leadership acknowledging that alleged abuse must be reported to the SSA within two hours.
Failure to Provide Adequate Supervision and Safe Transfers Resulting in Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate assistance and supervision to prevent accidents for three residents who were dependent on staff for mobility and transfers. One resident with anoxic brain injury, multiple contractures, abnormal posture, and idiopathic progressive neuropathy was documented on multiple MDS assessments as requiring substantial/maximal assistance for bed mobility and was described by nursing and therapy staff as totally dependent and unable to move or roll in bed without physical assistance. During nighttime care, a CNA entered the room in response to a call light, found that the resident had vomited, and focused on looking for towels while standing on one side of the bed. The CNA reported that the resident then began sliding off the opposite side of the bed; the CNA ran around the bed but was unable to prevent the resident from sliding off, and instead lowered the resident to the floor in a seated position. Subsequent imaging confirmed a stable right ankle fracture, and interviews with the NP, OT, LPN, and other CNAs confirmed that the resident was dependent for bed mobility and could not independently roll or slide out of bed, indicating that the resident did not receive the level of hands-on assistance and supervision consistent with their documented needs. A second resident with a history of brain bleed, seizure disorder, craniotomy, and left-sided paralysis had a care plan and therapy determination requiring a mechanical (Hoyer) lift with two staff for all transfers and was completely dependent on staff for bathing and transfers. During a transfer from a shower bed back to a wheelchair using a mechanical lift, the resident reported that the hooks of the lift were not properly attached to the bars, causing the front of the lift to become unbalanced and tilt backward, dropping the resident into the chair and allowing the lift bars to strike the top of the resident’s head at the craniotomy site. The resident stated that the lift was not moving when staff attempted to place him in the chair and that this type of incident had not occurred during prior showers, when he was typically returned to his room on the shower bed and transferred in bed. One CNA described that while assisting with the transfer, the lift appeared stuck and positioned sideways over the wheelchair; when she voiced concern and attempted to correct the position, the lift rose and the bar hit the resident’s head. The other CNA involved stated that as she operated the lift controls, the resident’s weight shifted, the lift tipped back, and the bar struck the top of his head. The physician documented a head strike from the Hoyer lift with subsequent head and neck pain, and the resident required repeated PRN pain medication for ongoing head and neck pain. A third resident with cerebral infarction and rheumatoid arthritis had orders and MDS documentation indicating a need for extensive to maximal assistance with bed mobility and dressing. After receiving a shower, this resident was brought back to the room on a shower bed. The facility’s incident report documented that the CNA lowered the side rail of the shower bed, pushed the shower bed against the resident’s bed, turned the resident on her side, removed the bath sheet, and began pushing the Hoyer pad underneath. During this process, the resident rolled and fell between the two beds to the floor, becoming very anxious and crying. A subsequent CT scan at the hospital revealed acute L2 and L3 vertebral compression fractures. In a later interview, the CNA acknowledged that she must have forgotten to lock the wheels on the shower bed before attempting the transfer, and described that when she rolled the resident to place the Hoyer pad, the shower bed separated from the resident’s bed, allowing the resident to fall between them. These events demonstrate that the resident did not receive adequate supervision and safe handling during the transfer process, despite her documented need for extensive assistance with mobility.
Failure to Timely Notify Provider of New Skin Blister After Coffee Spill
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a provider of a change in a resident’s skin condition following a coffee spill incident. The resident was admitted earlier in the month, and the admission MDS documented that the resident required set-up assistance for eating. On the morning of 3/30/26, a nurse documented that the resident placed a cup of coffee on the bed railing, and when he let go, the cup fell onto his lap, spilling hot coffee onto his bilateral upper thighs while he was not wearing pants and was about to receive morning care. At that time, the nurse documented nonblanchable redness on both upper thighs with all skin intact, and later that day a wound care RN documented that there was no scalded skin present and the resident denied pain. A late entry nurse’s note documented that during incontinence care on 3/31/26, a broken blister on the resident’s right upper thigh was identified, cleansed with saline, patted dry, and skin prep applied. Review of incident documentation showed that the physician was not notified of this blister until 4/1/26 at 8:38 AM, more than 24 hours after the blister was first identified. During interview, the NP stated she had been notified of the coffee spill on 3/30/26 but, upon reviewing the physician binder, confirmed there was no evidence that the change in skin condition noted on 3/31/26 had been communicated to a provider at that time. The facility therefore failed to notify the on-call provider when the resident experienced a change in skin condition after the coffee spill incident.
Failure to Obtain Timely RN Post-Fall Assessment After Assisted Descent to Floor
Penalty
Summary
The facility failed to ensure that an RN performed and documented an initial post-fall assessment for a resident who slid off the bed and was lowered to the floor during the 11 PM–7 AM shift. The resident had significant medical conditions including anoxic brain injury, abnormal posture, multiple contractures of the upper and lower limbs, and idiopathic progressive neuropathy. A facility-reported incident documented that the resident sustained a fall with later complaint of ankle pain, with an X-ray obtained and results unclear, and a repeat film obtained two days later. The clinical record showed that the initial post-fall assessment was not completed by an RN until 8:34 AM on the 7 AM–3 PM shift by the ADON, and there was no evidence of an RN assessment during the overnight shift when the fall occurred. A witness summary completed by an LPN documented that the resident was in a seated position after the fall, denied pain, had range of motion assessed, denied pain again, had vital signs taken, and was assisted by a CNA back to bed. During interviews, the DON stated that the fall was not reported by the CNA and the LPN because they did not consider it a fall since the resident was assisted to the floor. In a phone interview, the LPN confirmed being called by the CNA about the fall, stated that care and an assessment were provided, and indicated uncertainty about whether the RN was notified, noting that the written incident report was based on what the CNA reported and that the LPN was not present at the time of the fall.
Failure to Timely Report Allegation of Staff-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure immediate reporting of an allegation of staff-to-resident physical abuse in accordance with its abuse policy and regulatory time frames. The facility’s abuse policy, last updated January 2026, required that all alleged violations be reported to the Administrator, state agency, adult protective services, and other required agencies immediately but no later than two hours after the allegation is made. On 6/12/25 at 3:31 AM, an incident note in the clinical record documented that resident R83 alleged physical abuse by a CNA (E8). However, the allegation was not reported to the State Agency until 11:21 AM the same day, approximately nine hours after the allegation was made, exceeding the required reporting timeframe. During an interview on 4/23/26 at 11:06 AM, an RN (E6) confirmed that the allegation was not immediately reported and stated that the DON later informed her it should have been reported right away rather than waiting for day shift. In a separate interview at 11:14 AM, the DON (E2) confirmed these findings. The deficiency centers on the delayed reporting of the abuse allegation to the State Agency despite clear policy requirements for immediate notification. The survey findings were reviewed with the Nursing Home Administrator (E1), the DON (E2), and others at the exit conference on 4/23/26 at 3:00 PM.
Failure to Remove Accused Staff From Resident Care After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from further potential abuse by not immediately removing an accused staff member from resident care following an allegation of physical abuse. The facility’s abuse policy, updated January 2026, states that room or staffing changes are to be made as necessary to protect residents from the alleged perpetrator. On 6/12/25 at 11:21 AM, the facility reported an allegation of staff-to-resident physical abuse involving resident R83 and CNA E8. Record review of E8’s timesheet showed that after this allegation, E8 remained in the facility working with residents until 7:05 AM. During interview, LPN E7, who was assigned to R83’s unit at the time, confirmed that E8 continued caring for residents after R83’s accusation and stated that R83 had dementia and a care plan for false accusations, and that E8 was only stopped from caring for R83’s room for the rest of the shift. RN E6 also confirmed that E8 continued caring for residents after the allegation and stated that she instructed E8 to care for other patients. These findings were reviewed with the NHA (E1) and DON (E2) during the exit conference. The resident involved, R83, had dementia and a documented care plan for false accusations, which influenced staff’s decision to limit E8’s contact only with R83 rather than removing E8 from all resident care. Despite the facility’s written policy requiring protective staffing or room changes to safeguard residents from an alleged perpetrator, E8 remained on duty providing care to other residents for the remainder of the shift after the allegation of physical abuse was made.
Failure to Implement Timely Fluid Restriction and Monitoring for Resident With CHF and Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and monitoring consistent with professional standards of practice for a resident admitted with congestive heart failure and kidney disease requiring dialysis. The resident was hospitalized for multiple conditions, including heart failure, and then admitted to the facility with diagnoses of congestive heart failure and kidney disease. An admission assessment by an RN documented congestive heart failure, but the baseline care plan did not include any interventions related to this diagnosis. A nutrition assessment documented that the resident was on a therapeutic meal plan with a 1500 mL fluid restriction and indicated ongoing monitoring of oral intake, weight, skin integrity, and labs, yet the physician’s orders and dietary intake records did not contain an order for fluid restriction. A physician progress note documented that the resident had multiple complex comorbidities, including heart failure, and was at high risk for rehospitalization without proper care, specifying a plan for strict intake and output and daily weights. An admission MDS later confirmed that the resident was cognitively intact, experiencing shortness of breath, and had an active diagnosis of heart failure. A physician’s order for a 1500 mL fluid restriction was not written until several days after admission, at the request of the resident’s responsible party. The following day, nursing documentation showed the resident was sent to the hospital from dialysis for chest pain and shortness of breath. In interviews, the MD, the admitting RN, and the DON all confirmed that the resident should have been placed on a fluid restriction and monitoring upon admission, and the DON acknowledged that the fluid restriction order was not implemented in a timely manner.
Failure to Ensure Dietary Staff Used Required Hair and Beard Restraints During Food Service
Penalty
Summary
The deficiency involves failure to maintain sanitary conditions in the kitchen, specifically related to staff not using required hair and beard restraints during food service activities. During an observation and interview with the Dietary Manager (DM) on 03/29/26 from 9:25 AM to 10:28 AM, two Dietary Aides (DA1 and DA2) were seen engaged in food preparation and dishwashing without wearing beard or hair restraints, which the DM confirmed. In a subsequent observation and interview with the DM on 03/31/26 from 8:55 AM to 11:36 AM during the meal serving line, DA1 and DA3 were again observed not wearing beard or hair restraints, and the DM stated that such restraints should be worn at all times and acknowledged the facility was out of beard/hair restraints. These conditions affected 78 residents who received meals from the kitchen, out of a total census of 80 residents, with 2 residents receiving nutrition via feeding tubes. The observations document that multiple dietary staff members repeatedly failed to use required protective restraints while handling food and dishes, and that the facility lacked an adequate supply of beard/hair restraints, as confirmed by the DM. The report specifies that this failure occurred during both food preparation and meal service times and applied to nearly all residents receiving meals from the kitchen.
Unattended, Unlocked Medication Carts Left Accessible in Two Locations
Penalty
Summary
The deficiency involves the facility’s failure to keep medication carts locked and secured when not in use, as required by facility policy and professional standards. During an early morning observation on 04/01/26 at 4:53 AM, a medication cart on the [NAME] Hall in front of room W102 was found unlocked while an LPN was inside the resident’s room with the privacy curtain pulled. The medication cart was not visible from inside the room, and the only other staff member in the area, a CNA, was further down the hall delivering linen to another room. At 4:59 AM, the LPN returned to the cart and locked it, confirming that it had been left unlocked and out of her line of sight. A second unsecured cart was observed on 04/01/26 at 5:56 AM at the nurses’ station, where the medication cart shared by nurses on the [NAME] and East Halls was left unlocked. The ADON walked past this unlocked cart twice and then left the nurses’ station to go down the East Hall at 6:00 AM, leaving the cart unattended and still unlocked. At 6:05 AM, the ADON returned and locked the cart. In an interview at that time, the ADON stated that it was the expectation that all medication and treatment carts be kept locked when not in use. Review of the facility’s “Storage of Medication” policy, revised November 2020, confirmed that compartments containing drugs and biologicals are to be locked when not in use and that unlocked carts should not be left unattended.
Failure to Provide Required Written Information on Advance Directives and Treatment Rights
Penalty
Summary
The facility failed to provide written information regarding advance directives and the right to accept or refuse medical and surgical treatment to two residents reviewed for advance directives. One resident was admitted with hemiplegia and hemiparesis following cerebrovascular disease and major depressive disorder and had a BIMS score of 15/15, indicating intact cognition. Review of this resident’s EMR, including the admission record and MDS, showed no evidence that written information on advance directives had been provided. A second resident was re-admitted with heart failure, stage three chronic kidney disease, malignant neoplasm of the upper lobe of the left bronchus, and pain, and had a BIMS score of 12/15, indicating moderately impaired cognition. Review of this resident’s EMR also revealed no evidence that written information regarding advance directives had been provided. During interviews, the SSD stated she did not have any written information to provide residents about the distinct types of advance directives and that there was no signature page to indicate a verbal explanation was provided or that residents understood their right to accept or refuse medical and surgical treatments. The AD reported that the admission packet contained only one page asking if a resident had an advance directive or wished to formulate one, and that she did not have written information defining the types of advance directives to give residents on admission. The Administrator stated she was not aware of the regulatory guidance requiring written information on advance directives and the right to accept or refuse medical and surgical treatment, and was unaware that the facility’s own policy required this. The facility’s “Advanced Directives” policy, revised November 2025, stated that residents have the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment, and that written information must be provided in a manner easily understood by the resident or representative.
Failure to Timely Report Allegation of Sexual Abuse to SSA
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of sexual abuse to the State Survey Agency (SSA) within the required two-hour timeframe. A cognitively intact resident, admitted with cognitive communication deficit and mild cognitive impairment and having a BIMS score of 15/15, was the subject of an allegation reported by her son. On a grievance/concern form dated 09/18/25, the son reported that a male aide entered the resident’s room in the middle of the night stating he needed to check if she was wet; the resident refused, and the aide returned later, at which time the resident again refused. The facility’s investigation report dated 09/22/25 documented that the assigned CNA made an inappropriate verbal remark to the resident, stating, “you don’t know what you are missing,” when she refused incontinent care. An incident tracking form dated 09/22/25 at 8:21 PM showed that a police officer came to the facility and informed staff that they had received a complaint from the resident’s family alleging the resident had been spoken to in a manner that made her uncomfortable, and that the male staff assigned to her care made the same remark when she refused care. The Admissions Director stated she received the telephone call from the resident’s son on 09/18/25 describing the male staff entering the room, the resident’s refusals of care, and the uncomfortable comment, and that she immediately informed the DON of the concern, consistent with facility protocol to notify the Administrator and DON of all grievance and abuse concerns. The DON stated she did not remember receiving the grievance/concern form and reported that she first learned of the alleged abuse on 09/22/25 when a police officer came to the facility after receiving an allegation of abuse. The DON confirmed that the SSA was notified of the abuse allegation on 09/22/25, four days after the son’s grievance, and acknowledged that the SSA should have been notified on 09/18/25. The Administrator/Abuse Coordinator, who was out on leave at the time and unaware of the grievance, confirmed that alleged violations involving abuse should be reported to the SSA within two hours after the allegation is made. The facility’s written policy on abuse, neglect, exploitation, mistreatment, and misappropriation of property, dated 06/15/25, states that alleged violations involving abuse are to be reported to the SSA within two hours after the allegation is made, which did not occur in this case.
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