Failure to Properly Review and Document Admission Agreements
Summary
The facility failed to provide and review admission agreements with the appropriate resident or representative for two residents during a recertification/complaint survey. The first resident, admitted in early February 2024, was assessed with a Brief Interview of Mental Status (BIMS) score of '00', indicating severe cognitive impairment. Despite having an identified representative, the admission contract was electronically signed with initials that did not match either the resident or the representative. The Admissions Director was unable to verify the signature, and the employee responsible for completing the form was no longer employed at the facility. The second resident was noted to be unable to participate in the admission assessment due to mental status and was only oriented to 'self'. The admission contract contained neatly entered initials on one page and an illegible signature on another, which did not match, raising concerns about the validity of the signature. The resident was not identified as their own representative, and the person who should have received the admission contract was not properly documented. The discrepancies were confirmed by the Administrator and Admissions Director, and the responsible employee was no longer with the facility.
Penalty
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Facility staff did not ensure that residents knew where to find the list of contact names, addresses, and phone numbers for the ombudsman, adult protective services, and other State agencies. In a resident group meeting with the Resident Council President and four other residents, all five reported they did not know how to contact these agencies. The Activities Director later stated that residents are educated at each resident council meeting about the ombudsman and the location of the contact information, and that this is documented in council minutes. When these findings were presented to the Interim Administrator, DON, ADON, and Corporate Nurse Consultant, they did not offer comments or concerns.
Ombudsman contact information was not posted for public view in the facility. A resident reported trying to reach the ombudsman and said he only had the prior ombudsman’s contact information, while front desk staff stated the updated information was taped on her side of the desk rather than posted where residents and visitors could see it.
Missing State Survey Agency Posting: The facility failed to display the State Survey Agency phone number and contact information in prominent, readily accessible locations on two nursing units. During a tour, the DOSS was unsure where the postings were located, and the required complaint/reporting information could not be found in the nursing units or common areas. The NHA later confirmed the postings were not up and may have been removed during painting.
Staff failed to ensure residents knew where to find contact information for the State Survey Agency and the State LTC Ombudsman. Required lists of names, mailing/email addresses, and phone numbers were posted behind the concierge desk in an area not accessible to residents, and no other signage was present on the unit. During a Resident Council meeting, all residents present were unable to identify the location of this information and were unaware of their right to file complaints with the State or Ombudsman. Later, two residents taken to see the posting stated they had not known it was there, while the concierge reported residents must ask for the information and that none had done so during her tenure.
The facility failed to post required information informing residents how to formally complain to the State Agency. During a resident council meeting, residents reported they did not know how to make a formal complaint to the state, and a subsequent tour showed that the main bulletin board for residents and visitors did not include instructions for filing a complaint with the state agency. The NHA later confirmed the absence of this required complaint information, which was reviewed with the NHA, DON, and a corporate nurse during the survey exit conference.
The facility did not ensure that residents were informed of their right to file a complaint with the State Survey Agency, and failed to provide visible, readable, and accurate contact information. Multiple residents were unaware of where to find this information, and both the AD and DON confirmed that the posted details were not accessible or correct, contrary to facility policy.
Residents Unaware of How to Access Ombudsman and State Agency Contact Information
Penalty
Summary
Facility staff failed to ensure that residents knew the location of the list of contact names, addresses, and phone numbers for State agencies, the ombudsman, and adult protective services, resulting in 5 of 5 residents attending a resident group meeting being unaware of how to contact these entities. During a resident group meeting held with the Resident Council President and four regularly attending residents, all participants reported they did not know how to contact the ombudsman, adult protective services, or other state offices. A subsequent interview with the Activities Director revealed that she stated residents are educated at every resident council meeting about the ombudsman and where to find the contact information, and that this education is documented in the resident council minutes. In a final interview with the Interim Administrator, DON, ADON, and Corporate Nurse Consultant, the surveyor conveyed these findings, and the administrative team made no comments and voiced no concerns. No additional medical history or clinical conditions of the residents were provided in the report, and the deficiency centers on residents’ lack of awareness of how to access posted or available contact information for external advocacy and protective agencies.
Ombudsman Contact Information Not Posted
Penalty
Summary
The facility failed to post the State Long-Term Care Ombudsman's contact information. During a Resident Council meeting, a resident stated he had been trying to contact the ombudsman and wanted them to attend a resident council meeting, but he only had the contact information for the previous area ombudsman and was not aware there was a new ombudsman. He also stated there was no ombudsman information posted in the facility. Later that day, no ombudsman information was observed at the front desk, and front desk staff stated she had the ombudsman information taped on her side of the desk, but it was not posted for public view. The finding was discussed with the Regional Nurse Consultant, and no additional information was received.
Missing State Survey Agency Posting
Penalty
Summary
The facility failed to post the State Survey Agency phone number and contact information in readily accessible locations on two nursing floors, including the 1st Floor and 2nd Nursing Units. During a tour with the Director of Social Services, the employee stated she was new to the facility and was unsure where the State Survey Agency postings were located. A review of the nursing units and common areas did not locate the required State Survey Agency phone number, contact information, or reporting information. The Nursing Home Administrator later confirmed that the required postings were not up and may have been taken down during painting. The report states that the facility did not ensure the required postings, including the name, address, and telephone number for the State Survey Agency, were displayed in prominent places throughout the facility, along with a statement that residents may file a complaint with the State Survey Agency regarding abuse, neglect, exploitation, or misappropriation of resident property.
Failure to Inform Residents of Location of State and Ombudsman Contact Information
Penalty
Summary
Facility staff failed to ensure that residents were informed of the location of contact information for the State Survey Agency and the State Long-Term Care Ombudsman program. During an observation of the third floor, the required list of names, mailing and email addresses, and telephone numbers for the State licensure office and the State Long-Term Care Ombudsman was found posted behind the concierge’s desk on the wall, in a location inaccessible to residents. No other signage with this required information was posted on the third floor. At a Resident Council meeting, all 10 residents present were unable to identify where the contact information for the State licensure office and the State Long-Term Care Ombudsman was located and were unaware of their right to file a complaint with these entities. After the meeting, the Activities Director escorted two residents to view the Ombudsman information, and both stated they did not know it was posted there. Concierge staff reported that residents must ask for the information and phone numbers if they need them and that no resident had requested this information during the five years she had worked at the facility. The Activities Director reported there was another copy of the information outside her office on the second floor for assisted living residents. Leadership, including the DON, ADON, and Administrator, were later informed of these findings.
Failure to Post Information on How to File State Agency Complaints
Penalty
Summary
The facility failed to ensure that information on how residents can formally complain to the State Agency was displayed in a format and language residents understood. During a resident council meeting on 9/24/25 at 1:45 PM, all residents in attendance denied knowing how to make a formal complaint to the state of Delaware. Later that day at 2:08 PM, during a tour of the facility to check required postings, the surveyor observed that the first-floor bulletin case, which displayed information for residents and visitors, did not include information on how to make a complaint to the state agency. At 2:27 PM, the Nursing Home Administrator (E1) confirmed this finding. On 9/29/25 at 1:25 PM, the same finding regarding the lack of posted information about how to file a complaint with the state agency was reviewed with the NHA (E1), the DON (E2), and the Corporate Nurse (E3) during the exit conference.
Failure to Provide Accessible and Accurate State Survey Agency Contact Information
Penalty
Summary
The facility failed to ensure that residents were properly informed of their right to file a complaint with the State Survey Agency, and did not provide visible, readable, and accurate contact information for the agency. During a Resident Council meeting, four out of five residents stated they did not know where the State Survey Agency contact information was posted and had not been made aware of where to find it. Observations confirmed that the required contact information was either missing or posted in a manner that was not easily readable, with incorrect address and telephone number details. The Activity Director acknowledged that the information was not accessible or accurate, and that it should have been provided during monthly council meetings. Further observation with the DON confirmed that the posted contact information was not visible, easily readable, or up to date, and that the residents' right to file a complaint with the State was not honored. Review of the facility's policy and procedure indicated that residents are to be informed about their rights, including the right to communicate with outside agencies. The deficiency was identified through direct observation, resident interviews, and review of facility policy.
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