Delaware Hospital F/t Chronically Ill (dhci)
Inspection history, citations, penalties and survey trends for this long-term care facility in Smyrna, Delaware.
- Location
- 100 Sunnyside Road, Smyrna, Delaware 19977
- CMS Provider Number
- 085035
- Inspections on file
- 20
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 10 (2 serious)
Citation history
Health deficiencies cited at Delaware Hospital F/t Chronically Ill (dhci) during CMS and state inspections, most recent first.
Multiple residents with documented upper extremity impairments, balance problems, poor vision, seizure history, and unsafe smoking behaviors were allowed to keep cigarettes and lighters and to smoke without direct supervision, despite care plans and smoking safety evaluations identifying significant risks. One resident with quadriplegia and severely contracted fingers independently retrieved and lit cigarettes from a cross‑body bag while staff left him alone in the smoking area. Other residents with stroke, epilepsy, neuropathy, and vascular dementia were observed smoking outside without staff present, declining smoking aprons, and disposing of cigarettes in non‑fire‑safe metal cans, while the smoking areas lacked fire extinguishers, fire blankets, and properly assembled safety ashtrays. A resident who used oxygen via nasal cannula with an oxygen concentrator in the room kept a cigarette lighter in the room, even though staff acknowledged this should not occur for someone on oxygen. Facility leadership confirmed that certain smoking areas were not supervised, residents were permitted to retain smoking materials if care planned, and there were no smoking blankets available, contributing to the identified deficiency.
The facility failed to use menus that included defined portion sizes for regular, mechanical soft, and pureed diets during two observed lunch meal services. Staff plated food based solely on residents’ pre-selected menu choices, without portion sizes on the menus and using only a generalized serving-size list that did not address mechanical soft or pureed foods. The Dietary Manager confirmed that the current menus and pre-selected menus lacked portion sizes, and the RD reported she was unaware that such menus were being used. A comparison of what was actually served to menus that did include portion sizes showed multiple food items, including proteins, starches, vegetables, soups, and potatoes, were served in amounts less than the specified portions or without a defined portion, and the facility reported it had no menu policy.
The facility failed to develop person-centered, comprehensive care plans addressing psychotropic medication use for four residents receiving antipsychotic and related psychotropic drugs. In each case, MDS assessments and CAAs triggered psychotropic drug use and directed staff to develop a care plan, yet the EMR care plans did not include the specific antipsychotic or related medications being administered. One resident with severe cognitive impairment received a monthly IM antipsychotic without a corresponding care plan; another cognitively intact resident on quetiapine and escitalopram, and a third resident with moderate cognitive status on a twice-daily antipsychotic, also lacked psychotropic-focused care plan entries. A fourth cognitively intact resident with schizophrenia and schizoaffective disorder had only a general neurobehavioral health care plan without specific antipsychotic planning. MDS coordinators reported they decide whether to develop care plans after completing CAAs and stated the EMR lacks fields to specifically address psychotropic medications or black box warnings, while the DON indicated psychotropic information is contained in consent forms rather than in the care plans.
Surveyors found that the facility did not offer or document pneumococcal vaccinations according to current CDC guidelines for several older residents. Record review showed that some residents over age 50 or 65 had no documentation of receiving or being offered PCV20 or PCV21, even when they had only received PPSV23 in prior years. A pharmacy report showed very limited use of PCV20 over multiple years. The DON/IP confirmed that specific residents had not been offered PCV20, and the Medical Director reported no recent communication about pneumococcal vaccines and acknowledged that the facility’s vaccination policy, which still referenced PCV13 and PPSV23 for adults 65 and older, had not been updated to reflect current CDC recommendations.
Surveyors found that MDS assessments were inaccurately coded for pneumococcal vaccination status for three residents. For two residents with moderate cognitive impairment, the EMR showed only prior PPSV23 administration and no evidence that PCV13, PCV20, or PCV21 had been offered when they reached the recommended age, yet one MDS indicated the resident was up to date on pneumococcal vaccines and another left the pneumococcal section blank. For a third resident, the MDS documented that staff could not determine the BIMS score and that the resident was up to date on pneumococcal vaccination, while the EMR showed only PPSV23 and no documentation of PCV13, PCV20, or PCV21 being offered. During interviews, MDS staff reported relying on the clinical record for vaccine status and one coordinator stated she was not familiar with CDC pneumococcal vaccine recommendations.
A resident with an anoxic brain injury and a tracheostomy had physician orders for complete trach changes every three months, but EMR review showed missing TAR entries and lack of RT documentation for some scheduled changes. Nursing staff documented performing trach changes on certain dates, then later stated these entries were mistakes and that only the physician or RT should remove and replace the trach. The RT documented trach care only on multiple occasions, reported limited recent visits due to medical issues, and was unaware of the specific ordered schedule for trach changes. The DON expected the TAR to accurately reflect care provided, and the Medical Director stated staff were to follow his orders and notify him if they could not be carried out, noting the trach changes were required to maintain patency, prevent infections, and provide cleanliness.
Two residents with severe cognitive impairment and significant physical limitations were using bilateral side rails without complete assessment or informed consent. For one resident, side rails were included in the care plan but there was no physician order, and the bed rail assessment lacked documentation of risk–benefit discussion, entrapment risk evaluation, or attempted alternatives, despite staff stating the resident could not use the rails functionally. For the second resident, an order for bilateral upper side rails for safety and a care plan intervention for side rails were present, but the bed rail assessment again only cited keeping the resident in bed, with no documented explanation of risks versus benefits, no entrapment assessment, and no evidence of alternatives tried, while staff reported the resident could not grab the rails. An RN acknowledged that the assessments omitted required elements and that there was no facility policy for side rails, and surveyors noted this had the potential to place residents at risk of injury or death.
A resident with intact cognition and diagnoses of anemia and vitamin and vitamin D deficiencies had daily orders for ferrous sulfate, a multivitamin, and cholecalciferol. During a morning med pass, the resident was found in bed with three pills on the chest after reporting that the medications, given in a cup, had missed the mouth. An LPN confirmed she had given the medications and then left, not realizing they were not taken, while the unit manager and DON stated that no residents self-administer medications and that nurses are expected to remain with residents until medications are taken. The facility’s medication administration policy prohibits leaving meds at the bedside but does not explicitly require staff to verify ingestion.
A resident with a gastrostomy and receiving tube feeding was given medication via a PEG tube by an LPN who did not wear required PPE, and there was no Enhanced Barrier Precautions signage on the resident’s door. The LPN reported she thought PPE was only needed for treatments like cleaning the PEG site, while the IP and DON confirmed that PPE is required for PEG medication administration and that staff had been trained on this. Facility policy states that Standard Precautions, Enhanced Barrier Precautions, and Transmission-Based Precautions must be used as clinically indicated to prevent and control infectious diseases, including MDROs.
Two residents experienced serious incidents due to inadequate supervision: one, with severe cognitive impairment and a high risk for elopement, was able to leave the facility undetected through an unsecured window after repeated exit-seeking behaviors were not addressed with individualized care planning or consistent monitoring; another, who was non-ambulatory and fully dependent, suffered a femur fracture after falling from bed during care, as staff did not recognize the need for fall prevention measures.
A resident with severe cognitive impairment and total dependence on staff for transfers was being moved from bed to wheelchair using a mechanical lift by a CNA and an LPN. During the transfer, the LPN was not in position to provide hands-on assistance as required, and the resident's legs slipped from the sling, causing her to fall and sustain fatal head injuries. The facility did not follow its policy or the resident's care plan requiring two-person, hands-on assistance during such transfers.
Failure to Ensure Safe, Supervised Smoking for Residents With Impairments and Oxygen Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe smoking practices and adequate supervision for multiple residents who smoked, despite identified physical impairments and safety risks. Several residents were assessed as having upper extremity limitations, balance problems, or a history of unsafe smoking behaviors, yet were allowed to keep cigarettes and lighters and to smoke without direct supervision. The facility’s own smoking safety assessments and care plans documented that certain residents had impaired range of motion, poor vision, difficulty safely handling or extinguishing cigarettes, and a pattern of burning clothing or dropping ashes, but these findings were not consistently translated into supervised smoking or restricted access to smoking materials. One resident with quadriplegia and bilateral upper extremity impairment was care planned as preferring to keep his lighter and to smoke at his leisure, and he declined to wear a smoking apron. Staff interviews confirmed that this resident kept his cigarettes and lighter in a cross‑body bag and that staff would transport him to the front smoking area and then leave him to smoke alone. Observations showed the resident, with severely contracted fingers and limited arm movement, independently retrieving and lighting a cigarette while staff present nearby were not actively supervising and were unaware of the availability of a smoking blanket. The front smoking area contained buckets and a large metal ashtray, but there was no indication of specialized fire‑safety equipment being used during these observations. Another resident with tobacco use, cataracts, vascular dementia, and a documented smoking safety evaluation indicating poor vision, balance problems, and inability to safely light, hold, or extinguish cigarettes was observed being wheeled to the smoking area without being offered a smoking apron. The LPN left this resident outside alone with his own cigarettes and lighter, and the resident confirmed that staff did not supervise him while he smoked. The 500‑unit smoking area lacked a fire extinguisher, fire blanket, and fire‑safe ashtrays, with only large metal cans present. A third resident with epilepsy, neuropathy, hemiplegia, and upper extremity impairment was similarly assessed as having balance problems and limited range of motion, yet was observed wheeling himself with a cigarette and lighter in hand, refusing a smoking apron, and smoking outside alone after staff left the area; he confirmed he kept his cigarettes and lighter, and used non‑fireproof metal cans for cigarette disposal. A fourth resident with a history of stroke and seizure disorder had a smoking safety evaluation documenting balance problems, burning of skin and clothing, dropping ashes on self, non‑adherence to smoking location and time policies, and inability to safely extinguish cigarettes or use an ashtray. The care plan stated this resident often declined a smoking apron, was supposed to keep cigarettes at the nurse’s station, and needed reminders to follow the smoking schedule and designated area. Despite this, the resident was observed in his room with a pack of cigarettes and a lighter concealed under a washcloth on the wheelchair armrest, and later was seen smoking outside the 500‑unit smoking area without staff supervision, confirming he kept his cigarettes and lighter. Another resident who smoked and used oxygen via nasal cannula with an oxygen concentrator in her room was care planned to have aides assure proper storage of smoking materials, with cigarettes kept at the nurse’s station and some cigarettes in her room. Her smoking safety evaluation indicated she could safely light, hold, and extinguish cigarettes and use an ashtray, but staff interviews revealed that while her cigarettes were stored at the nurse’s station, she kept her own lighter in her private room. Multiple staff, including RNs and CNAs, acknowledged that it was not appropriate for a resident using oxygen in the room to keep a lighter there. The facility’s administrator and other leadership confirmed that residents from the 500 unit using the back smoking area did not require supervision, that residents were permitted to keep cigarettes and lighters if care planned, and that there were no smoking blankets in either the front or back smoking areas. The maintenance director verified that the necks to the safety ashtray bottoms were not attached in the smoking areas. The report also cites NFPA 99 provisions requiring removal of smoking materials from patients receiving respiratory therapy and prohibiting smoking in areas where oxygen is used or stored. Immediate Jeopardy was identified when three residents with upper extremity impairments who smoked were found to be unsupervised and retaining their smoking materials, and the facility’s practices and environment did not align with the documented risks and applicable fire safety standards.
Failure to Use Menus With Defined Portion Sizes for Regular, Mechanical Soft, and Pureed Diets
Penalty
Summary
The deficiency involves the facility’s failure to use menus that included portion sizes for regular, mechanical soft, and pureed diets for two observed meals. Review of the week-two Spring 2025 menus showed they did not include portion sizes for these diet types, and individual residents’ pre-selected menu sheets for lunch on 01/06/26 and 01/07/26 also lacked portion sizes. A diet type report showed multiple residents on regular, mechanical soft, and pureed diets. During observations of the tray line on the 200 unit on both days, a food service worker plated meals by reading residents’ pre-selected menus without any portion sizes listed and without using any other menu to determine portions. The worker stated he relied on a list of portion sizes kept in the main kitchen. The Dietary Manager confirmed that portion sizes were not included on the facility’s week-two Spring 2025 menus or pre-selected menus and provided a “Standard Serving Sizes” list that contained only generalized food groups and did not address mechanical soft or pureed foods. The Registered Dietitian stated she was not aware that menus without portion sizes were being used and acknowledged the requirement for menu portion sizes. When actual servings on 01/06/26 and 01/07/26 were compared to the week-two Spring 2025 menus with portion sizes, multiple items, including roasted potatoes, pureed salmon, pureed soup, pureed stuffed pasta shells, pureed asparagus, mechanical soft roast beef, rice, pureed roast beef, baked potatoes, asparagus, and regular soup, were found to have been served in amounts less than the specified portions or without a measurable portion. The facility also reported that it did not have a policy for menus.
Failure to Care Plan Psychotropic Medication Use for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop person-centered, comprehensive care plans with measurable goals and interventions for residents receiving psychotropic medications. For one resident admitted with schizophrenia and a BIMS score of 0/15 indicating severe cognitive impairment, the admission MDS and CAA triggered the use of psychotropic medications and directed staff to develop a care plan. Despite a physician’s order for a monthly intramuscular antipsychotic injection, the resident’s care plan in the EMR did not contain any evidence that the use of aripiprazole was addressed. Another resident, cognitively intact with a BIMS score of 15/15, had physician orders for oral medications to treat bipolar disorder and major depressive disorder and was receiving an antipsychotic medication on a routine basis. The annual MDS and CAA triggered for psychotropic drug use and directed staff to develop a care plan, but the care plan did not address the use of quetiapine fumarate or escitalopram. A third resident, admitted with major depressive disorder and a BIMS score of 10/15 indicating moderate cognitive status, had an order for an oral antipsychotic medication and had been administered the medication twice daily, as shown on the MAR. The CAA documented that the resident had received antipsychotic medication for seven days prior to the assessment, yet the care plan dated later that month did not address the resident’s use of the antipsychotic medication. A fourth resident, cognitively intact with a BIMS score of 15/15 and diagnoses including schizophrenia and schizoaffective disorder with related depression, had orders for oral medications for these conditions. The annual MDS and CAA triggered psychotropic drug use for care planning, but the care plan, revised later in the year, only contained a Neurobehavioral Health problem and did not include a specific care plan for antipsychotic medications. During interviews, MDS coordinators stated that they complete the CAAs and then decide whether to develop a care plan, and reported that the EMR care plan system does not have the capacity to specifically address psychotropic medications or include black box warning information. The DON stated that care plans were individualized and that information about psychotropic use was contained in residents’ consents. The RAI Manual excerpt in the report states that MDS and CAA findings are to be used by the IDT to develop care plans that address identified problems, including psychotropic drug use.
Failure to Offer and Document Pneumococcal Vaccinations per Current CDC Guidelines
Penalty
Summary
Surveyors identified that the facility failed to offer influenza and pneumococcal vaccinations in accordance with current CDC guidelines and its own policies for multiple residents. Record review showed that several residents over age 50 or 65 did not have documentation of being offered or receiving the recommended pneumococcal conjugate vaccines PCV20 or PCV21. One resident admitted in January 2025, over age 55, had no record of receiving any pneumococcal vaccine or being offered PCV20 or PCV21. Another resident admitted in February 2024, over age 65, similarly had no documentation of pneumococcal vaccination or an offer of PCV20 or PCV21. A third resident, admitted in 2016, had received PPSV23 in December 2016, but there was no evidence that she or her representative had been offered PCV20 or PCV21. Two additional long-stay residents who turned the qualifying age during their stays had received PPSV23 in 2015, but their records lacked any indication that they or their representatives were offered PCV20 or PCV21. A pharmacy report showed only a small number of residents received PCV20 between 2023 and 2025. In interviews, the pharmacist stated PCV20 was ordered in 2025 and would require a report to determine ordering frequency, and the DON/Infection Preventionist confirmed that the identified residents had not been offered PCV20. The Medical Director reported there had been no communication regarding pneumococcal vaccines for at least six months and acknowledged that the facility’s policy had not been updated to reflect current CDC recommendations. Review of the facility’s written protocol showed it still referenced PCV13 and PPSV23 for adults 65 and older, which did not align with the CDC’s updated guidance recommending PCV15, PCV20, or PCV21 for adults 50 and older and shared decision-making use of PCV20 or PCV21 in certain adults 65 and older.
Inaccurate MDS Coding for Pneumococcal Vaccination Status
Penalty
Summary
The deficiency involves inaccurate completion of the Minimum Data Set (MDS) assessments related to pneumococcal vaccination status and cognitive assessment for three residents. For one resident admitted in 2016, a quarterly MDS with an Assessment Reference Date (ARD) in December 2025 documented that staff could not determine the resident’s Brief Interview for Mental Status (BIMS) score and indicated the resident was up to date on pneumococcal vaccination. However, the electronic medical record (EMR) immunization section showed only a PPSV23 vaccine given in 2019, with no evidence that the resident or representative had been offered PCV13 before age 55 or PCV20/PCV21 after age 55, as referenced in CDC guidance. For another resident admitted in 2018, the EMR showed a PPSV23 vaccine given in 2015, but there was no evidence in the record that PCV13, PCV20, or PCV21 had been offered during the stay when the resident reached the applicable age. The quarterly MDS for this resident, with an ARD in October 2025 and a BIMS score of 12 (moderate cognitive impairment), left blank the section that identifies whether the resident was offered or was up to date on pneumococcal vaccination. A third resident, admitted in 2008, had an EMR immunization record showing PPSV23 administration in 2015, with no evidence that PCV13, PCV20, or PCV21 had been offered during the stay when the resident reached the applicable age. Despite this, the quarterly MDS with an ARD in December 2025, which documented a BIMS score of 9 (moderate cognitive impairment), indicated that the resident was up to date on pneumococcal vaccination. During an interview, the MDS Coordinators stated they obtained pneumococcal vaccine information from the clinical record and relied on its accuracy, noting that influenza vaccine information was easier to locate because it appeared on the Medication Administration Record. One MDS Coordinator acknowledged not being familiar with CDC recommendations for pneumococcal vaccination. These findings, combined with the RAI Manual and CDC guidance cited in the report, demonstrate that the facility failed to ensure accurate MDS coding for pneumococcal vaccination status for the three residents.
Failure to Ensure Ordered Tracheostomy Changes Were Completed and Accurately Documented
Penalty
Summary
The facility failed to ensure a resident with an anoxic brain injury received complete tracheostomy (trach) changes as ordered by the physician and respiratory therapist (RT). The resident was admitted with a trach and had physician orders for a complete trach change every three months in April, July, October, and January, specifying a size six extra-long Shiley cuffed trach tube with disposable inner cannula. Review of the electronic medical record (EMR) showed missing or blank Treatment Administration Records (TARs) for some of the months when trach changes were due, including January and October, and there were no corresponding RT progress notes documenting that the ordered trach changes were completed. Documentation showed that on some dates nursing staff (RNs) recorded that they had changed the trach, but during interviews those RNs stated these entries were errors and that only the physician or RT should perform a complete trach change. RT progress notes and interviews further demonstrated inconsistency and lack of awareness of the specific physician orders. The RT documented performing trach care only on several dates and stated in interview that she tried to come weekly but had not been able to recently due to medical issues, and that the last time she changed the resident’s trach was in December. She also stated she was not aware of the physician’s specific schedule for trach changes and clarified that a trach change meant removal of the trach and was to be done only by the RT. The DON stated that the TAR was expected to reflect the care provided and that nursing needed to ensure documentation was correct, while the Medical Director stated that clinical staff were to follow his orders and notify him if they could not be implemented, and that the complete trach changes were required to maintain patency, prevent infections, and provide cleanliness.
Failure to Assess Bed Rail Need and Obtain Informed Consent
Penalty
Summary
The deficiency involves the facility’s failure to properly assess the need for bed/side rails and obtain informed consent, including discussion of risks and benefits and assessment of entrapment risk, for two residents who were using side rails. For one resident with severe cognitive impairment, epilepsy, traumatic brain injury, tracheostomy status, and total dependence for all ADLs, the care plan documented use of a wide low air loss mattress and bilateral side rails, but there was no physician order for side rails in the EMR. A bed rail assessment indicated side rails/assist bar were used as an enabler to promote independence and included the resident representative’s signature, but there was no documentation that risks versus benefits were explained, no assessment of entrapment risk, and no indication that alternatives were tried before using bed rails. Observations showed this resident in a low bed with side rails in use and fall mats in place, and a CNA stated the side rails were used to keep the resident in bed so she did not fall, while also stating the resident had not fallen from bed and could not grab or use the side rails. For a second resident with severe cognitive impairment, functional limitations in upper and lower extremities, a feeding tube, and diagnoses including Alzheimer’s disease, epilepsy, and cerebrovascular accident, there was a physician order for bilateral upper side rails for safety without specified directions. The care plan for falls and safety included bilateral side rails to ensure safety, and the bed rail assessment documented the reason for side rail use as keeping the resident in bed. The assessment included the resident representative’s signature but lacked documentation that risks versus benefits were explained, did not assess entrapment risk, and did not show that alternatives were attempted before side rail use. Observations showed this resident in a low bed with fall mats and contracted hands with cloth rolls, and a CNA reported the side rails were for falling and that the resident could not grab or use them. An RN stated that side rail assessments did not include risks versus benefits or entrapment risk and that she was unsure what alternatives had been tried, and also reported that there was no facility policy for side rails. The surveyors noted that this failure had the potential to place residents at risk of injury or death.
Medications Left Unattended and Not Administered as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered medications were properly administered to a resident and not left unattended. The resident had intact cognition with a BIMS score of 15 and diagnoses including unspecified vitamin deficiency, anemia, and vitamin D deficiency. Physician orders in the EMR included daily ferrous sulfate for anemia, a daily multivitamin for vitamin supplementation, and daily cholecalciferol for vitamin D. The resident’s care plan indicated a need for some assistance with ADLs due to arthritis and physical challenges. During a morning medication pass, the resident was found awake in bed wearing a hospital gown with three pills (a small white tablet, a medium off-white tablet, and a medium black tablet) on her chest. The resident stated she had been given her medications in a cup but must have missed her mouth. When questioned, an LPN confirmed she had given the medications to the resident in a medicine cup but did not notice that the resident had not taken them, and identified the pills as a multivitamin, iron, and a medication “to reduce fat.” The LPN was in the hallway when the pills were discovered rather than remaining with the resident. The Unit Manager (an RN) stated there were no residents who self-administered medications and confirmed that the LPN should have stayed with the resident to ensure the medications were taken, adding that medications should never be left with the resident. The DON also stated there were no residents who self-administered medications and that her expectation was for the nurse to stay with the resident until medications were taken, and she was unaware of the incident at the time it occurred. The facility’s Medication Administration policy stated that medications should never be left at the bedside to be taken later, but did not specifically include language requiring staff to ensure residents actually take the medications.
Failure to Use PPE During PEG Tube Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff used appropriate personal protective equipment (PPE) during medication administration via a percutaneous endoscopic gastrostomy (PEG) tube. A resident admitted with a diagnosis of gastrostomy status and documented on the MDS as receiving nutrition through a feeding tube was observed receiving medications through the PEG tube from an LPN who did not wear any PPE. At the time of the observation, there was no signage on the resident’s door indicating the use of Enhanced Barrier Precautions (EBP). During an interview, the LPN stated she believed PPE was only required when providing treatments such as cleaning the PEG tube area and acknowledged she should have worn PPE during PEG tube medication administration. In a subsequent interview, the Infection Preventionist and the DON confirmed that staff are required to wear PPE when administering medications to residents with PEG tubes and that staff had been trained on this requirement, including at a recent skills fair. Review of the facility’s policy on Enhanced Barrier Precautions and Isolation Procedures indicated that the facility is to use Standard Precautions, EBP, and Transmission-Based Precautions as clinically indicated to prevent and control infectious disease, including MDROs.
Failure to Prevent Elopement and Fall-Related Injury Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for two residents identified as being at risk for accidents. One resident, who was severely cognitively impaired and assessed as high risk for elopement, was admitted to a secured unit and repeatedly expressed a desire to leave the facility. Despite multiple documented episodes of exit-seeking behavior and verbalizations about wanting to return to his previous residence, the resident's care plan lacked person-centered interventions specific to elopement risk. The resident was able to elope from the facility during the overnight shift by opening an unsecured window, which was later found to lack an alarm and could be easily opened. Video review showed that staff failed to perform required visual checks, missing 18 out of 20 opportunities to observe the resident as per the care plan. Staff interviews revealed a lack of awareness regarding the resident's elopement risk and the need for frequent checks. Another resident, who was non-ambulatory, completely dependent on staff for all activities of daily living, and had severe intellectual disability and cerebral palsy, sustained a right femur fracture after falling from the bed during care. The resident was not care planned for falls because staff believed she was unable to move herself. During care, a CNA turned the resident on her side and, while reaching for a washcloth, the resident rolled off the bed and fell face down on the floor. The incident resulted in a right femur fracture requiring surgery. The facility's investigation confirmed that the resident was not provided adequate supervision or assistance to prevent the fall during care. Both incidents demonstrate failures in the facility's implementation of policies and procedures designed to prevent accidents and ensure resident safety. The first resident's repeated exit-seeking behaviors and high elopement risk were not adequately addressed through individualized care planning or environmental safeguards, and staff did not consistently follow monitoring protocols. The second resident's complete dependence on staff was not reflected in her care plan for fall prevention, leading to inadequate supervision during a high-risk activity.
Removal Plan
- All staff in the facility and staff reporting for scheduled shifts were in-serviced on the current elopement policy and face-to-face checks for residents at risk for elopement.
- The facility reviewed all current residents and identified residents deemed to be at higher risk for elopement. These residents were placed on every one-hour face-to-face checks.
- The care plans were updated to reflect specific interventions for high elopement risks.
- An alarm was placed on R1's window and all the windows on the units were checked and locked. When windows were found to be damaged, maintenance was called for immediate repair.
- R1 was moved to another secure unit with alarm on the window and double locks on both entrances.
- All the windows on the secure unit have hard wired alarms and were tested.
- Window limiters were approved by the fire marshal and will be installed upon delivery.
- Staff interviews conducted, and in-service education and training verified.
- Staff training records reviewed and verified.
- R2's care plan was revised and updated for 2 staff members assistance with bed mobility.
- All nursing staff were trained on fall prevention during resident care. The training included not rolling the resident away from the staff's body. Ensure that the resident is in the middle of the bed before turning him/her away from your body (if you must turn the resident away from you.)
- The certified nursing assistant (CNA) involved in the fall was required to re-take new hire orientation, which included shadowing another CNA before she could return to provide resident care independently.
Failure to Provide Required Two-Person Assistance During Mechanical Lift Transfer Results in Fatal Fall
Penalty
Summary
A cognitively impaired and fully dependent resident with diagnoses including dementia, chronic kidney disease, and weight loss was admitted to the facility and required two-person assistance with a mechanical lift for all transfers, as documented in her care plan. The resident's MDS indicated complete dependence on staff for all activities of daily living, including transfers. On the day of the incident, two staff members, a CNA and an LPN, attempted to transfer the resident from her bed to a wheelchair using a mechanical lift. During the transfer, the CNA attached the sling to the lift and began raising the resident, while the LPN was occupied with another task in the room and was not in position to provide hands-on assistance as required by the care plan. As the transfer proceeded, the resident's legs slipped out of the sling, and the LPN, upon noticing this, attempted to intervene but was unable to reach the resident in time. The resident slid from the sling and fell to the floor, sustaining a subdural hematoma and two scalp lacerations. Both staff members confirmed in their statements that the LPN did not have hands on the resident during the lift, and the CNA was behind the lift, attempting to maneuver it. The facility's fall prevention policy required adequate supervision and adherence to care plans specifying two-person, hands-on assistance during mechanical lift transfers, which was not followed in this instance. Following the fall, the resident was found with significant head bleeding and was emergently transferred to the hospital, where she was diagnosed with an intracranial traumatic hemorrhage and large scalp lacerations. The resident was placed on comfort care and subsequently expired at the hospital. The failure to provide the required two-person, hands-on assistance during the mechanical lift transfer directly resulted in the resident's fall and fatal injuries.
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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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