Westminster Village Health
Inspection history, citations, penalties and survey trends for this long-term care facility in Dover, Delaware.
- Location
- 1175 Mckee Road, Dover, Delaware 19904
- CMS Provider Number
- 085032
- Inspections on file
- 20
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 13 (1 serious)
Citation history
Health deficiencies cited at Westminster Village Health during CMS and state inspections, most recent first.
Surveyors identified that the facility’s call bell system was not functioning across multiple hallways, with call bells in numerous resident rooms failing to produce sound or activate corridor lights when pressed. An LPN, CNAs, and the Maintenance Director confirmed that call bells and associated personal pagers were inoperative throughout the building, and the Maintenance Director suggested a power surge as a possible cause. The NHA later provided call bell logs showing no call bell activations for several hours, indicating that residents had been without a working call system during that time.
Surveyors found that food was not stored and monitored according to professional standards. An undated, unlabeled sandwich and an expired pudding cup were discovered in a unit refrigerator, and review of food temperature logs showed that required temperature checks were not documented before several meals. A staff member confirmed both the presence of the undated/expired items and the missing temperature records, and these issues were later discussed with facility leadership including the NHA, DON, and ED.
A resident with a history of CVA and abnormal gait experienced an unwitnessed fall, resulting in multiple bruises and a fractured toe. The facility did not promptly notify the physician or state agency about the injuries as required, and the incident report was not completed in a timely manner.
A deficiency was found when a newly admitted resident's initial care plan and admission assessment were completed by an LPN rather than an RN, contrary to state nursing regulations. The LPN confirmed performing these tasks, and the DON stated this was in line with facility policy. The issue was reviewed with facility leadership.
A resident with cognitive impairment and a known risk for dehydration did not receive adequate fluids, as documented intake was consistently below the recommended amount. Despite being dependent on staff for eating and drinking, and family requests for IV fluids, the facility delayed interventions and did not monitor supplement or fluid intake as required. Staff and family interviews confirmed insufficient intake and lack of proper monitoring.
A resident with a history of CVA and abnormal gait experienced a fall and was sent to the hospital, then returned with documented purple bruising to the right fifth toe, right flank, and scattered bruising to the left lower leg, with additional notes of bruising to the right fifth toe. Several days later, a mobile X-ray of the right foot revealed a fracture at the base of the right fifth toe, and a physician’s order for the X-ray was documented. However, there was no evidence that the physician was notified of the significant bruising and injury of unknown source to the toe during the days between the fall and the X-ray, and the DON confirmed that no call was made to the physician despite facility expectations that such injuries be reported.
A resident with dementia and an impairment of the right middle finger had a physician’s order for a rolled washcloth to be placed in the right hand, and nurses documented completing this intervention on the TAR. Despite this, review of the clinical record showed no care plan addressing the resident’s limited ROM, contractures, or the rolled washcloth intervention. In an interview, the DON confirmed that no care plan had been developed for the contractures and explained that this was because the resident was on hospice, and these findings were later discussed with facility leadership.
A resident with COPD, CHF, and obstructive sleep apnea had a physician’s order for BiPap use at night with 3L O2, but the treatment administration record did not include instructions for storage of the respiratory equipment. During observations and interviews, an RN and the DON acknowledged that the resident’s BiPap mask and tubing were not stored in a protective plastic bag when not in use, despite the expectation that the equipment should be bagged, resulting in a failure to follow professional standards of respiratory care.
A deficiency was identified when a resident receiving quetiapine for multiple psychiatric conditions did not receive a repeat AIMS assessment as ordered to monitor for antipsychotic side effects. An initial AIMS at admission showed mild abnormal movements, and a consultant pharmacist later recommended a repeat AIMS, which the primary care provider ordered. Facility records, however, contained no completed repeat AIMS, and the DON acknowledged that staff performed a different psychiatric assessment instead of the ordered AIMS.
A resident had a physician order for a urinalysis culture and sensitivity, which was collected by the contracted lab and later phoned in to an LPN. The resident’s record did not show that the LPN notified the physician or NP when the results were received, and the NP did not review the results until two days after the facility had been informed. Facility nursing leadership later confirmed there was an unexplained delay in notifying the practitioner of the lab findings.
A resident on transmission-based precautions had a physician-ordered urinalysis culture and sensitivity collected by a contracted lab, but the test results were not filed in the clinical record as required by facility policy. During record review, surveyors found no lab report in the chart, and the ADON/IP later produced a copy of the results and acknowledged they had not yet been filed. These findings were discussed with facility leadership during the exit conference.
Surveyors found that two residents had no documentation of being offered or receiving a pneumococcal (PNA) vaccine, despite facility policy requiring that all residents be offered this immunization with education and documented consent or refusal. Review of immunization records showed no evidence of PNA vaccination or declination for these residents, and consents were only obtained on the same day they were requested by surveyors. The DON confirmed that the residents had not been offered the PNA immunization before the survey.
A resident with confusion and a history of wandering eloped from the facility by removing a window screen and disengaging the safety latch, exiting undetected due to the absence of window alarms. The resident crossed a parking lot and busy road before being located by staff and law enforcement. Staff interviews revealed that although a Wander guard device was in use, there was no order for regular checks, and the care plan required the device to be on at all times. The lack of window alarms and the resident's ability to exit through the window contributed to the incident.
The facility failed to ensure food safety in its kitchen operations, as observed during a survey. There were no sanitizing solutions for wiping cloths, incorrect chemical test strips were used, and compromised food cans were not separated. Additionally, the ice scoop was improperly stored, and food temperatures were not consistently recorded for several meals. These deficiencies were confirmed with the cook and reviewed with facility leadership.
The facility failed to ensure accurate MDS assessments for three residents, as their admission MDS documented the use of restraints, specifically bilateral bed rails, which were actually used as enabler bars for turning and repositioning. This miscoding was attributed to an RNAC in training and was discovered during a surveyor's request for the Matrix.
A facility failed to ensure required IDT members, specifically a physician or representative, participated in care plan meetings for a resident. Despite the presence of nursing, therapy, CNA, social worker, and dietary staff, the physician did not coordinate with care plan meetings, as confirmed by an RNAC. The issue was discussed with facility leadership during an exit conference.
The facility failed to follow physician orders for two residents, resulting in the administration of medications outside prescribed parameters. One resident received Lantus insulin despite a low blood sugar level, and another received midodrine HCL despite high blood pressure. Interviews and records confirmed these discrepancies, with no evidence of monitoring or addressing the irregularities.
The facility failed to provide adequate continence care for two residents, leading to frequent incontinence episodes. Despite having care plans with specific interventions, staff did not adhere to these plans, and there was no structured toileting program in place. Interviews revealed reliance on a two-hour check and change routine, which was insufficient to meet the residents' needs.
A resident's dietary preferences were not followed on two occasions, with breakfast trays missing specified items and including disliked foods. Staff confirmed the discrepancies, and it was noted that the staff responsible for plating was inexperienced.
The facility's MRR policy lacked necessary time frames for pharmacist responses to urgent medication recommendations. This deficiency was confirmed during an exit conference with the NHA, DON, and Executive Director, acknowledging that the policy did not meet expected requirements.
A resident with advanced dementia reported an allegation of sexual assault to nursing staff, but the facility failed to notify the attending physician and medical director as required by policy. The medical team only became aware of the incident more than twelve hours later, not through standard communication channels but via informal staff discussions. Review of communication logs confirmed no timely notification was made to the medical team.
The facility did not report allegations of sexual and emotional abuse involving two residents within the required 2-hour timeframe. In both cases, staff were aware of the allegations but delayed notifying the State Agency, with one report made over twelve hours later and another five days after the initial complaint. This failure occurred despite staff having access to reporting systems and knowledge of the incidents.
Facility-Wide Failure of Call Bell System Across Multiple Hallways
Penalty
Summary
The deficiency involves the facility’s failure to maintain a functioning call bell system throughout the building. During multiple observations on 12/9/25, the surveyor found that call bells in several resident rooms were not working; when the call bells were pressed, there was no audible sound and no corridor light activation. Staff present at the time, including LPNs and CNAs, confirmed that the call bells in these rooms were not functioning. Subsequent testing by staff and the surveyor revealed that call bells were not working on the 400 hallway, and then on the 200, 300, 500, and 100 hallways as well. On the 100 hallway, a CNA also confirmed that the personal pagers used to alert CNAs when a call bell is activated were not functioning. The Maintenance Director acknowledged the widespread failure of the call bell system and suggested that a power surge earlier that morning might be the cause. The Nursing Home Administrator confirmed being notified that the call bell system was not functioning and stated that he was reviewing the call bell logs. Review of those logs showed a lack of call bell activations starting at 7:31 AM, indicating that the system had been nonfunctional for several hours before the surveyor’s observations. During this period, residents across multiple hallways did not have access to a working call bell system in their rooms and related areas.
Failure to Maintain Proper Food Storage and Temperature Monitoring
Penalty
Summary
Surveyors identified a failure to store and serve food in accordance with professional standards. During a tour of the short-term unit refrigerator on 12/15/25 at 8:39 AM, they observed an undated, unlabeled sandwich and a pudding cup that was past its expiration date of 12/10/25. In addition, review of the facility’s food temperature logs at 9:00 AM on the same day showed missing documentation that food temperatures were taken prior to serving multiple meals, specifically breakfast, lunch, and dinner on 11/13/25; lunch on 11/20/25; dinner on 11/26/25; dinner on 11/28/25; and lunch on 12/4/25. During an interview at 9:52 AM on 12/15/25, staff member E21 (DDS) confirmed the presence of the undated and expired food items and acknowledged the missing food temperature recordings. These findings were later reviewed at the exit conference on 12/16/25 at 3:45 PM with the NHA (E1), DON (E2), and ED (E3).
Failure to Timely Report Injury of Unknown Source
Penalty
Summary
A deficiency occurred when the facility failed to timely report an injury of unknown source for one resident with a history of CVA and abnormal gait. The resident experienced an unwitnessed fall in the TV/dining room and was later found to have multiple bruises and a fractured right fifth toe. Documentation shows that the resident returned from the hospital with visible injuries, but the medical doctor on call was not notified upon return, and the incident was not reported to the state agency on the same day as required. Interviews with facility staff confirmed that the expected protocol was not followed, including timely notification of the physician, family, and state agency, as well as completion of the incident report.
Admission Assessment and Care Plan Not Completed by RN
Penalty
Summary
A deficiency was identified when the facility failed to ensure that the initial care plan and admission assessment for a newly admitted resident were completed by a Registered Nurse (RN), as required by the Delaware Board of Nursing Professional Regulations. Record review showed that both the baseline care plan and the admission assessment, which included documentation of vital signs, skin condition, care needs, and general condition upon arrival, were completed by an LPN. During interviews, the LPN confirmed she performed these tasks, with assistance from an aide for the skin assessment. The Director of Nursing stated that, according to facility policy, LPNs were permitted to complete admission assessments and care plans. These findings were discussed with facility leadership during the exit conference.
Failure to Provide Sufficient Hydration to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with mild cognitive impairment and a documented risk for hydration concerns was not provided with sufficient fluids to meet her assessed needs. The facility's policy required processes to ensure adequate hydration, but records showed the resident consistently received less than the recommended 1500 mL of fluids per day, with intake ranging from 140 mL to 540 mL on documented days. The resident was dependent on staff for assistance with eating and drinking, and her care plan reflected this need. Despite family concerns and requests for IV fluids due to poor oral intake, the facility delayed intervention pending lab results and did not initiate supplementation until after a nutrition assessment indicated malnourishment. The order for a nutritional supplement was not implemented until a day after it was recommended, and there was no evidence that the facility monitored the amount of supplement consumed or tracked total fluid intake as required. Interviews with staff and family confirmed that the resident required assistance with feeding and that her intake was inadequate. The registered dietitian and nursing staff acknowledged that the resident's fluid intake was below the minimum threshold for adequate hydration, and documentation practices did not ensure accurate monitoring of supplement or fluid consumption. The resident was ultimately sent to the hospital after a fall and did not return to the facility. The deficiency was reviewed with facility leadership during the exit conference.
Failure to Notify Physician of Significant Injury of Unknown Source
Penalty
Summary
The facility failed to notify the physician of a significant injury for one resident with a history of CVA and abnormal gait who was reviewed for accidents. The resident was admitted on 7/15/25 and experienced a fall on 8/1/25, after which a progress note at 4:00 PM documented transfer to the hospital. When the resident returned from the hospital at 11:40 PM the same day, documentation noted purple bruising to the right fifth toe and right flank, and scattered bruising to the left lower leg, with an additional note at 12:35 AM on 8/2/25 documenting bruising to the right fifth toe. On 8/4/25 at 2:58 PM, a mobile X-ray of the right foot was performed and revealed a fracture at the base of the right fifth toe, and at 3:00 PM a physician’s order for the X-ray was documented. There was no evidence in the clinical record that the physician was consulted or notified between 8/1/25 and 8/3/25 regarding the significant bruising and injury of unknown source to the resident’s right fifth toe. During interviews, a supervisor stated that the expectation for an unwitnessed fall with injuries was that the nurse would call the supervisor, and that the supervisor would notify the doctor and family, complete an incident report, and report to the state agency. The DON confirmed that no call was made to the physician when the injury of unknown source to the right fifth toe occurred, and these findings were reviewed with facility leadership during the exit conference.
Failure to Care Plan Contractures and ROM Interventions for Hospice Resident
Penalty
Summary
The facility failed to develop and implement a care plan addressing limited range of motion and contractures for one resident with an impairment to the right middle finger. The resident was admitted with multiple diagnoses including dementia and a right middle finger impairment, and later had a physician’s order dated 7/8/25 for placement of a rolled washcloth in the right hand, with task completion documented by nursing staff on the treatment administration record. However, review of the resident’s care plans on 12/11/25 at 10:05 AM showed no care plan addressing the resident’s contractures or the rolled washcloth intervention. During an interview at 10:21 AM, the DON confirmed the absence of a care plan for the contractures and stated there was no care plan because the resident was on hospice. These findings were subsequently reviewed with facility leadership at the exit conference on 12/16/25 at 3:45 PM.
Failure to Properly Store BiPap Equipment Between Uses
Penalty
Summary
The facility failed to follow professional standards of practice for respiratory care by not ensuring a resident’s BiPap equipment was stored in a protective plastic bag when not in use. The resident had been admitted with COPD, CHF, and obstructive sleep apnea and had a physician’s order for BiPap use at night with 3L oxygen. The resident’s treatment administration record did not contain any order regarding storage of the BiPap equipment. During surveyor interviews and observations, an RN and the DON both confirmed that the resident’s BiPap mask and tubing were not stored in a plastic bag when not in use, despite the expectation that the respiratory equipment should be bagged.
Failure to Complete Ordered AIMS Monitoring for Antipsychotic Therapy
Penalty
Summary
A deficiency occurred when the facility failed to complete ordered monitoring for side effects of psychotropic medication for one resident. The resident was admitted with multiple psychiatric diagnoses, including dementia with psychotic disturbance, psychotic disorder with delusions, and schizophrenia, and an AIMS assessment completed at admission showed a score of 3, indicating mild abnormal movements associated with antipsychotic use. The following day, a physician ordered quetiapine twice daily. During a subsequent consultant pharmacist medication regimen review, the pharmacist noted the baseline AIMS score of 3 and recommended obtaining an order to repeat the AIMS assessment due to the ongoing antipsychotic therapy. The primary care provider agreed with this recommendation and documented an order to repeat the AIMS assessment. However, review of the clinical record months later showed no evidence that a repeat AIMS assessment had been completed, and the DON confirmed that instead of performing the ordered repeat AIMS, another psychiatric assessment was done while the DON was on vacation. These findings were confirmed through record review and interviews and were discussed with facility leadership during the exit conference.
Delay in Practitioner Notification of Urine Culture Results
Penalty
Summary
The facility failed to promptly notify a practitioner of laboratory results for one resident on transmission-based precautions. The resident’s clinical record showed that a physician ordered a urinalysis culture and sensitivity test on 12/8/25, which was collected by the contracted laboratory on 12/11/25. On 12/13/25, the laboratory relayed the urinalysis culture and sensitivity results to the facility by phone to an LPN (E24), but the resident’s progress notes contained no evidence that this nurse informed the resident’s physician or nurse practitioner of the results at that time. The results were not reviewed by the nurse practitioner (E23) until 12/15/25, two days after the facility had been notified of the findings. During an interview on 12/16/25, the ADON/IP (E22) and DON (E2) confirmed there was a delay in practitioner notification without explanation, and these findings were later reviewed with facility leadership at the exit conference.
Failure to File Laboratory Test Results in Resident Clinical Record
Penalty
Summary
The facility failed to ensure that laboratory reports were filed in the clinical record for one resident on transmission-based precautions. The facility’s diagnostic services policy, last updated 12/24/24, stated that all test results would be maintained in the clinical record. For this resident, a physician ordered a urinalysis culture and sensitivity test on 12/8/25, and the contracted laboratory collected the specimen on 12/11/25. However, review of the resident’s clinical record on 12/16/25 at 1:00 PM showed no evidence that the urinalysis culture and sensitivity results were present in the record. At 2:00 PM on the same day, the ADON/IP provided the surveyor with a copy of the urinalysis culture and sensitivity results and confirmed that the report was not in the resident’s clinical record, stating that the results were waiting to be filed. These findings, including the absence of the laboratory report in the clinical record despite the completed test, were reviewed with the NHA, DON, and ED during the exit conference at 3:45 PM on 12/16/25.
Failure to Offer and Document Pneumococcal Vaccinations for Two Residents
Penalty
Summary
The facility failed to follow its immunization policy requiring that each resident be offered a pneumococcal vaccination and that the medical record contain documentation of education and either receipt or refusal of the vaccine. Record review for two residents admitted on 1/22/25 and 6/25/25 showed no evidence in their immunization records of pneumococcal vaccination or declination as of 12/15/25 at 12:35 PM. When the surveyor requested evidence of consent or declination, the DON and ADON/ICP later produced consents that were dated 12/15/25, the same day as the surveyor’s request, and the DON confirmed that these two residents had not been offered the pneumococcal immunization prior to that time. These findings were discussed with the NHA, DON, and ED during the exit conference on 12/16/25 at 3:45 PM, confirming that the required offer and documentation of pneumococcal vaccination had not occurred for the two residents reviewed for immunizations.
Resident Elopement Due to Inadequate Supervision and Window Security
Penalty
Summary
A deficiency occurred when a resident with a history of confusion, impaired safety awareness, and wandering behaviors was able to elope from the facility by climbing out of a window in their room. The resident had previously demonstrated goal-directed and aimless wandering, had been found attempting to leave the facility, and was identified as being at risk for elopement. Despite these behaviors, the resident was able to remove the window screen and disengage the safety latch without staff awareness, as the windows were not equipped with alarms to alert staff to unauthorized exits. On the day of the incident, the resident was noted to be fixated on leaving the facility to pay taxes and required repeated redirection by staff. The resident was last seen in their room after being assisted with bathing and toileting, and shortly thereafter, was observed outside the facility by staff and members of the public. The resident crossed a parking lot and a busy roadway, and was missing for approximately seven minutes before being located by staff and law enforcement. The resident was combative and refused to return to the facility, ultimately being transported to the hospital for evaluation. Interviews with staff confirmed that the resident had a Wander guard device, but there was no order for regular checks of its placement and function. The care plan indicated the need for the Wander guard to be on at all times, but the lack of window alarms and the resident's physical ability to exit through the window without detection contributed to the elopement. The facility's investigation identified the disengaged window safety latch as the means of exit and noted the absence of an alarm system on the windows as a critical factor in the incident.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in a manner that prevents foodborne illness to the residents. During an initial tour of the kitchen, it was observed that there were no buckets containing sanitizing solution for storing wet wiping cloths used for sanitizing food preparation surfaces. Additionally, the cook tested the sanitizing solution in the three-compartment sink and found that the chemical concentration was insufficient for proper sanitization. It was later revealed that the facility had been using incorrect chemical test strips for testing sanitizer levels. Further observations revealed that there were three compromised food cans with dented sides that were not separated from the cans of food being served to residents. The ice scoop was improperly stored inside the ice machine, exposing the ice to potential contaminants. A review of the food temperature logs showed that food temperatures were not recorded for 23 out of 336 meals sampled, indicating a lack of consistent monitoring of food temperatures. These findings were confirmed with the cook and later reviewed with the Nursing Home Administrator, Director of Nursing, and Executive Director at the exit conference.
Inaccurate MDS Coding for Three Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for three residents, identified as R16, R32, and R217, out of an investigative sample of eighteen. Each of these residents was admitted to the facility in September or October 2024, and their admission MDS documented the use of restraints, specifically bilateral bed rails. However, observations conducted on October 21 and 22, 2024, revealed that these side rails were being used as enabler bars for turning and repositioning, not as restraints. This discrepancy was discovered when surveyors requested the Matrix, and it was revealed that the MDS had been miscoded. The miscoding of the MDS was attributed to E7, a Registered Nurse Assessment Coordinator (RNAC) who was still in training at the time. During an interview on October 25, 2024, with E6 (RNAC), E7 (RNAC), and E1 (Nursing Home Administrator), it was confirmed that the MDS for these residents was incorrectly coded. The issue was discussed further during an exit conference on October 31, 2024, with E1, E2 (Director of Nursing), and E4 (Executive Director).
Lack of Physician Participation in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that the required interdisciplinary team (IDT) members participated in the care plan meetings for one resident out of eighteen reviewed. The resident, identified as R37, was admitted to the facility on October 3, 2024. A care plan meeting was held on October 16, 2024, with attendees including the resident, a family member, nursing staff, therapy, a CNA, a social worker, and dietary staff. However, it was confirmed through an interview with E6, a Registered Nurse Assessment Coordinator (RNAC), that a physician or physician's representative did not participate in R37's care plan conferences. E6 stated that the physician reviews residents monthly but not in coordination with the care plan meetings. These findings were reviewed with the Nursing Home Administrator (E1), Director of Nursing (E2), and Executive Director (E4) during the exit conference on October 31, 2024.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders for two residents, leading to the administration of medications outside of prescribed parameters. For one resident, who was admitted with diabetes mellitus, a physician's order specified that Lantus insulin should be held if the blood sugar was less than 100. However, on February 17, 2024, the resident's glucose level was recorded at 78 ml/dl, yet the Lantus was administered by an LPN. Interviews with the involved LPNs confirmed the administration of the insulin despite the low blood sugar reading, which was contrary to the physician's order. In another case, a resident had a physician's order for midodrine HCL to be held if the systolic blood pressure exceeded 130. On November 5, 2023, the resident's blood pressure was documented at 152/81, yet the medication was administered. A consultant pharmacist's review noted the discrepancy, and an LPN confirmed the administration despite the blood pressure exceeding the specified parameter. The facility lacked documentation of monitoring or addressing the irregularity of administering medication outside the prescribed parameters.
Failure to Implement Effective Continence Care Programs
Penalty
Summary
The facility failed to provide adequate services to restore bowel and bladder continence for two residents, R21 and R37, as observed through their clinical records and interviews. R21 was admitted with an indwelling catheter and was frequently incontinent of bowel. Despite having a care plan with specific interventions to assist with continence, such as scheduled toileting and the use of a voiding diary, the CNA task flow sheets for August, September, and October 2024 showed a lack of adherence to these interventions. Interviews with staff revealed that R21 was not on a structured toileting program, and there was no evidence of attempts to restore bowel function. R37 was admitted with a care plan to remain continent of bowel and bladder, but the CNA task flow sheets indicated frequent incontinence of urine. The care plan included interventions like using incontinence products and assisting with toileting upon request. However, the flow sheets lacked evidence of following these individualized interventions. Interviews with R37 and staff indicated that R37 was not on a structured toileting program, and the resident reported incontinence due to delays in staff assistance. Interviews with facility staff, including an LPN and a CNA, confirmed the absence of a set toileting program, with reliance on a two-hour check and change routine. This routine was not sufficient to meet the individualized needs of the residents, as evidenced by the frequent incontinence episodes and lack of adherence to care plans. The findings were discussed with the Nursing Home Administrator, Director of Nursing, and Executive Director during the exit conference.
Failure to Follow Resident Dietary Preferences
Penalty
Summary
The facility failed to adhere to the dietary preferences and nutritional needs of a resident, identified as R47, during meal service. On two separate occasions, the resident received breakfast trays that did not match the meal ticket specifications. On the first occasion, the tray was missing apple juice and a fresh whole apple, and included items that the resident disliked, such as eggs and milk. The resident expressed dissatisfaction with receiving food she did not like. A CNA confirmed the discrepancies and noted that there was no apple juice available, offering cranberry juice as a substitute instead. On the following day, the resident's breakfast tray again did not match the meal ticket, missing a fresh whole orange and scrambled eggs with onions, and included bacon and sausage, which the resident could not eat due to a dislike of pork. An RN confirmed these discrepancies and offered sliced oranges as a substitute. The dietary regional support staff revealed that the staff responsible for plating the tray was inexperienced in this task, having been temporarily assigned from another area. The dietician confirmed the need for nutritionally equivalent substitutes when items are unavailable.
Deficiency in MRR Policy for Urgent Medication Response Times
Penalty
Summary
The facility failed to develop comprehensive policies and procedures for the monthly Medication Regimen Review (MRR) process, specifically lacking time frames for pharmacist responses to urgent medication recommendations. During a review of the facility's policy titled 'Consultant Pharmacist Reports,' it was noted that the policy did not include necessary information regarding the time frames for a pharmacist's response to urgent medication recommendations. This deficiency was confirmed during an exit conference with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Executive Director, where it was acknowledged that the MRR policy did not meet the expected requirements for urgent medication response times.
Failure to Notify Physician and Medical Director of Abuse Allegation
Penalty
Summary
The facility failed to implement its written abuse policy by not notifying a resident's physician or the medical director of an abuse allegation in a timely manner. The policy requires immediate reporting of abuse allegations to the Department of Health and prompt notification of the resident's attending physician, medical director, and family. On the night of the incident, a resident with profound dementia reported to a nurse that she had been sexually assaulted. The nurse attempted to inform the nursing supervisor but was unable to reach them and left a message with another staff member. Documentation and interviews revealed that neither the attending physician nor the medical director was notified of the allegation until more than twelve hours after the initial report. The physician only learned of the incident indirectly through staff discussions and was not informed via the standard communication channels, such as the doctor communication book or the on-call service. The nurse practitioner, who was present in the facility on the day following the allegation, also reported not being informed about the incident. Further review of communication logs and interviews with medical staff confirmed that there were no entries or notifications regarding the abuse allegation in the designated communication systems. The medical director and nurse practitioner both stated they were not contacted by the facility regarding the incident, and the on-call log did not show any record of notification. This lack of timely communication with the medical team constituted a failure to follow the facility's abuse reporting policy.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse within the required 2-hour timeframe for two out of three residents reviewed. In the first case, a resident with profound dementia alleged sexual assault to a registered nurse (RN) at approximately 11 PM. The RN informed several staff members, including certified nursing assistants (CNAs) and another RN supervisor, but the allegation was not reported to the State Agency until over twelve hours later. Multiple staff members were aware of the allegation, and the term 'rape' was used in conversations among staff, but the required immediate reporting did not occur. In the second case, a resident's daughter reported that a certified nursing assistant (CNA) was disrespectful and rude to her mother, constituting an allegation of emotional abuse. The facility initiated an internal investigation and placed the CNA on administrative leave, but the incident was not reported to the State Agency until five days after the facility became aware of the allegation. Both incidents demonstrate a failure by the facility to adhere to mandated reporting timelines for suspected abuse. The delay in reporting was due to staff not immediately escalating the allegations to the appropriate authorities, despite being aware of the requirements and having access to the necessary reporting systems.
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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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