Polaris Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Milford, Delaware.
- Location
- 21 W Clarke Avenue, Milford, Delaware 19963
- CMS Provider Number
- 085058
- Inspections on file
- 25
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Polaris Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, an unsteady gait, and elopement risk left the unit through an emergency door after staff lost sight of the resident, and the resident was later found outside in the employee parking lot. In a separate incident, a CNA transferred another resident alone without the required Hoyer lift or two-person assist, despite the resident’s care plan requiring both.
Failure to document informed consent for psychotropic medications: Two residents received antipsychotic, antidepressant, and anti-anxiety medications without evidence that they or their representatives were informed of the risks, side effects, benefits, or alternatives. One resident had intact cognition and the other had moderate cognitive impairment; the DON confirmed there was no evidence of education, and the Administrator stated consents should be signed to confirm education.
Failure to provide SNF ABN notifications to three residents who remained in the facility after Medicare Part A skilled coverage ended. Records showed each resident had skilled needs such as muscle weakness, difficulty walking, lack of coordination, or muscle wasting, but no SNF ABN was issued before the last covered day. The SW stated she was unaware the form was required, and the Administrator said she was unaware the notices were not being provided.
Incomplete Abuse Investigation: The facility failed to conduct a thorough abuse investigation after allegations of verbal abuse by a housekeeper were reported by two cognitively intact residents. The investigation included interviews with the accused employee, one staff member, and the two reporting residents, but no additional resident interviews were documented even though the abuse policy required interviews with staff on all shifts and other residents cared for by the accused employee.
Incomplete Comprehensive Care Plans for Cardiac Monitoring, Isolation, and Elopement Risk: The facility failed to include key care needs in the care plans for three residents. One resident had an order for cardiac monitoring, another had MRSA with contact and respiratory isolation orders, and a third was identified as at risk for elopement with severe cognitive impairment, but their care plans did not reflect the related goals or interventions. The RNUM and MDSC confirmed the missing care plan content.
An LPN failed to follow the facility’s trach care procedure for a resident with chronic respiratory failure and trach status. The LPN initialed trach care orders but later said she had not performed the care yet and was only responsible for certain tasks. During observation, she did not set up a sterile field, did not clean the stoma with antiseptic as required, replaced trach ties and the inner cannula while working alone, and did not secure the trach site as outlined in the facility policy.
A resident with MRSA and multiple skin-related diagnoses had orders for contact isolation and a dermatologist order for respiratory and contact isolation, but the care plan did not reflect respiratory isolation interventions. Staff observed only contact precautions signage and used gown and gloves, while a CNA and an LPN were unaware that a mask or respiratory isolation was required. The IP was aware of contact precautions but did not review the record during oversight, and the facility policy required signage and PPE instructions for transmission-based precautions.
The facility did not provide enough nursing staff to meet resident needs, resulting in multiple instances where residents experienced prolonged call bell response times and delays in receiving assistance with ADLs such as toileting, changing, and being put to bed. Several residents reported waiting from 20 minutes to over an hour for help, with some left in soiled conditions or requiring family intervention due to staff unavailability. These delays were confirmed through observations, interviews, and facility documentation.
A resident repeatedly requested extraction of her remaining lower teeth and the provision of full dentures, as documented in multiple dental progress notes and interviews. Despite these ongoing requests and the facility's ability to perform extractions, the resident was not scheduled for the necessary procedure, resulting in a significant delay in receiving dental services.
Two cognitively intact residents experienced significant delays in accessing their personal funds due to a vacancy and transition in the business office manager position. Despite multiple requests, both residents waited longer than the facility's policy allows before receiving their money, and there was no evidence that residents were informed about interim procedures for fund access during the staffing gap.
A resident reported unauthorized charges on a credit card and a loan taken out in their name, but staff did not recognize or report this as an allegation of misappropriation of funds to the State Agency within the required timeframe. Multiple staff members were aware of the grievance, but it was not identified as a reportable incident, resulting in non-compliance with federal reporting requirements.
A resident reported that a former employee was stealing money, and while the facility notified the police and submitted an incident report, no internal investigation was conducted. The DON confirmed that no interviews or statements were obtained, and no investigation documentation was available.
A resident with a history of severe mental health conditions was transferred to the hospital for suicidal ideation and later denied readmission to the facility after discharge from an inpatient psychiatric facility. Staff interviews confirmed the denial was due to a large outstanding bill, and the facility did not comply with discharge requirements.
A resident with multiple sclerosis and paraplegia, dependent for bed mobility and unable to perform ADLs without assistance, was left unsupervised on her side during care when a CNA stepped into the bathroom, resulting in the resident rolling off the bed and sustaining a head laceration that required hospital treatment. Staff interviews confirmed the resident could not maintain her position without support, and the care plan required extensive assistance and supervision.
A resident with a right heel wound did not receive proper physician supervision for pressure ulcer care. Progress notes from follow-up visits lacked documentation of a physical wound assessment by the provider, who stated that wound care was managed by a wound NP and her involvement was limited to ordering medications. The absence of documented wound assessments indicated a failure to ensure appropriate medical supervision.
A resident had abnormal lab results indicating an elevated white blood cell count following a physician's order for CBC and CMP. There was no documented evidence that the provider was promptly notified of these results, as confirmed by the RN UM and facility leadership.
A resident with a new order for thickened liquids was served thin liquids at a meal, resulting in coughing, because the order was not properly communicated to dietary staff. The CNA was not informed of the change, the order was not entered as a dietary order in the EMR, and no dietary communication slip was provided, leaving the dietician unaware of the resident's needs.
A resident with baseline confusion experienced an unwitnessed fall, and the required neurological assessments were not fully documented in the medical record as per facility policy. The RN involved recorded assessment details on a personal notepad with the intention to later transfer them to the official form, but this was not completed, resulting in incomplete documentation in the clinical record.
The facility failed to maintain nourishment refrigerators in a sanitary condition, with improperly stored food items and spills observed. Items included outdated Boost drinks, undated sandwiches, and unlabeled leftovers. These issues were confirmed and discussed with the DON.
The facility failed to maintain the dignity and respect of three residents during care. Two residents were exposed to the hallway while receiving care with the door open, confirmed by the CNAs involved. Another resident experienced inappropriate behavior from a former CNA, who spoke in a loud and aggressive manner during care, corroborated by an agency RN. The resident reported feeling upset and crying after the incident.
A resident's diet was downgraded to a dysphagia mechanical soft texture for safety, but the facility failed to notify the resident's contact person of this change. The registered dietitian assumed nursing would handle the notification, but the clinical record showed no evidence of this communication. This deficiency was identified during a review and discussed with the NHA and DON.
The facility failed to provide accessible call bell systems for two quadriplegic residents. One resident was given call bells that were out of reach and unusable, despite communicating this to staff. The issue was only addressed after a surveyor's observation. Another resident had a sip and puff call bell positioned out of reach, confirmed by a respiratory therapist. These deficiencies were discussed with the facility's NHA and DON.
A facility failed to provide a resident with the Notice to Medicare Provider Non-Coverage (NOMIC) form before terminating services. The resident was discharged home without receiving the form, which is crucial for informing beneficiaries of their right to an expedited review of service termination. This issue was confirmed by the Nursing Home Administrator and discussed during an exit conference with the Director of Nursing.
A facility failed to recognize and report an abuse incident between two residents. One resident admitted to throwing soda cans and using derogatory language, but the incident was not reported as abuse because the can did not hit the other resident. Interviews revealed a lack of awareness and acknowledgment of the incident as abuse.
A facility failed to ensure the accuracy of the MDS assessment for a resident, as the admission assessment did not include evaluations for cognitive function, behaviors, mood, and pain levels. This omission was confirmed by the Director of Reimbursement Services, who acknowledged that the assessment was missed and the resident should have been interviewed.
A facility failed to conduct timely PASARR screenings for a resident with mental health disabilities, including bipolar disorder, anxiety disorder, and major depressive disorder. The resident remained in the facility beyond the authorized 60-day period without a new PASARR Level I and II screening. Interviews confirmed the oversight, and the resident was not discharged as planned, despite the short-term approval without specialized services.
A facility failed to develop a care plan for a resident prescribed an anticoagulant medication. The resident was admitted with a physician's order for anticoagulant use, documented in both admission and quarterly MDS assessments. However, the care plans lacked evidence of addressing the anticoagulant use. This deficiency was confirmed by the Director of Reimbursement Services and discussed with the NHA and DON during the exit conference.
The facility failed to include all required interdisciplinary team members in care plan meetings for several residents. Care plan meetings lacked input from physicians, CNAs, dietary, activities, and the medical director. Interviews revealed that CNAs were generally not involved unless requested by residents, and there was no formal documentation of their input. The NHA confirmed these deficiencies during the exit conference.
The facility failed to reposition two residents, both at high risk for skin breakdown, every two hours as required. One resident with hypoxic ischemic encephalopathy was observed lying on her back for four hours without being turned, despite a care plan indicating the need for repositioning. Similarly, another resident with quadriplegia was also observed lying on her back for four hours without repositioning. Interviews with CNAs and the residents confirmed the lack of adherence to repositioning protocols.
A resident admitted to the facility was identified as incontinent and a candidate for scheduled prompted voiding, but the facility failed to implement a toileting program. Staff did not assist the resident with toileting, and the resident was not offered a urinal or bedpan, despite being able to verbalize the need to use the bathroom. The facility's continence check program was not documented, and staff did not follow recommendations to promote continence.
The facility failed to provide adequate respiratory care for two residents. One resident with COPD did not have their oxygen tubing and humidifier bottle changed or labeled weekly, as required. Another resident with acute respiratory failure had their tracheal suction machine equipment unchanged since January, despite a physician's order for weekly changes. These issues were confirmed by staff and discussed with facility leadership.
The facility did not ensure that pharmacist recommendations were reviewed by the attending physician for a resident. The facility's policy requires the physician to document any irregularities and actions taken. A Pharmacist Consultant Note recommended evaluating the discontinuation of vitamin C and adjusting a laxative's timeframe, but no physician response was found. The Nursing Home Administrator confirmed the absence of documentation during an interview.
A facility failed to conduct AIMS testing every six months for a resident on antipsychotic medication, as required by its policy. The resident received an AIMS test in July, but by the following April, testing had not been completed for nine months. This deficiency was confirmed by the ADON and discussed with the NHA and DON.
The facility failed to ensure cleanliness in a resident's room, where a large brown stain on the floor persisted for several days despite daily cleaning routines. Initially, the room also had stained bedding and balled paper napkins on the floor. A housekeeper confirmed the stain's presence, noting that the facility employs daily cleaning staff, yet the stain remained until it was eventually removed.
Unsafe Elopement and Improper Transfer
Penalty
Summary
The facility failed to ensure resident safety for a resident who had been assessed as at risk for elopement and falls and who also had severe cognitive impairment and an unsteady gait. The resident’s elopement evaluation showed a score indicating risk, but the care plan did not include the elopement risk or any interventions. A nursing note documented that the resident was wandering on the unit, could not be redirected, and was later found in the back employee parking lot tending to flowers after leaving the unit without staff knowledge. Staff interviews and video review showed that the resident was sitting in the visiting area near the fish tanks while staff were not visible in the camera view, then walked to an emergency/egress door, pressed the emergency bar, and exited after the door unlocked. The resident remained outside for approximately one hour before being located by staff in the back employee parking lot. Staff reported hearing a faint alarm that stopped, and the maintenance director stated the door alarm would sound when the bar was pushed and then stop once the door was opened. The facility’s investigation and interviews also showed that the alarm system and wander guard system were not being tested before the incident. The facility also failed to follow a resident’s transfer care plan for another resident who had weakness and difficulty walking. That resident’s care plan required use of a Hoyer lift for transfers and two staff to be present at all times. Instead, a CNA transferred the resident alone using a stand-pivot type transfer without the Hoyer lift. The resident reported pain during the transfer, and the facility’s investigation confirmed that the resident was transferred inappropriately.
Failure to Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to provide evidence that two residents were informed of the risks, potential side effects, and available treatment options for psychotropic medications. R12 was admitted with diagnoses of major depressive disorder, other recurrent depressive disorders, and dementia. The EMR showed orders for Rexulti 0.5 mg at bedtime for agitation associated with dementia and Cymbalta 60 mg daily for depression, along with a side effect assessment to be completed every shift. R12’s MDS assessment showed a BIMS score of 14 out of 15, indicating intact cognition, and the assessment period included antipsychotic and antidepressant use. During interview, the DON stated the resident came into the facility already on those medications and there was no evidence that education was provided to the resident. R66 was admitted with diagnoses of major depressive disorder, dementia, and metabolic encephalopathy. The EMR showed an order for a side effect assessment every shift, sertraline 50 mg daily for depression and anxiety, and later buspirone 5 mg twice daily for anxiety. R66’s quarterly MDS showed a BIMS score of 9 out of 15, indicating moderate cognitive impairment, and antidepressants and anxiety agents were used during the assessment period. During interview, the DON stated there was no evidence that education was provided to the resident. The Administrator stated the expectation was that consents should be signed to confirm education, and the facility policy required review of non-pharmacological alternatives, indications, risks and benefits, and the resident’s or representative’s right to accept or decline treatment before initiating or changing psychotropic medication.
Failure to Provide SNF ABN Notifications
Penalty
Summary
The facility failed to provide Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) notifications to three residents who remained in the facility after their Medicare Part A covered services ended. Review of the records for R109, R81, and R110 showed each resident had skilled services under Medicare Part A, with the last covered dates documented on their SNF Beneficiary Notification Review forms, and no SNF ABN notification was provided prior to the last covered date of services. The residents’ admission records also showed diagnoses including muscle weakness, difficulty walking, lack of coordination, and muscle wasting. During interviews, the Social Worker stated she was unaware that the SNF ABN form was supposed to be issued when a resident’s Medicare Part A benefits ended and the resident remained in the facility. The Administrator stated she was unaware that SNF ABN notices were not being provided and said she expected the policy to be followed and beneficiaries to be notified timely. The facility policy titled Beneficiary Notice - NOMNC and SNF ABN - Policy and Procedure stated the facility would inform residents about potential non-coverage and the option to continue services with financial liability if the resident intended to continue services and the facility believed the services may not be covered under Medicare.
Incomplete Abuse Investigation
Penalty
Summary
The facility failed to follow its abuse policy and did not conduct a thorough investigation into allegations of verbal abuse involving two cognitively intact residents, R59 and R72. R59’s record showed diagnoses of cerebrovascular accident, seizure disorder, and depression, and a quarterly MDS with a BIMS score of 15 out of 15. R72’s record showed diagnoses of diabetes mellitus, anxiety disorder, and depression, and a quarterly MDS with a BIMS score of 15 out of 15. A Facility Reported Incident signed by the previous DON documented allegations of verbal abuse by a housekeeper reported by R59 and R70. The facility initiated an investigation and interviewed the housekeeper, one staff member present on the unit, and the two alert and oriented residents who made the report, but there were no indications of additional resident interviews. The ADON stated that during an investigation the facility should interview the resident making the complaint, staff working with the resident at the time, and other residents from the floor where the allegation was made, and verified that only R59 and R70 were interviewed. The DON stated that for a thorough investigation, similar residents should be interviewed. The facility policy required, at a minimum, interviews with the reporting person, staff members on all shifts who had contact with the resident during the alleged incident, and other residents to whom the accused employee provides care or services.
Incomplete Comprehensive Care Plans for Cardiac Monitoring, Isolation, and Elopement Risk
Penalty
Summary
The facility failed to develop person-centered comprehensive care plans for three residents with identified care needs. For one resident, the record showed an order for cardiac monitoring with a monitor placement check every shift for 30 days, but the current care plan did not address the cardiac monitor or include specific, measurable, achievable, relevant, and time-bound goals or interventions related to the monitoring. During interview, the RNUM stated that care, treatment, and services should be reflected in the care plan to ensure continuity of care, including assessment of the skin for reaction to the electrode adhesive and ensuring the monitor remained in place and dry. The MDS Coordinator reviewed the care plan and confirmed it did not reflect objectives or interventions for monitoring the cardiac monitor or the risk of actual wounds. For another resident, the record showed diagnoses including cellulitis, unspecified dementia, carcinoma in situ of the skin of the scalp and neck, and actinic keratosis. Orders included contact isolation for MRSA skin and nares every shift, and a dermatologist’s order stated the resident was MRSA positive and needed respiratory and contact isolation. The care plan initiated on 02/09/26 did not reflect interventions specific and relevant to respiratory isolation precautions, including the use of personal protective equipment to prevent airborne and droplet transmission of MRSA. The RNUM stated that care for a resident on transmission-based precautions should be reflected in the care plan, and the MDS Coordinator confirmed the care plan did not reflect objectives and interventions for respiratory isolation. For a third resident, the record showed diagnoses including history of falling, muscle weakness, and abnormalities of gait and mobility. An elopement evaluation indicated the resident was at risk for elopement, but the care plan did not include the elopement risk or any interventions. The resident’s MDS showed a BIMS score of 3 out of 15, indicating severe cognitive impairment. The Administrator stated that the nurse who completed the admission elopement assessment should have implemented a care plan and immediate intervention, and that the IDT should have met the following day to determine what else, if anything, needed to be put in place. The facility policy on wandering and elopements stated that if a resident is identified as at risk on admission, a wandering/elopement assessment is completed, a wanderguard is placed, and a care plan is initiated with the wanderguard and strategies and interventions to maintain safety.
Tracheostomy Care Not Performed Per Policy
Penalty
Summary
The facility failed to follow professional standards and its own tracheostomy care procedure for one resident with chronic respiratory failure with hypoxia, tracheostomy status, and a history of hemorrhage from the tracheostomy stoma. The resident had orders for tracheostomy care every shift, changing the inner cannula every 24 hours, pulse oximetry every shift and as needed, and changing trach ties every Monday and Thursday. On the day of the observation, an LPN initialed the TAR for tracheostomy care orders but later stated she had not yet performed the care and believed she was only responsible for trach care on Mondays and Thursdays. She also said the respiratory therapist performed trach care that included changing ties and that she was only responsible for cleaning the inner cannula. During the observed tracheostomy care, the LPN placed the gauze and inner cannula package on the resident’s blanket without setting up a sterile field, did not ensure the procedure area was clean, and did not use an antiseptic solution to clean the skin at the stoma site when removing the old inner cannula and inserting the new one. She replaced the trach ties with new ties and a foam collar, performed the care alone, and did not secure the trach site to prevent dislodgment. The facility’s tracheostomy care policy required cleaning the stoma with peroxide, rinsing with saline, wiping dry, disinfecting with antiseptic-soaked gauze, and having two staff members present to remove and replace neck ties. The DON stated nurses were checked off on skills during OJT and that a nurse could perform trach care without a second person if competent.
Failure to Implement Respiratory Isolation for Resident with MRSA
Penalty
Summary
Provide and implement an infection prevention and control program was not ensured when respiratory isolation precautions were not implemented for a resident with MRSA. The resident had diagnoses including cellulitis, unspecified dementia, carcinoma in situ of the skin of the scalp and neck, and actinic keratosis. The resident’s EMR included an order for contact isolation for MRSA skin and nares every shift, and a dermatologist’s order stating the resident was MRSA positive and needed respiratory and contact isolation. The resident’s care plan did not reflect interventions specific and relevant to respiratory isolation precautions to ensure appropriate PPE was worn to prevent airborne and droplet transmission of MRSA. During observation, an isolation sign was not posted outside the resident’s room at one point, and later a contact precautions sign was posted listing only gown and gloves. A CNA stated she wore a gown and gloves because the contact precautions sign was posted, while another CNA said she did not know she should wear a mask or that the resident should be on respiratory isolation. An LPN stated she was unaware of the respiratory precautions written in the order and relied on shift report and the care plan indicating contact precautions for MRSA related to wounds on the resident’s legs. The IP stated she was aware the resident was on contact precautions for MRSA but did not conduct record review as part of oversight, and the dermatologist stated she ordered respiratory and contact isolation because MRSA could be dormant in the nares and spread by respiratory droplets. The facility policy stated that transmission-based precautions require appropriate notification on the room entrance door and that droplet precautions include masks when entering the room.
Insufficient Nursing Staff Leads to Delayed Resident Care and Unmet Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in prolonged call bell response times and unmet care needs for multiple residents. The facility assessment indicated that a significant number of residents required assistance from one or two staff members, and over fifty residents were dependent on staff for activities of daily living (ADLs). Despite this, several residents experienced delays in receiving assistance, particularly with toileting, changing, and being put to bed. Observations and interviews revealed instances where residents waited from 20 minutes to over an hour for staff response, with some residents reporting that staff would turn off call lights without providing the needed care. Specific examples included a resident waiting over an hour for toileting assistance, another resident's call bell ringing for 40 minutes before staff responded, and a resident not being placed in bed until late at night. Additional reports documented residents being left in soiled conditions and family members intervening to provide care due to staff unavailability. These findings were corroborated by staff interviews and concern forms, confirming that the facility did not ensure adequate staff availability to respond to resident care needs in a timely manner.
Failure to Provide Timely Dental Extractions and Dentures
Penalty
Summary
A resident was admitted to the facility and, over the course of nearly a year, repeatedly requested dental services, specifically the extraction of her remaining lower teeth and the provision of full dentures. Multiple dental progress notes documented the resident's ongoing requests for extractions and dentures, with the treatment plan reflecting these needs. Despite these documented requests and the resident's continued desire for dental intervention, the necessary extractions and denture process were not initiated in a timely manner. During interviews, the resident reported having four loose lower teeth and expressed frustration at the lack of progress, demonstrating the mobility of one of her teeth. Facility staff confirmed awareness of the resident's requests and the dental team's ability to perform extractions on-site. However, the resident was not scheduled for extractions, and the upcoming dental appointment was only for an initial exam with a new dentist, not for the requested procedure. The delay in providing the required dental services was acknowledged by facility leadership.
Failure to Provide Timely Access to Resident Personal Funds
Penalty
Summary
The facility failed to ensure that two cognitively intact residents had timely access to their personal funds, as required by facility policy. The policy states that residents should have access to funds of fifty dollars or less within twenty-four hours, and access to larger amounts within three banking days. One resident reported requesting funds at the beginning of the month to send Christmas cards but did not receive the money until two days before Christmas, despite multiple requests to staff. Another resident also experienced a delay in accessing personal funds after requesting a withdrawal, which was not fulfilled until a new business office manager (BOM) was acclimated to the position. During the period when the BOM position was vacant, there was no documented evidence of how residents were informed about accessing their funds or who was responsible for disbursing them. Facility records showed no disbursements of personal funds for a ten-day period in December, and interviews with staff confirmed that coverage was provided by a regional person and reception, but this information was not communicated to residents. Both residents eventually received their funds, but only after significant delays that did not comply with the facility's stated policy.
Failure to Timely Report Alleged Misappropriation of Resident Funds
Penalty
Summary
A deficiency occurred when the facility failed to recognize and report an allegation of misappropriation of resident property/funds within the required 24-hour timeframe. A grievance was filed on behalf of a resident who reported unauthorized charges on his credit card and a loan taken out in his name. The grievance was documented and assigned for investigation, but the incident was not identified as a potential misappropriation of resident funds and was not reported to the State Agency as required by federal regulations. Multiple staff members, including the Business Office Manager, Social Worker, and former Nursing Home Administrator, were aware of the grievance but did not recognize it as an allegation that required mandatory reporting. Interviews with facility staff confirmed that the grievance related to missing money was not reported to the State Agency because it was not recognized as an allegation of misappropriation. The Director of Nursing was unaware of the grievance, and the former Nursing Home Administrator stated he thought the allegation was related to an old incident and did not recall the details. The failure to recognize and report the allegation resulted in non-compliance with the facility's abuse policy and federal requirements for timely reporting of suspected misappropriation of resident property.
Failure to Investigate Allegation of Misappropriation of Resident Property
Penalty
Summary
For one of two residents reviewed for allegations of misappropriation of resident property, the facility failed to provide evidence that an allegation was thoroughly investigated. The facility's abuse policy requires investigation and reporting of any allegations of abuse, neglect, or misappropriation within federally required timeframes. An incident report was submitted to the State Agency after a resident alleged that a previous employee was stealing money, and the police were contacted. However, upon request, the facility was unable to provide documentation of an internal investigation, including interviews or statements related to the allegation. The Director of Nursing confirmed that no investigation was conducted beyond contacting the police.
Resident Denied Readmission After Hospitalization Due to Outstanding Bill
Penalty
Summary
A resident with a history of major depressive disorder, severe psychotic symptoms, anxiety, and suicidal ideation was admitted to the facility and was documented as cognitively intact with a goal to remain in the facility. The resident was transferred to the hospital for suicidal ideation, and the facility provided a transfer/discharge notice and bed hold policy notification, both signed by the resident. Following the transfer, facility staff initiated a referral to another nursing home and completed a discharge return not anticipated MDS assessment without documenting a discharge plan or referrals. When the inpatient psychiatric facility later requested information on transferring the resident back, the facility provided the necessary information but did not facilitate the resident's return. Multiple staff interviews confirmed that the resident was denied readmission to the facility after discharge from the inpatient psychiatric facility. The admissions staff, unit manager, and controller all stated that the denial was due to the resident owing a large outstanding bill, and corporate leadership would not allow readmission until Medicaid approval, which was ultimately denied. The facility's transfer list indicated the resident was transferred out for medical leave, but the resident was not permitted to return, and the facility did not comply with discharge requirements.
Failure to Provide Adequate Supervision During Care Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with multiple sclerosis, paraplegia, and generalized weakness was left unsupervised during care, resulting in a fall from bed and a head injury. The resident was dependent for bed mobility and unable to perform activities of daily living without assistance, as documented in the care plan and MDS assessment. The care plan included interventions such as keeping the bed in the lowest position when not providing care and providing extensive assistance with bed mobility. During the incident, a CNA rolled the resident onto her side to change her but left her unattended on her side while stepping into the bathroom to wet additional washcloths, leaving the bed in a raised position. The resident, who lacked the strength to remain on her side without support, rolled off the bed and sustained a laceration to the back of the head, requiring hospital evaluation and treatment. Interviews with staff confirmed that the resident could not maintain her position on her side independently and that the CNA left her unsupervised for a brief period. The incident report and clinical documentation corroborated that the resident was found on the floor after the fall, and the care plan was subsequently updated to increase rounding as a result of the event.
Failure to Ensure Physician Supervision for Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when a resident with a right heel wound was not adequately supervised by a physician for the care of pressure ulcers. The resident was admitted with a wound and subsequently seen by a practitioner for follow-up visits related to the wound and for antibiotic management. However, the progress notes from these visits lacked documentation of a physical assessment of the wound's characteristics by the provider. The practitioner confirmed during an interview that she did not follow wound care, stating that the wound nurse practitioner was responsible for that aspect, and her role was limited to ordering medications related to wound care. Further review of the clinical record showed that the wound was documented as a deep tissue injury, unstageable, with necrotic tissue and suspected infection. Despite ongoing treatment and diagnostic orders, there was no evidence in the provider's notes that a physical wound assessment was performed. This lack of documentation and direct assessment by the provider constituted a failure to ensure the resident's medical care was properly supervised by a physician for the pressure ulcer.
Failure to Promptly Notify Provider of Abnormal Lab Results
Penalty
Summary
A deficiency was identified when the facility failed to promptly notify the ordering medical practitioner of abnormal laboratory results for one resident. The resident was admitted and had a physician's order for a complete blood count (CBC) and comprehensive metabolic panel (CMP), with subsequent lab results indicating an elevated white blood cell count. Despite these abnormal findings, there was no documented evidence in the progress notes that the provider was notified of the lab results in a timely manner. This lack of prompt communication was confirmed during an interview with the RN Unit Manager, and the findings were reviewed with facility leadership.
Failure to Provide Prescribed Thickened Liquids Due to Communication Breakdown
Penalty
Summary
A deficiency occurred when a resident who had a physician's order for thickened liquids was served thin liquids, including water, coffee, and juice, during a meal. The resident was observed actively drinking the thin liquids, which resulted in coughing. The clinical record showed that the resident was admitted to the facility and was initially independent with eating, but a new order for thickened liquids was entered the day before the incident. Interviews with staff revealed that the certified nursing assistant (CNA) was not informed of the thickened liquid order during shift report, and the thin liquids were only replaced after the deficiency was noticed. Further investigation found that the new diet order was not entered as a dietary order in the electronic medical record (EMR), so the dietary department was not notified electronically. Additionally, no dietary communication slip was completed or delivered to the dietary department, and the dietician was unaware of the new order. This series of communication failures led to the resident not receiving fluids in the prescribed form.
Incomplete Documentation of Neurological Assessments After Resident Fall
Penalty
Summary
A deficiency was identified when a resident with baseline confusion experienced an unwitnessed fall. The facility's policy required that documentation in the medical record be objective, complete, and accurate. Following the fall, a neurological assessment form was initiated to monitor the resident, but the clinical record lacked specific information regarding the neurological checks performed. Progress notes written by the RN referenced that neuro checks were in progress but did not provide detailed documentation of the assessments. Upon review, the neurological assessment form was found to be incomplete, with missing entries for several hours following the incident. During interviews, the Director of Nursing confirmed the incompleteness of the neurological assessment form. The RN involved later produced handwritten notes from a personal notepad, stating that the intention was to transfer the information to the official form but was interrupted and unable to do so before the form was taken by another nurse. The handwritten notes were subsequently scanned into the resident's clinical record, but the original required documentation on the neurological assessment form was not completed as per facility policy.
Unsanitary Conditions in Nourishment Refrigerators
Penalty
Summary
The facility failed to maintain nourishment refrigerators in a sanitary condition and ensure safe food storage, which could lead to food-borne illness. On April 7, 2024, at 8:45 AM, the Reserve Unit nourishment refrigerator contained several improperly stored items, including a Boost drink dated October 17, 2023, a sandwich in a green and white wrapper dated February 21, an unmarked brown paper bag, a partially eaten pretzel salad without a date, opened and unlabeled cheese doodles, and salad dressing dated September 8, 2023. These items were confirmed and removed by a supervisor at 9:47 AM. On April 8, 2024, the nourishment refrigerator adjacent to the small dining room in the Riverside unit was found with a large semi-dried spill of orange liquid on the middle and bottom shelves of the door. Additionally, the full-sized refrigerator in the same dining room contained an undated and unlabeled small plastic food storage bowl of leftover food. These findings were reviewed during the exit conference on April 11, 2024, with the Director of Nursing.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to maintain the dignity and respect of three residents during care. For one resident, two CNAs provided care with the door open, exposing the resident's unclothed lower body to the hallway. This incident was confirmed by the CNAs involved. Similarly, another resident was observed receiving care with the door open, leaving their lower body exposed to the hallway, which was also confirmed by the CNA providing the care. In a separate incident, a resident with an intact cognitive state and dependent on staff for toilet use experienced inappropriate behavior from a former CNA. The CNA was argumentative and spoke in a loud and aggressive manner to the resident during care, which was corroborated by an agency RN present at the time. The resident reported feeling upset and crying after the incident, although they had not experienced issues with other staff members.
Failure to Notify Resident's Contact Person of Diet Change
Penalty
Summary
The facility failed to notify a resident's contact person about a change in the resident's diet texture, which constitutes a deficiency in communication regarding the resident's care. The resident, admitted with diagnoses including hypertension, stroke, left side weakness, and depression, had their diet downgraded from a regular textured diet to a dysphagia mechanical soft texture for safety reasons. This change was documented by a physician and a registered dietitian. However, the registered dietitian assumed that the nursing staff would notify the resident's contact person, which did not occur. An interview with a licensed practical nurse confirmed that nursing was responsible for notifying the contact person, but the clinical record lacked evidence of such notification. This oversight was identified during a review of the resident's clinical record and discussed in an exit conference with the nursing home administrator and director of nursing.
Failure to Provide Accessible Call Bell Systems for Quadriplegic Residents
Penalty
Summary
The facility failed to ensure that two residents, both with quadriplegia, had accessible and usable call bell systems. One resident, admitted with a spinal injury and quadriplegia, was provided with a standard push button call bell and a metal bell, both of which were out of reach and unusable due to his condition. Despite the resident's repeated communication of his inability to use the provided call bells, the facility did not provide an alternative solution until after the surveyor's observation. The unit manager was unaware of the availability of a suitable call bell system and only took action after the issue was highlighted during the survey. Another resident, also with quadriplegia and additional complex medical needs, was observed with a sip and puff call bell positioned out of reach, rendering it unusable. Despite being totally dependent, the resident was left without a functional means to call for assistance. The issue was confirmed by a respiratory therapist, who noted that the resident could call out for help, but this did not address the lack of a functional call bell system. These deficiencies were discussed with the facility's nursing home administrator and director of nursing during the exit conference.
Failure to Provide NOMIC Form Before Service Termination
Penalty
Summary
The facility failed to provide a resident with the Notice to Medicare Provider Non-Coverage (NOMIC) form before terminating services. This deficiency was identified during a review of the resident's clinical record, which showed that the resident was discharged to home on March 20, 2024. During an interview on April 11, 2024, the Nursing Home Administrator (E1) confirmed that the NOMIC form was not given to the resident. The NOMIC form is essential as it informs the beneficiary of their right to an expedited review of the service termination. These findings were discussed during the exit conference on April 11, 2024, with the Nursing Home Administrator and the Director of Nursing.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to recognize and immediately report an allegation of abuse involving two residents. On March 21, 2024, a disagreement occurred between two roommates, leading to a recommendation for a room change by the on-call nurse. However, an earlier incident on March 12, 2024, was documented by an LPN, indicating that one resident admitted to throwing soda cans and using derogatory language towards the other resident. Despite this, the incident was not recognized as an allegation of abuse and was not reported immediately. Interviews conducted on April 11, 2024, revealed that the RN supervisor was unaware of the soda can being thrown, and the DON confirmed that the incident was not recognized as abuse because the soda can did not physically hit the resident. The affected resident later stated that the soda can was thrown at him and his wife, causing them to get wet and prompting them to scream for assistance. The failure to report this incident as abuse was acknowledged during the exit conference with the Nursing Home Administrator and the DON.
Failure to Ensure Accurate MDS Assessment
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident, identified as R42, out of five residents reviewed for medication review. R42 was admitted to the facility on May 9, 2023. However, the admission MDS assessment conducted on May 15, 2023, did not include assessments for cognitive function, behaviors, mood, and pain levels. This omission was confirmed during an interview on April 9, 2024, with the Director of Reimbursement Services, who acknowledged that the assessment was missed and that R42 should have been interviewed. These findings were discussed during the exit conference on April 11, 2024, with the Nursing Home Administrator and the Director of Nursing.
Failure to Conduct Timely PASARR Screening for Resident with Mental Health Disability
Penalty
Summary
The facility failed to ensure timely coordination of the PASARR screening process for a resident with a mental health disability. The resident, identified as R68, was admitted with diagnoses including bipolar disorder, anxiety disorder, and major depressive disorder. Initially, a PASARR Level I screen was conducted, granting a 60-day approval period. However, the facility did not complete a new PASARR Level I and II screening by or before the 60th day, as required. This oversight resulted in the resident remaining in the facility beyond the authorized timeframe without the necessary updated screening. Interviews and record reviews confirmed that the PASARR Level I screen was not conducted within the required timeframe, and the PASARR Level II approval ended without appropriate follow-up. Despite the short-term approval without specialized services, the resident was not discharged as planned. These findings were discussed during the exit conference with the Nursing Home Administrator and the Director of Nursing, highlighting the facility's failure to adhere to the PASARR process for residents with mental health disabilities.
Failure to Develop Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop a care plan for a resident, identified as R42, who was prescribed an anticoagulant medication. R42 was admitted to the facility on May 9, 2023, and on the same day, a physician's order was written for the resident to receive an anticoagulant medication twice daily for blood clot prevention. The admission Minimum Data Set (MDS) assessment on May 15, 2023, and a quarterly MDS assessment on February 15, 2024, both documented that R42 received anticoagulant medication. However, a review of R42's care plans revealed a lack of evidence that a care plan was created to address the resident's use of the anticoagulant medication. This deficiency was confirmed during an interview with the Director of Reimbursement Services on April 9, 2024, and was discussed during the exit conference on April 11, 2024, with the Nursing Home Administrator and the Director of Nursing.
Lack of Interdisciplinary Team Input in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that all required interdisciplinary team (IDT) members participated in the care plan meetings for four residents. For one resident, the quarterly care plan meetings lacked input from the physician and the CNA. Another resident's care plan meetings also missed contributions from the physician and CNA. A third resident's care plan meeting was missing input from the physician, nurse, and CNA, and subsequent meetings continued to lack input from the physician and CNA. Interviews with CNAs revealed that they were generally not involved in care plan meetings unless specifically requested by the resident, and there was no formal process to document their input. Additionally, a fourth resident's care plan meeting lacked input from the CNA, dietary, activities, and the medical director. The Nursing Home Administrator (NHA) confirmed the absence of necessary team members in the care plan meetings. These deficiencies were discussed during the exit conference with the NHA and the Director of Nursing (DON). The report highlights a systemic issue in the facility's care planning process, where essential team members' input is not consistently documented or included.
Failure to Reposition Residents at High Risk for Skin Breakdown
Penalty
Summary
The facility failed to adhere to professional standards of practice for turning and repositioning two residents, R24 and R57, who were at high risk for skin breakdown. R24, who was readmitted with conditions including hypoxic ischemic encephalopathy and anoxic brain damage, was documented as totally dependent on staff for turning and repositioning. Despite a care plan indicating the need for repositioning every two hours, observations on 4/8/24 showed R24 lying on her back for four hours without being turned. Interviews with CNAs revealed inconsistencies in the repositioning practices, with one CNA stating R24 was turned every two hours, while observations contradicted this claim. Similarly, R57, who was readmitted with quadriplegia and other conditions, was also documented as totally dependent on staff for repositioning. Despite a care plan requiring repositioning every two hours, observations on 4/8/24 showed R57 lying on her back for four hours without being turned. Interviews with CNAs and R57 confirmed that repositioning was not occurring as required, with one CNA stating R57 was always on her back and R57 herself confirming the lack of repositioning. These failures were discussed with the Nursing Home Administrator and Director of Nursing during the exit conference.
Failure to Provide Continence Care
Penalty
Summary
The facility failed to provide appropriate care and services to restore bladder continence for a resident, identified as R75, who was admitted on March 8, 2024. Upon admission, R75 was documented as incontinent, and a subsequent evaluation indicated that R75 was a candidate for scheduled prompted voiding. However, the facility did not attempt a toileting program, as confirmed by an admission MDS on March 14, 2024. Observations and interviews revealed that staff did not assist R75 with toileting when the call light was activated, and the resident was not offered a urinal or bedpan, despite being able to verbalize the need to use the bathroom. The CNA task flow sheet also lacked documentation of a two-hour continence check, which was supposed to be part of the facility's toileting program. Interviews with various staff members, including CNAs, a COTA, and the Rehab Director, highlighted a lack of communication and implementation of recommended continence care for R75. The COTA confirmed that R75 could voice the need to use the toilet and had initiated the use of a bedpan and urinal during therapy sessions. However, direct care staff did not follow these recommendations, and the resident's care plan was not updated to reflect changes in R75's alertness and continence capabilities. The facility's failure to provide care and services that promoted maintaining and/or restoring continence was confirmed during an exit conference with the Nursing Home Administrator and Director of Nursing.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, R3 and R66, as per professional standards of practice. For R66, who was admitted with chronic obstructive pulmonary disorder (COPD) and hypoxic respiratory failure, the facility did not change or label the oxygen tubing and humidifier bottle weekly as required by the facility's policy. Observations on multiple occasions revealed that the oxygen equipment was not dated, and this was confirmed by a registered nurse during an interview. For R3, who was admitted with acute respiratory failure and other conditions, the facility did not change the tracheal suction machine equipment as per the physician's order. The suction canister, which contained thick secretions, had not been changed since 1/26/24, despite the order to change it weekly and as needed. This was confirmed by an LPN during an interview, who acknowledged the oversight. These deficiencies were discussed with the nursing home administrator and director of nursing during the exit conference.
Failure to Review Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that pharmacist recommendations were reviewed by the attending physician for one resident out of five reviewed for medication review. According to the facility's policy for Medication Regimen Reviews (MRR), the attending physician is required to document in the medical record that any irregularities have been reviewed and to note any actions taken. On February 5, 2024, a Pharmacist Consultant Note indicated that recommendations were made to evaluate and consider discontinuing the use of vitamin C and to consider switching the timeframe of a laxative for the resident. However, a review of the resident's MRR from that date revealed a lack of physician response to these recommendations. During an interview on April 10, 2024, the Nursing Home Administrator (E1) confirmed that the facility was unable to locate a physician response to the February 2024 MRR. These findings were discussed during the exit conference on April 11, 2024, with the Nursing Home Administrator (E1) and the Director of Nursing (E2).
Failure to Conduct Timely AIMS Testing for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to adhere to its policy on psychotropic medication use by not completing the Abnormal Involuntary Movement Scale (AIMS) testing every six months for a resident on antipsychotic medications. The policy, last updated in July 2022, mandates that psychotropic medications be monitored with AIMS testing as required. A review of the clinical record for a resident revealed that a physician's order was written for the resident to receive an antipsychotic medication daily, and an AIMS test assessment was conducted in July 2023. However, by April 2024, it was found that AIMS testing had not been completed for nine months, contrary to the facility's protocol. This deficiency was confirmed during an interview with the Assistant Director of Nursing (ADON) and discussed during the exit conference with the Nursing Home Administrator (NHA) and Director of Nursing (DON).
Failure to Maintain Cleanliness in Resident Room
Penalty
Summary
The facility failed to maintain cleanliness in one of the resident rooms, specifically room [ROOM NUMBER]. During multiple observations over several days, a large brown circular stain was noted on the floor of the room. Initially, the stain was accompanied by three large brown stains on the fitted sheet of an occupied bed and balled paper napkins on the floor. Although the fitted sheet was later cleaned and the napkins removed, the stain on the floor persisted for several days. A housekeeper confirmed the presence of the stain and explained that the facility employs three housekeepers daily, along with a floor technician responsible for floors, trash, and common areas. Despite daily sweeping and mopping, the stain remained until it was finally removed by the last observation date.
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Three residents who were dependent on staff for bed mobility and transfers did not receive adequate supervision and safe handling during care and transfers, resulting in serious injuries. A resident who was totally dependent for bed mobility slid from the bed to the floor while a CNA focused on gathering supplies during care, later being found to have an ankle fracture. Another resident with a prior brain bleed, craniotomy, and left-sided paralysis, requiring a mechanical lift with two staff, sustained a head injury when a Hoyer lift was improperly positioned or controlled during transfer from a shower bed to a wheelchair, causing the lift bar to strike the top of the head and leading to ongoing head and neck pain. A third resident needing extensive assistance fell between a shower bed and her regular bed when a CNA attempted to transfer her without locking the shower bed wheels, resulting in acute L2–L3 compression fractures confirmed by CT.
A resident who required set-up assistance for eating spilled coffee onto bare upper thighs while being prepared for morning care, initially resulting in nonblanchable redness with intact skin and no reported pain. During later incontinence care, staff identified a broken blister on the resident’s right upper thigh, cleansed the area, and applied skin prep, but did not notify the MD until more than a day after the blister was first noted. An NP confirmed that although she had been informed of the coffee spill itself, there was no documentation that the subsequent change in skin condition had been communicated to a provider, resulting in a failure to promptly notify the on-call provider of the new skin alteration.
A resident with significant neurologic impairment and multiple contractures slid from bed and was assisted to the floor during the night shift, but an RN did not complete the initial post-fall assessment until the following day shift. An LPN documented that the resident was seated after the event, denied pain, had ROM and VS assessed, and was assisted back to bed with a CNA. The DON later reported that the CNA and LPN did not report the event as a fall because the resident was assisted down, and the LPN stated she relied on the CNA’s account when completing the incident report and was unsure if the RN had been notified.
A resident reported an allegation of physical abuse by a CNA during the night shift, which was documented in the clinical record. Facility policy required that all alleged violations be reported to the Administrator, state agency, APS, and other required agencies immediately but no later than two hours after the allegation. Instead, the allegation was reported to the state agency approximately nine hours after it was made. An RN acknowledged not reporting the allegation right away and waiting for the day shift, and the DON confirmed that the reporting timeframe was not followed.
A resident with dementia and a care plan for false accusations alleged physical abuse by a CNA. Facility policy required staffing or room changes to protect residents from an alleged perpetrator, but the CNA remained on duty providing care to other residents for the rest of the shift. An LPN and an RN confirmed that the CNA continued working with residents, with the CNA only being stopped from caring for the accusing resident’s room, resulting in a failure to fully implement the abuse protection policy.
A resident with CHF and kidney disease requiring dialysis was admitted and assessed as having congestive heart failure, but the baseline care plan lacked CHF-related interventions and there was no timely physician order for fluid restriction despite a nutrition assessment referencing a 1500 mL limit. A physician note identified the resident as high risk for rehospitalization and called for strict I&O and daily weights, yet a formal fluid restriction order was not entered until several days later, only after the responsible party requested it. The next day, the resident was sent to the hospital from dialysis for chest pain and shortness of breath. In interviews, the MD, RN, and DON all confirmed the resident should have been placed on fluid restriction and monitoring upon admission and that this was not done in a timely manner.
Surveyors found that dietary staff repeatedly failed to wear required hair and beard restraints while preparing food, washing dishes, and serving meals, and the Dietary Manager acknowledged that restraints should be worn at all times but that the facility had run out of them. These unsanitary practices occurred during routine kitchen operations and affected nearly all residents who received meals from the kitchen, with only two residents receiving nutrition via feeding tubes.
Surveyors found that medication carts were left unlocked and unattended in two separate locations. One cart on a hall outside a resident room was left unlocked while an LPN was inside the room with the privacy curtain pulled and unable to see the cart, with only a CNA present further down the hall. Another cart at the nurses’ station, shared by nurses on two halls, remained unlocked while the ADON walked past it twice and then left the area, leaving no one at the station until returning several minutes later to lock it. Facility policy required all medication and treatment carts to be locked when not in use and not left unattended while unlocked.
The facility did not provide required written information on advance directives and the right to accept or refuse medical and surgical treatment to two residents, one cognitively intact and one with moderately impaired cognition, as confirmed by EMR review showing no such documentation. The SSD reported having no written materials explaining types of advance directives or any signature page confirming verbal explanations or resident understanding. The AD stated the admission packet only asked whether a resident had or wanted an advance directive and did not include written definitions or explanations. The Administrator acknowledged being unaware of regulatory requirements and of the facility policy, which states that residents have the right to formulate an advance directive and to accept or refuse treatment, and that written information must be provided in an easily understood manner.
A cognitively intact resident with mild cognitive impairment reported to her son that a male CNA entered her room at night to provide incontinent care, which she refused, and that he returned and made an inappropriate sexualized remark when she again refused care. The son called the facility to report the concern, and the Admissions Director stated she immediately informed the DON, in line with protocol to notify leadership of abuse-related grievances. However, the DON reported she did not recall receiving the grievance and only became aware of the allegation when law enforcement arrived several days later after receiving a family complaint. The DON confirmed that the SSA was not notified of the abuse allegation until four days after the initial grievance, despite facility policy and leadership acknowledging that alleged abuse must be reported to the SSA within two hours.
Failure to Provide Adequate Supervision and Safe Transfers Resulting in Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate assistance and supervision to prevent accidents for three residents who were dependent on staff for mobility and transfers. One resident with anoxic brain injury, multiple contractures, abnormal posture, and idiopathic progressive neuropathy was documented on multiple MDS assessments as requiring substantial/maximal assistance for bed mobility and was described by nursing and therapy staff as totally dependent and unable to move or roll in bed without physical assistance. During nighttime care, a CNA entered the room in response to a call light, found that the resident had vomited, and focused on looking for towels while standing on one side of the bed. The CNA reported that the resident then began sliding off the opposite side of the bed; the CNA ran around the bed but was unable to prevent the resident from sliding off, and instead lowered the resident to the floor in a seated position. Subsequent imaging confirmed a stable right ankle fracture, and interviews with the NP, OT, LPN, and other CNAs confirmed that the resident was dependent for bed mobility and could not independently roll or slide out of bed, indicating that the resident did not receive the level of hands-on assistance and supervision consistent with their documented needs. A second resident with a history of brain bleed, seizure disorder, craniotomy, and left-sided paralysis had a care plan and therapy determination requiring a mechanical (Hoyer) lift with two staff for all transfers and was completely dependent on staff for bathing and transfers. During a transfer from a shower bed back to a wheelchair using a mechanical lift, the resident reported that the hooks of the lift were not properly attached to the bars, causing the front of the lift to become unbalanced and tilt backward, dropping the resident into the chair and allowing the lift bars to strike the top of the resident’s head at the craniotomy site. The resident stated that the lift was not moving when staff attempted to place him in the chair and that this type of incident had not occurred during prior showers, when he was typically returned to his room on the shower bed and transferred in bed. One CNA described that while assisting with the transfer, the lift appeared stuck and positioned sideways over the wheelchair; when she voiced concern and attempted to correct the position, the lift rose and the bar hit the resident’s head. The other CNA involved stated that as she operated the lift controls, the resident’s weight shifted, the lift tipped back, and the bar struck the top of his head. The physician documented a head strike from the Hoyer lift with subsequent head and neck pain, and the resident required repeated PRN pain medication for ongoing head and neck pain. A third resident with cerebral infarction and rheumatoid arthritis had orders and MDS documentation indicating a need for extensive to maximal assistance with bed mobility and dressing. After receiving a shower, this resident was brought back to the room on a shower bed. The facility’s incident report documented that the CNA lowered the side rail of the shower bed, pushed the shower bed against the resident’s bed, turned the resident on her side, removed the bath sheet, and began pushing the Hoyer pad underneath. During this process, the resident rolled and fell between the two beds to the floor, becoming very anxious and crying. A subsequent CT scan at the hospital revealed acute L2 and L3 vertebral compression fractures. In a later interview, the CNA acknowledged that she must have forgotten to lock the wheels on the shower bed before attempting the transfer, and described that when she rolled the resident to place the Hoyer pad, the shower bed separated from the resident’s bed, allowing the resident to fall between them. These events demonstrate that the resident did not receive adequate supervision and safe handling during the transfer process, despite her documented need for extensive assistance with mobility.
Failure to Timely Notify Provider of New Skin Blister After Coffee Spill
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a provider of a change in a resident’s skin condition following a coffee spill incident. The resident was admitted earlier in the month, and the admission MDS documented that the resident required set-up assistance for eating. On the morning of 3/30/26, a nurse documented that the resident placed a cup of coffee on the bed railing, and when he let go, the cup fell onto his lap, spilling hot coffee onto his bilateral upper thighs while he was not wearing pants and was about to receive morning care. At that time, the nurse documented nonblanchable redness on both upper thighs with all skin intact, and later that day a wound care RN documented that there was no scalded skin present and the resident denied pain. A late entry nurse’s note documented that during incontinence care on 3/31/26, a broken blister on the resident’s right upper thigh was identified, cleansed with saline, patted dry, and skin prep applied. Review of incident documentation showed that the physician was not notified of this blister until 4/1/26 at 8:38 AM, more than 24 hours after the blister was first identified. During interview, the NP stated she had been notified of the coffee spill on 3/30/26 but, upon reviewing the physician binder, confirmed there was no evidence that the change in skin condition noted on 3/31/26 had been communicated to a provider at that time. The facility therefore failed to notify the on-call provider when the resident experienced a change in skin condition after the coffee spill incident.
Failure to Obtain Timely RN Post-Fall Assessment After Assisted Descent to Floor
Penalty
Summary
The facility failed to ensure that an RN performed and documented an initial post-fall assessment for a resident who slid off the bed and was lowered to the floor during the 11 PM–7 AM shift. The resident had significant medical conditions including anoxic brain injury, abnormal posture, multiple contractures of the upper and lower limbs, and idiopathic progressive neuropathy. A facility-reported incident documented that the resident sustained a fall with later complaint of ankle pain, with an X-ray obtained and results unclear, and a repeat film obtained two days later. The clinical record showed that the initial post-fall assessment was not completed by an RN until 8:34 AM on the 7 AM–3 PM shift by the ADON, and there was no evidence of an RN assessment during the overnight shift when the fall occurred. A witness summary completed by an LPN documented that the resident was in a seated position after the fall, denied pain, had range of motion assessed, denied pain again, had vital signs taken, and was assisted by a CNA back to bed. During interviews, the DON stated that the fall was not reported by the CNA and the LPN because they did not consider it a fall since the resident was assisted to the floor. In a phone interview, the LPN confirmed being called by the CNA about the fall, stated that care and an assessment were provided, and indicated uncertainty about whether the RN was notified, noting that the written incident report was based on what the CNA reported and that the LPN was not present at the time of the fall.
Failure to Timely Report Allegation of Staff-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure immediate reporting of an allegation of staff-to-resident physical abuse in accordance with its abuse policy and regulatory time frames. The facility’s abuse policy, last updated January 2026, required that all alleged violations be reported to the Administrator, state agency, adult protective services, and other required agencies immediately but no later than two hours after the allegation is made. On 6/12/25 at 3:31 AM, an incident note in the clinical record documented that resident R83 alleged physical abuse by a CNA (E8). However, the allegation was not reported to the State Agency until 11:21 AM the same day, approximately nine hours after the allegation was made, exceeding the required reporting timeframe. During an interview on 4/23/26 at 11:06 AM, an RN (E6) confirmed that the allegation was not immediately reported and stated that the DON later informed her it should have been reported right away rather than waiting for day shift. In a separate interview at 11:14 AM, the DON (E2) confirmed these findings. The deficiency centers on the delayed reporting of the abuse allegation to the State Agency despite clear policy requirements for immediate notification. The survey findings were reviewed with the Nursing Home Administrator (E1), the DON (E2), and others at the exit conference on 4/23/26 at 3:00 PM.
Failure to Remove Accused Staff From Resident Care After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from further potential abuse by not immediately removing an accused staff member from resident care following an allegation of physical abuse. The facility’s abuse policy, updated January 2026, states that room or staffing changes are to be made as necessary to protect residents from the alleged perpetrator. On 6/12/25 at 11:21 AM, the facility reported an allegation of staff-to-resident physical abuse involving resident R83 and CNA E8. Record review of E8’s timesheet showed that after this allegation, E8 remained in the facility working with residents until 7:05 AM. During interview, LPN E7, who was assigned to R83’s unit at the time, confirmed that E8 continued caring for residents after R83’s accusation and stated that R83 had dementia and a care plan for false accusations, and that E8 was only stopped from caring for R83’s room for the rest of the shift. RN E6 also confirmed that E8 continued caring for residents after the allegation and stated that she instructed E8 to care for other patients. These findings were reviewed with the NHA (E1) and DON (E2) during the exit conference. The resident involved, R83, had dementia and a documented care plan for false accusations, which influenced staff’s decision to limit E8’s contact only with R83 rather than removing E8 from all resident care. Despite the facility’s written policy requiring protective staffing or room changes to safeguard residents from an alleged perpetrator, E8 remained on duty providing care to other residents for the remainder of the shift after the allegation of physical abuse was made.
Failure to Implement Timely Fluid Restriction and Monitoring for Resident With CHF and Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and monitoring consistent with professional standards of practice for a resident admitted with congestive heart failure and kidney disease requiring dialysis. The resident was hospitalized for multiple conditions, including heart failure, and then admitted to the facility with diagnoses of congestive heart failure and kidney disease. An admission assessment by an RN documented congestive heart failure, but the baseline care plan did not include any interventions related to this diagnosis. A nutrition assessment documented that the resident was on a therapeutic meal plan with a 1500 mL fluid restriction and indicated ongoing monitoring of oral intake, weight, skin integrity, and labs, yet the physician’s orders and dietary intake records did not contain an order for fluid restriction. A physician progress note documented that the resident had multiple complex comorbidities, including heart failure, and was at high risk for rehospitalization without proper care, specifying a plan for strict intake and output and daily weights. An admission MDS later confirmed that the resident was cognitively intact, experiencing shortness of breath, and had an active diagnosis of heart failure. A physician’s order for a 1500 mL fluid restriction was not written until several days after admission, at the request of the resident’s responsible party. The following day, nursing documentation showed the resident was sent to the hospital from dialysis for chest pain and shortness of breath. In interviews, the MD, the admitting RN, and the DON all confirmed that the resident should have been placed on a fluid restriction and monitoring upon admission, and the DON acknowledged that the fluid restriction order was not implemented in a timely manner.
Failure to Ensure Dietary Staff Used Required Hair and Beard Restraints During Food Service
Penalty
Summary
The deficiency involves failure to maintain sanitary conditions in the kitchen, specifically related to staff not using required hair and beard restraints during food service activities. During an observation and interview with the Dietary Manager (DM) on 03/29/26 from 9:25 AM to 10:28 AM, two Dietary Aides (DA1 and DA2) were seen engaged in food preparation and dishwashing without wearing beard or hair restraints, which the DM confirmed. In a subsequent observation and interview with the DM on 03/31/26 from 8:55 AM to 11:36 AM during the meal serving line, DA1 and DA3 were again observed not wearing beard or hair restraints, and the DM stated that such restraints should be worn at all times and acknowledged the facility was out of beard/hair restraints. These conditions affected 78 residents who received meals from the kitchen, out of a total census of 80 residents, with 2 residents receiving nutrition via feeding tubes. The observations document that multiple dietary staff members repeatedly failed to use required protective restraints while handling food and dishes, and that the facility lacked an adequate supply of beard/hair restraints, as confirmed by the DM. The report specifies that this failure occurred during both food preparation and meal service times and applied to nearly all residents receiving meals from the kitchen.
Unattended, Unlocked Medication Carts Left Accessible in Two Locations
Penalty
Summary
The deficiency involves the facility’s failure to keep medication carts locked and secured when not in use, as required by facility policy and professional standards. During an early morning observation on 04/01/26 at 4:53 AM, a medication cart on the [NAME] Hall in front of room W102 was found unlocked while an LPN was inside the resident’s room with the privacy curtain pulled. The medication cart was not visible from inside the room, and the only other staff member in the area, a CNA, was further down the hall delivering linen to another room. At 4:59 AM, the LPN returned to the cart and locked it, confirming that it had been left unlocked and out of her line of sight. A second unsecured cart was observed on 04/01/26 at 5:56 AM at the nurses’ station, where the medication cart shared by nurses on the [NAME] and East Halls was left unlocked. The ADON walked past this unlocked cart twice and then left the nurses’ station to go down the East Hall at 6:00 AM, leaving the cart unattended and still unlocked. At 6:05 AM, the ADON returned and locked the cart. In an interview at that time, the ADON stated that it was the expectation that all medication and treatment carts be kept locked when not in use. Review of the facility’s “Storage of Medication” policy, revised November 2020, confirmed that compartments containing drugs and biologicals are to be locked when not in use and that unlocked carts should not be left unattended.
Failure to Provide Required Written Information on Advance Directives and Treatment Rights
Penalty
Summary
The facility failed to provide written information regarding advance directives and the right to accept or refuse medical and surgical treatment to two residents reviewed for advance directives. One resident was admitted with hemiplegia and hemiparesis following cerebrovascular disease and major depressive disorder and had a BIMS score of 15/15, indicating intact cognition. Review of this resident’s EMR, including the admission record and MDS, showed no evidence that written information on advance directives had been provided. A second resident was re-admitted with heart failure, stage three chronic kidney disease, malignant neoplasm of the upper lobe of the left bronchus, and pain, and had a BIMS score of 12/15, indicating moderately impaired cognition. Review of this resident’s EMR also revealed no evidence that written information regarding advance directives had been provided. During interviews, the SSD stated she did not have any written information to provide residents about the distinct types of advance directives and that there was no signature page to indicate a verbal explanation was provided or that residents understood their right to accept or refuse medical and surgical treatments. The AD reported that the admission packet contained only one page asking if a resident had an advance directive or wished to formulate one, and that she did not have written information defining the types of advance directives to give residents on admission. The Administrator stated she was not aware of the regulatory guidance requiring written information on advance directives and the right to accept or refuse medical and surgical treatment, and was unaware that the facility’s own policy required this. The facility’s “Advanced Directives” policy, revised November 2025, stated that residents have the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment, and that written information must be provided in a manner easily understood by the resident or representative.
Failure to Timely Report Allegation of Sexual Abuse to SSA
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of sexual abuse to the State Survey Agency (SSA) within the required two-hour timeframe. A cognitively intact resident, admitted with cognitive communication deficit and mild cognitive impairment and having a BIMS score of 15/15, was the subject of an allegation reported by her son. On a grievance/concern form dated 09/18/25, the son reported that a male aide entered the resident’s room in the middle of the night stating he needed to check if she was wet; the resident refused, and the aide returned later, at which time the resident again refused. The facility’s investigation report dated 09/22/25 documented that the assigned CNA made an inappropriate verbal remark to the resident, stating, “you don’t know what you are missing,” when she refused incontinent care. An incident tracking form dated 09/22/25 at 8:21 PM showed that a police officer came to the facility and informed staff that they had received a complaint from the resident’s family alleging the resident had been spoken to in a manner that made her uncomfortable, and that the male staff assigned to her care made the same remark when she refused care. The Admissions Director stated she received the telephone call from the resident’s son on 09/18/25 describing the male staff entering the room, the resident’s refusals of care, and the uncomfortable comment, and that she immediately informed the DON of the concern, consistent with facility protocol to notify the Administrator and DON of all grievance and abuse concerns. The DON stated she did not remember receiving the grievance/concern form and reported that she first learned of the alleged abuse on 09/22/25 when a police officer came to the facility after receiving an allegation of abuse. The DON confirmed that the SSA was notified of the abuse allegation on 09/22/25, four days after the son’s grievance, and acknowledged that the SSA should have been notified on 09/18/25. The Administrator/Abuse Coordinator, who was out on leave at the time and unaware of the grievance, confirmed that alleged violations involving abuse should be reported to the SSA within two hours after the allegation is made. The facility’s written policy on abuse, neglect, exploitation, mistreatment, and misappropriation of property, dated 06/15/25, states that alleged violations involving abuse are to be reported to the SSA within two hours after the allegation is made, which did not occur in this case.
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