Excelcare At Newark Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Newark, Delaware.
- Location
- 4949 Ogletown-stanton Road, Newark, Delaware 19713
- CMS Provider Number
- 085025
- Inspections on file
- 20
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Excelcare At Newark Llc during CMS and state inspections, most recent first.
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.
A cognitively intact resident reported, through a family grievance and subsequent interviews, that a male CNA entered her room at night to check her incontinence status, returned after she refused care, and made an inappropriate sexual remark, with a state police report noting she may have been touched inappropriately. The facility’s grievance documentation was incomplete, with a missing page and no retained copy by the AD, and the DON reported first learning of the allegation only when law enforcement arrived. The internal investigation focused on a single inappropriate remark and used only broad, general questions with the resident, her roommate, and other residents, without targeted questions about possible sexual abuse, unwanted touching, or sexual advances, resulting in a failure to thoroughly investigate the alleged abuse as required by facility policy.
Two residents with complex medical conditions had current admission records and physician orders indicating Full Code status, yet their care plans continued to list DNR under psychosocial well-being. Quarterly MDS assessments showed one resident was cognitively intact and the other had moderately impaired cognition. During interviews, an LPN and the ADON confirmed that the care plans were incorrect and acknowledged that nurses and unit managers were responsible for updating them, contrary to facility policy requiring care plans to be revised when resident information or condition changes.
A resident with cerebrovascular disease, hemiplegia, gait abnormalities, and a history of falls, who was totally dependent for ADLs and care planned for two-person Hoyer lift transfers, was transferred by a CNA using a Hoyer lift without the required second staff member. During the transfer from bed to a shower stretcher, the CNA had to repeatedly reposition the lift while the resident swung in the lift sheet and held onto the lift with one arm. An LPN later stated the resident was care planned for two-person assistance and had assumed another staff member was present, while the CNA admitted she knew two-person assistance was required but proceeded alone because other staff were busy.
A resident with a history of femur fracture developed acute shortness of breath and low oxygen saturation, but nursing staff failed to consistently assess, monitor, or document vital signs and did not promptly notify the provider or initiate emergency care. Despite observable respiratory distress and declining oxygen levels, interventions were delayed and inconsistently applied, resulting in the resident being transferred to the hospital unresponsive, where she later expired.
A resident admitted with metastatic cancer was not allowed to sign multiple consent forms, despite an initial assessment indicating normal cognitive function. Instead, a friend and staff signed the consents, based on a later BIMS score showing moderate impairment. Staff relied on incomplete information and did not verify the resident's cognitive status or responsible party, resulting in the resident's exclusion from important care decisions.
A resident with a history of femur fracture experienced new shortness of breath and low oxygen saturation, leading staff to initiate oxygen therapy and call EMS. Despite these significant changes, there was no evidence that the physician was consulted or notified, as confirmed by record review and staff interviews.
A resident's care plan conference was conducted without participation or input from a Physician, Nurse Practitioner, or Physician Assistant. Only social services, an LPN, and a therapy staff member attended, with the dietician providing input in advance. The provider did not participate or contribute, and any concerns raised would be relayed after the conference.
A resident admitted with metastatic prostate cancer did not have a completed and signed admission agreement due to being asleep or too tired during multiple attempts, and the agreement remained incomplete until the resident's death. The medical record was missing this legal document, which should have outlined rights, facility policies, and services.
The facility failed to ensure adequate supervision and a safe environment for two residents, leading to accidents and injuries. One resident fell and sustained facial bone fractures due to inadequate support during bed mobility. Another resident was exposed to tripping hazards from fall mats left on the floor while in a wheelchair, contrary to their care plan.
The facility failed to ensure proper sanitation practices and food storage. Observations included a dietary aide without proper coverings, a lack of paper towels at the hand washing sink, and unlabeled containers in the freezer. Additionally, the dishwashing machine did not reach the required temperature for sanitization, and no chemical sanitization was attached.
The facility failed to meet professional standards by allowing LPNs to complete admission assessments and progress notes for five residents, tasks that should have been performed by RNs according to Delaware State regulations. Interviews revealed confusion among staff regarding proper procedures for completing admission paperwork.
The facility failed to honor the care preferences of three residents, leading to deficiencies in resident self-determination and choice. One resident was forced to receive care despite refusal, another did not receive scheduled showers due to conflicting dialysis appointments, and a third had inconsistent shower provision with inadequate documentation.
The facility failed to provide evidence that a resident or her responsible party was notified of Medicare non-coverage prior to discharge. The resident had moderate cognitive impairment and was admitted with ataxia and weakness. The absence of a Notice of Medicare Non-Coverage (NOMNC) form was confirmed during an interview with the NHA and reviewed with other staff and Ombudsman representatives.
A resident reported an allegation of physical abuse by someone posing as an aide while in the hospital. The facility's investigation lacked documented evidence of attempts to interview the resident in the hospital, the hospital staff, and specific residents. Additionally, the facility's Verification of Investigation form was incomplete, missing critical elements and signatures from key personnel.
The facility failed to accurately complete resident assessments for three residents. One resident's need for continuous oxygen was not documented in the MDS assessment, another resident's Parkinson's Disease was omitted from the admission MDS, and a third resident's pressure ulcer was not recorded in the discharge MDS. These errors were confirmed by staff and reviewed with facility leadership and Ombudsman representatives.
The facility failed to revise care plans for two residents to reflect their current care needs, including restorative walking services and monitoring for nephrostomy tube dislodgement, despite multiple hospitalizations.
The facility failed to properly plan and execute the discharge process for a resident with ataxia and weakness, leading to inadequate care and multiple falls post-discharge. The resident's functional abilities were not accurately assessed, and the caregiver was not adequately informed about the resident's care needs, resulting in a readmission to the hospital.
A resident who experienced a fall resulting in multiple wounds was discharged without proper documentation of wound care treatment orders in the discharge summary. This omission was confirmed by a registered nurse and reviewed with facility administrators.
A resident's care plan required daily ambulation with a walker, but documentation and interviews revealed inconsistent assistance with walking. The resident reported irregular walking therapy, and an RN unit manager confirmed aides sometimes marked tasks as 'not applicable' without proper verification. These findings were reviewed with facility leadership and Ombudsman representatives.
The facility failed to complete AIMS assessments for a resident on anti-psychoactive medications and did not effectively monitor another resident for side effects related to antipsychotic medication use. Additionally, a resident missed seven doses of Olanzapine due to a lapse in pharmacy delivery, and the facility did not follow its pharmacy policy.
The facility failed to ensure that residents received the selected food and drinks from the menu as indicated on their meal tickets. During random dining observations, it was noted that one resident did not receive cranberry juice or sautéed spinach for lunch, and another resident did not receive oatmeal for breakfast. These discrepancies were confirmed by the staff members present at the time.
A facility failed to create an accurate care plan for a resident on IV antibiotics for endocarditis, incorrectly identifying the diagnosis as sepsis and omitting specific details about the IV access and antibiotic therapy. This was identified during a record review and discussed with facility administrators and Ombudsman representatives.
A resident with normal cognition experienced distress when the nebulizer facemask was left on for over an hour after a treatment. Despite multiple calls for help, staff did not respond promptly, and the facemask was eventually removed by a nurse after a family member intervened. The facility's policy on nebulizer therapy was not followed, leading to the resident's unnecessary anxiety.
The facility failed to ensure timely transportation for a resident requiring dialysis. The resident, with end-stage renal disease, missed the scheduled pick-up for dialysis and had to wait in the lobby until an alternative ride was arranged. Staff interviews revealed confusion about transportation responsibilities, despite the facility's agreement stating it is their duty.
The facility failed to maintain an infection control program as an LPN did not disinfect a glucometer between uses on two residents, contrary to policy and manufacturer guidelines.
The facility failed to provide training for nephrostomy care, as evidenced by a resident requiring daily saline flushes performed by an LPN without specific facility training. The Staff Developer confirmed the lack of nephrostomy tube flush education for nursing staff.
The facility failed to provide a comprehensive Medication Regimen Review (MRR) policy with specific time frames for provider response to identified irregularities and a complete process for urgent action follow-up. The policy lacked critical components, leading to deficiencies in ensuring timely and appropriate responses to medication regimen review irregularities.
The facility failed to maintain a clean and sanitary environment in two shower rooms and multiple resident rooms. Observations revealed blackened substances and chipped tiles in the shower rooms, and a thick, blackened, greasy substance on the floors of several resident rooms. These findings were confirmed with facility management and reviewed with relevant staff and representatives.
The facility failed to maintain and safeguard medical records for six residents, resulting in incomplete and inaccurately documented records. Urine culture results, including organism identification and sensitivities, were not uploaded into the EMRs, making them inaccessible. This issue was confirmed through staff interviews and review of the facility's practices.
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.
Failure to Thoroughly Investigate Alleged Abuse Involving Male CNA
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into an allegation of abuse involving one cognitively intact resident. The resident was admitted with cognitive communication deficit and mild cognitive impairment but had a BIMS score of 15/15, indicating intact cognition. A grievance form documented that the resident’s son reported a male CNA entered the resident’s room in the middle of the night stating he needed to check if she was wet, that the resident refused, and that the aide later returned and she again refused. The grievance form provided by the facility was missing its second page, and the Admissions Director stated she did not retain a copy and had no documentation beyond what was given to the DON. The DON reported not remembering receiving the grievance and stated she first became aware of the alleged abuse when law enforcement arrived several days later. The facility’s internal investigation documentation identified that the assigned male CNA allegedly made an inappropriate verbal remark to the resident after she refused an incontinence check/change, specifically, “you don’t know what you are missing.” However, the resident interview process conducted by the facility was limited to general questions about whether residents had concerns or complaints about the CNA or whether he had been inappropriate or spoken inappropriately. The interviews did not include targeted questions related to potential sexual abuse, such as inquiries about inappropriate sexual remarks, unwanted touching, or sexual advances, despite the nature of the allegation. A state police report indicated the resident reported she may have been touched inappropriately by a staff member while he was checking her, but this level of detail was not reflected in the facility’s interview documentation. Statements from the Social Services Director showed that when the resident was interviewed, she reported that around 4:00 a.m. the prior week the aide entered her room to check her diaper, left, then returned and stated, “you don’t know what you missed.” The SSD’s documentation of these interviews focused on asking the resident if she felt safe, with limited follow-up and no additional documented questions exploring the alleged inappropriate touching or sexual nature of the remark. The roommate was only asked a single, broad question about whether she knew of any problem between the resident and the male CNA on the night shift, with no further probing questions documented. Overall, the facility’s records and interviews lacked detailed, allegation-specific questioning and complete documentation, despite a policy requiring evidence that all alleged violations are thoroughly investigated.
Failure to Update Care Plans to Reflect Current Code Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that comprehensive care plans were revised to accurately reflect residents’ current code status. For one resident with diagnoses including hemiplegia and hemiparesis following cerebrovascular disease, major depressive disorder, COPD, and thoracic spine pain, the admission record and current physician orders in the EMR identified the resident as Full Code, and the resident’s most recent MDS showed she was cognitively intact with a BIMS score of 15/15. However, the resident’s care plan, initiated earlier, continued to list an advance directive of DNR under psychosocial well-being, creating a discrepancy between the care plan and the current code status documented in the admission record and physician orders. A second resident, re-admitted with diagnoses including heart failure, stage III chronic kidney disease, malignant neoplasm of the upper lobe of the left bronchus, and pain, also had a discrepancy between the care plan and current code status. The admission record and current physician orders identified this resident as Full Code, and the quarterly MDS showed a BIMS score of 12/15, indicating moderately impaired cognition. Despite this, the resident’s care plan continued to list an advance directive of DNR. During interviews, an LPN and the ADON confirmed that the care plans for both residents were incorrect and did not reflect the current Full Code status, and acknowledged that nurses and unit managers were usually responsible for updating care plans. The facility’s policy stated that care plans must be revised as information about residents and their conditions changes, which was not followed in these cases.
Failure to Use Required Two-Person Assist for Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure a resident was safely transferred using a mechanical lift in accordance with the care plan and required supervision. The resident had cerebrovascular disease with hemiplegia and hemiparesis, abnormalities of gait, and a history of falls, and was assessed on the MDS as totally dependent on staff for ADLs and requiring Hoyer lift transfers. The resident’s care plan, revised on 10/22/24, specified the need for two staff members for bed mobility and Hoyer lift transfers. On the observed date at 10:30 AM, a CNA used the Hoyer lift alone to transfer the resident from the bed to a shower stretcher. During this transfer, the CNA had to reposition the lift several times to move it closer to the stretcher, and the resident was swinging in the lift sheet and holding onto the lift with his functional arm. Later interviews confirmed that the LPN was aware the resident was care planned for two-person assistance and had assumed another staff member was present, while the CNA acknowledged she knew the resident required two-person assistance but proceeded alone because she found it difficult to get help as other staff were busy and recognized that what she did was wrong.
Failure to Assess and Respond to Acute Respiratory Distress
Penalty
Summary
A deficiency occurred when a resident with a history of a right femur fracture experienced a significant change in condition, specifically acute shortness of breath, during the early morning hours. Despite the resident's complaints and observable respiratory distress, there was a lack of timely and thorough assessment by nursing staff. Vital signs and oxygen saturation were either not monitored or not documented, and there was no evidence that the medical provider was promptly consulted during the initial onset of symptoms. The resident's oxygen saturation dropped to critically low levels, and interventions such as oxygen therapy were inconsistently applied and not properly documented. Multiple staff interviews revealed that although the resident was placed on oxygen and her condition was recognized as serious, there was confusion and delay in escalating care. Staff could not recall exact times of interventions, and several admitted to not documenting vital signs or assessments. The resident's respiratory status continued to deteriorate, and only after a significant delay was emergency medical assistance requested. When EMS arrived, the resident's oxygen saturation remained low, and she was ultimately transferred to the hospital unresponsive, where she later expired. The facility's own documentation and staff statements indicated a failure to follow established protocols for monitoring, assessment, and timely notification of changes in resident condition. There was also a lack of adherence to training regarding oxygen therapy and emergency response. These failures led to an Immediate Jeopardy finding due to the inadequate response to the resident's acute respiratory distress and the absence of appropriate clinical interventions and documentation.
Removal Plan
- Licensed nursing staff were re-educated on recognition of respiratory distress, respiratory assessments, including vital signs and oxygen saturation, initiation and monitoring of oxygen therapy, and provider notification
- Residents were screened by licensed nursing staff for respiratory distress
- Residents identified with respiratory distress were assessed and interventions were implemented
Failure to Support Resident Self-Determination in Consent Process
Penalty
Summary
A deficiency occurred when the facility failed to promote and facilitate a resident's right to self-determination regarding the signing of multiple consents upon admission. The resident was admitted with diagnoses including prostate cancer with metastasis to the bone and brain and was listed as his own responsible party. Documentation showed conflicting cognitive assessments: a speech therapy evaluation recorded a BIMS score of 14/15 (normal cognition), while a subsequent BIMS by a social worker and the admission MDS both recorded a score of 10/15 (moderate impairment). Despite the initial indication of cognitive intactness, the facility allowed a friend (not a legal representative) and staff to sign various consent forms, including those for CPR/DNR, treatment, care management, and vaccinations, rather than obtaining the resident's own signature. Staff interviews revealed that the admitting nurse did not obtain the required consents, and another nurse completed them later, relying on the lower BIMS score to justify not seeking the resident's signature. The nurse was unaware of the higher BIMS score documented by speech therapy and stated that she was told the friend was the resident's brother, which was later found to be untrue. The facility's failure to verify the resident's cognitive status and responsible party status led to the omission of the resident's participation in consent decisions, thereby not supporting the resident's right to self-determination.
Failure to Notify Physician of Resident's Respiratory Distress and Oxygen Initiation
Penalty
Summary
A deficiency was identified when the facility failed to consult with a resident's physician after the resident experienced a new onset of shortness of breath and required initiation of oxygen therapy. The resident, who had been admitted with a right femur fracture, was noted by a certified occupational therapy assistant to have labored breathing and an oxygen saturation of 89%, resulting in a shortened therapy session. There was no documentation in the clinical record that the medical provider was notified of this change in condition. Subsequently, nursing staff responded to the resident's complaint of difficulty breathing, observed an oxygen saturation of 88%, and initiated oxygen therapy at 2 liters per minute. Later, emergency medical services were called, and the resident was placed on 5 liters per minute of oxygen via a non-rebreather mask. Interviews with staff confirmed that the resident's complaints and low oxygen saturation were observed and reported among staff, but there was no evidence that the physician was consulted at any point during these events. The deficiency was confirmed through record review and staff interviews, and findings were reviewed with facility leadership during the exit conference.
Failure to Ensure Full IDT Participation in Care Plan Conference
Penalty
Summary
The facility failed to ensure that all required interdisciplinary team (IDT) members contributed to the care plan conference for one resident reviewed for death. Review of the resident's clinical record showed that the Care Conference Summary was unsigned and incomplete, lacking documentation of input from a Physician, Nurse Practitioner, or Physician Assistant. Only social services, an LPN/Charge Nurse, and a therapy staff member attended the care plan conference, with the dietician providing input ahead of time due to absence. Interviews confirmed that the provider did not participate in the conference or provide input, and any concerns raised by the resident during the conference would only be shared with the provider afterward. The deficiency was confirmed during interviews and record review, with no evidence that all required IDT members contributed to the resident's care plan conference.
Incomplete Admission Agreement for Deceased Resident
Penalty
Summary
A deficiency was identified when a resident admitted with advanced prostate cancer and metastases to the bone and brain did not have a completed and signed admission agreement upon entry to the facility. The resident was admitted on a Friday evening shift and was listed as his own responsible party. Attempts to complete the admission agreement were unsuccessful: the resident was asleep during the initial attempt, remained asleep during a follow-up, and later refused due to fatigue. The admission packet remained incomplete and unsigned up to the time of the resident's death. Additionally, the hospital facesheet listed two individuals as siblings, but it was later discovered they were not family members, and the resident's actual brother was only identified on the day of death. As a result, the resident's medical record lacked a completed and signed admission packet, which is a legal document outlining resident rights, facility policies, and healthcare services to be provided.
Failure to Ensure Resident Safety and Adequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and a safe environment for two residents, leading to accidents and injuries. One resident, admitted with a history of falls and a broken pelvis, was care planned for extensive assistance with bed mobility and other activities of daily living. Despite this, a CNA unfamiliar with the resident's needs did not provide the necessary support during a bed mobility task, resulting in the resident rolling off the bed and sustaining facial bone fractures. The CNA admitted to not holding or supporting the resident during the turn, which directly led to the fall and subsequent injury. Another resident, with diagnoses including dementia, schizoaffective disorder, and impaired mobility, was observed multiple times with fall mats placed on the floor while the resident was in a wheelchair. The resident's care plan specified that fall mats should only be on the floor when the resident was in bed. Despite this, staff consistently left the fall mats on the floor, creating a tripping hazard. Interviews with staff revealed a misunderstanding of the care plan, as they believed the mats were a precautionary measure regardless of the resident's position. The facility's failure to adhere to care plans and provide appropriate supervision and environmental safety measures resulted in significant risks and actual harm to the residents. The incidents were reviewed with facility leadership and representatives from the Ombudsman Office, highlighting the need for better adherence to care plans and staff training on resident-specific needs and safety protocols.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper sanitation practices and food storage in accordance with professional standards. During an initial kitchen tour, it was observed that a dietary aide did not have a hair net or beard covering, the hand washing sink lacked paper towels, and the walk-in freezer contained unlabeled and undated containers of soup and gravy. These findings were immediately confirmed with the Dietary Services Director (E42). Additionally, the facility did not ensure that dishes were chemically sanitized when the dishwashing machine temperatures failed to reach the required level for heat sanitization. During a follow-up kitchen tour, it was observed that the dishwashing machine's wash cycle was at 130°F, below the required 140°F, and no chemical sanitization was attached. The Dietary Services Director confirmed the absence of the sanitizing agent and subsequently attached a replacement sanitizer/bleach to the machine. These findings were reviewed with the Nursing Home Administrator, Director of Nursing, Corporate Clinical Operations, Regional Clinical Specialist, and representatives from the Ombudsman Office.
Failure to Adhere to Delaware Board of Nursing Scope of Practice
Penalty
Summary
The facility failed to meet professional standards of the Delaware Board of Nursing Scope of Practice by allowing Licensed Practical Nurses (LPNs) to complete the admission assessments and admission progress notes for five residents. According to Delaware State regulations, Registered Nurses (RNs) are required to perform these tasks. The deficiency was identified through a review of clinical records and interviews with staff members. Specifically, LPNs completed the clinical admission forms, elopement risk evaluations, fall risk evaluations, dehydration risk evaluations, and Braden scale assessments for residents R37, R63, R96, R446, and R447. Additionally, LPNs wrote the clinical admission notes for these residents, which is also a task that should have been performed by an RN as per state regulations. Interviews with staff members revealed a lack of clarity and adherence to the proper procedures for completing admission paperwork. One LPN confirmed completing the admission process for two residents, while another LPN stated that the nurse assigned to the room of the new admit patient completes the admission process paperwork. The RN Unit Manager explained that the unit manager or nursing supervisor is supposed to complete the admission process, depending on the shift. However, the Assistant Director of Nursing (ADON) was unaware of the state-required RN admission assessment and deferred to the Director of Nursing (DON) for clarification. These findings were reviewed with the Nursing Home Administrator (NHA), DON, Corporate Clinical Operations, Regional Clinical Specialist, and representatives from the Ombudsman office.
Failure to Honor Resident Care Preferences
Penalty
Summary
The facility failed to honor the care preferences of three residents, leading to deficiencies in resident self-determination and choice. One resident, admitted with a stroke and aphasia, was forced to receive care from a CNA despite indicating refusal through gestures. The CNA insisted on providing care, causing the resident distress, and other staff members confirmed the resident's refusal and the CNA's aggressive behavior. This incident highlighted the facility's failure to respect the resident's right to refuse care and choose their caregiver. Another resident, admitted with end-stage renal disease and on hemodialysis, reported only being bathed once since admission, despite having scheduled showers. The resident's dialysis schedule conflicted with the assigned shower times, and the facility's documentation confirmed that the resident was often unavailable for showers due to dialysis appointments. The facility did not adjust the shower schedule to accommodate the resident's needs, resulting in inadequate personal hygiene care. A third resident, admitted with a left kneecap fracture, had scheduled showers that were not consistently provided. The resident's medical records showed instances where showers were either refused or not given, and there was a lack of documentation indicating that the nurse was informed of these occurrences. The facility failed to ensure that the resident received the scheduled showers and did not properly document the refusals or missed showers, leading to a deficiency in care provision.
Failure to Provide Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide evidence that a resident or her responsible party was notified of Medicare non-coverage prior to her discharge. The resident was admitted with diagnoses including ataxia and weakness and had a BIMS score indicating moderate cognitive impairment. Despite these conditions, the facility did not have a Notice of Medicare Non-Coverage (NOMNC) form for the resident at the time of her discharge. This deficiency was confirmed during an interview with the Nursing Home Administrator and reviewed with other facility staff and representatives from the Ombudsman office.
Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse made by a resident (R100) who was cognitively intact, as indicated by a BIMS score of 13. The resident was sent to the hospital for an unrelated medical reason, where she reported an allegation of physical abuse by someone posing as an aide. The facility's documentation included a typed statement of a conversation between the resident's family member and the DON, transcribed statements from 14 nursing staff, progress notes, and abuse in-service sign-in sheets. However, the investigation lacked documented evidence of attempts to interview the resident in the hospital, the hospital nursing staff to whom the allegation was made, and specific residents interviewed as part of the investigation. Additionally, the facility's Verification of Investigation form was incomplete, missing critical elements such as a summary of factual investigative findings and signatures from the DON and Executive Director. Despite the facility's efforts to gather information from staff and other residents, there was no documented evidence of a thorough investigation into the specific details of the abuse allegation. The facility did not attempt to interview the resident in the hospital or the hospital staff who received the initial report. Furthermore, the facility's documentation did not include a completed Verification of Investigation form, which should have contained a summary of the investigation, contributing factors, interventions, and signatures from key personnel. This lack of thorough documentation and follow-up indicates a failure to properly address and investigate the abuse allegation made by the resident.
Failure to Accurately Complete Resident Assessments
Penalty
Summary
The facility failed to accurately complete resident assessments for three residents. For one resident, a physician's order indicated the need for continuous oxygen, but the quarterly MDS assessment incorrectly documented that oxygen was not in use, despite daily administration as recorded in the MAR. This error was confirmed by the RNAC during an interview. Another resident, admitted with Parkinson's Disease, had physician's orders for specific medications and a care plan addressing the condition. However, the admission MDS assessment did not include Parkinson's Disease under the Neurological Diagnoses section, an omission confirmed by the RNAC in an interview. A third resident, admitted with multiple diagnoses including diabetes and dementia, had a documented pressure ulcer that was not accurately reflected in the discharge MDS assessment. The resident's medical records detailed the presence and progression of a sacral wound, which was noted by the Wound MD as an unavoidable stage 3 pressure injury. Despite this, the discharge MDS assessment failed to document the pressure ulcer, an error confirmed by the MDS Coordinator. These findings were reviewed with the facility's NHA, DON, Corporate Clinical Operations, Regional Clinical Specialist, and representatives from the Ombudsman Office.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plan to reflect the current care needs for two residents. For one resident, the clinical record indicated that the resident received restorative services for walking training and range of motion (ROM). However, the care plan did not include interventions related to walking, despite the CNA Task list indicating the resident should participate in a restorative walking program. This discrepancy was confirmed by the unit manager during an interview. For another resident, who was admitted with multiple diagnoses including kidney cancer and chronic kidney disease, the care plan was not updated to reflect the monitoring for nephrostomy tube dislodgement. This resident had multiple hospitalizations due to the nephrostomy tube becoming dislodged, yet the care plan did not include these incidents. This was confirmed by an LPN during an interview. The findings were reviewed with the nursing home administrator, director of nursing, corporate clinical operations, regional clinical specialist, and representatives from the Ombudsman Office.
Inadequate Discharge Planning and Communication
Penalty
Summary
The facility failed to adequately plan and execute the discharge process for a resident (R96) with ataxia and weakness, who had moderate cognitive impairment. The resident's functional abilities were not properly assessed, and the caregiver's availability and capability to perform required care were not considered. The facility did not re-evaluate and update the resident's changing needs, nor did it show evidence of the Interdisciplinary Team (IDT) involvement in the discharge process. Additionally, the facility failed to document community referrals and contact information for the resident's post-discharge care. The resident's clinical records indicated that the resident required substantial assistance with toileting and mobility at the time of admission, but the discharge goals were set unrealistically high, aiming for independence. In the week prior to discharge, the resident's functional abilities fluctuated significantly, requiring varying levels of assistance. Despite these fluctuations, the facility did not adequately educate the resident's caregiver about the resident's current mobility levels and care needs. The caregiver was not informed about the need for new equipment or the resident's medication requirements, leading to multiple falls and a subsequent readmission to the hospital. Interviews with facility staff revealed that the social worker responsible for the discharge process left the facility abruptly on the day of discharge, and there was no documentation of the home care agency's contact information in the discharge plan. The granddaughter of the resident reported that she was not contacted to discuss the discharge plans and was not provided with necessary information about the resident's care needs. The facility's failure to properly plan and communicate the discharge process resulted in inadequate care and safety for the resident post-discharge.
Failure to Document Post-Discharge Wound Care Instructions
Penalty
Summary
The facility's discharge summary failed to accurately capture and document a resident's post-discharge plan of care. The resident was admitted to the facility from the hospital and later experienced an unwitnessed fall resulting in a skin tear to the left arm and lacerations to the left eye and cheek. Physician's orders were given for wound care, including monitoring steri strips, cleansing the skin tear with soap and water, applying bacitracin, and covering with a dry dressing. However, upon discharge, the discharge instructions and post-discharge plan of care form lacked documentation of these wound care treatment orders. This omission was confirmed during an interview with a registered nurse and reviewed with facility administrators and representatives from the Ombudsman Office.
Inconsistent Restorative Services for Resident
Penalty
Summary
The facility failed to ensure that a resident received consistent restorative services as prescribed. The resident's care plan was updated to include participation in a restorative walking program, requiring ambulation with a walker for 30 feet daily or as tolerated. However, documentation and interviews revealed that the resident was not consistently assisted with walking on multiple dates in February. The resident expressed that receiving walking therapy had been inconsistent. An RN unit manager confirmed that aides sometimes marked tasks as 'not applicable' when they believed it was not their responsibility, and there was a lack of verification that the walking was completed. These findings were reviewed with the nursing home administrator, director of nursing, corporate clinical operations, regional clinical specialist, and representatives from the Ombudsman Office.
Failure to Complete AIMS Assessments and Medication Administration Lapses
Penalty
Summary
The facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident (R2) taking anti-psychoactive medications. Despite a documented requirement for quarterly AIMS evaluations, the clinical record lacked evidence of such an evaluation for October 2023. Interviews with the RN and DON confirmed the absence of the required AIMS assessment for R2, who was on Seroquel for major depressive disorder and delusions. This oversight indicates a failure to monitor for adverse side effects as per the facility's policy and recognized standards of practice. Additionally, the facility did not effectively monitor another resident (R198) for side effects related to antipsychotic medication use, as AIMS testing was not completed from November 2022 to May 2023. Furthermore, R198 missed seven doses of Olanzapine due to a lapse in pharmacy delivery. The facility's pharmacy policy was not followed, and the facility only utilized one pharmacy, which led to the medication unavailability. Interviews with the DON and an LPN confirmed the medication was not administered due to the delay in delivery, and the facility was in the process of setting up a backup pharmacy system.
Failure to Provide Menu-Selected Food and Drinks
Penalty
Summary
The facility failed to ensure that residents received the selected food and drinks from the menu as indicated on their meal tickets. During a random dining observation, it was noted that one resident did not receive cranberry juice or sautéed spinach for lunch, and another resident did not receive oatmeal for breakfast. These discrepancies were confirmed by the staff members present at the time. The findings were reviewed with the Nursing Home Administrator, Director of Nursing, Corporate Clinical Operations, Regional Clinical Specialist, and representatives from the Ombudsman Office.
Inaccurate Care Plan for Resident on IV Antibiotics
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that accurately reflected a resident's medical needs. The resident was admitted with diagnoses including heart disease and anxiety and was on IV antibiotics for endocarditis. However, the care plan incorrectly identified the diagnosis as sepsis, despite a negative blood culture indicating no active sepsis. The care plan also lacked specific details about the IV access location and type, as well as the specific antibiotic and its duration. These deficiencies were identified during a review of the resident's records and discussed with facility administrators and representatives from the Ombudsman office.
Failure to Provide Proper Nebulizer Treatment
Penalty
Summary
The facility failed to provide care consistent with professional standards regarding a resident's albuterol nebulizer treatment. The resident, who had normal cognition, was prescribed albuterol sulfate inhalation nebulization solution to be administered four times a day. On one occasion, the resident's family member reported that the nebulizer facemask was left on the resident's face for over an hour, causing the resident to become anxious. The resident's roommate confirmed the incident, stating that after the resident's evening nebulizer treatment, the facemask was left on for an extended period, and despite calling for help multiple times, no staff responded promptly. Eventually, the roommate had to call a family member to contact the front desk, after which a nurse came in and removed the facemask without explanation. The incident was corroborated by the resident during an interview, who confirmed that the facemask was left on for over 45 minutes. The facility's policy on nebulizer therapy states that treatments should be administered by nursing staff using proper technique and standard precautions, and the treatment should be considered complete with the onset of nebulizer sputtering. The failure to adhere to this policy resulted in the resident experiencing unnecessary distress. The findings were reviewed with the nursing home administrator, director of nursing, corporate clinical operations, regional clinical specialist, and representatives from the Ombudsman office.
Failure to Ensure Timely Transportation for Dialysis
Penalty
Summary
The facility failed to ensure that a resident's transportation needs related to dialysis were met. The resident, who was admitted with end-stage renal disease requiring hemodialysis, had a care plan indicating dialysis appointments on Mondays, Wednesdays, and Fridays with a scheduled pick-up time between 6:00 and 6:30 AM. On the day of the incident, the resident was observed sitting in the facility lobby at 7:15 AM because the arranged transportation did not arrive. The facility had to arrange an alternative ride, and the resident was eventually driven to the dialysis treatment in the facility bus at 9:35 AM. Interviews with staff revealed confusion regarding the responsibility for arranging dialysis transportation. The Assistant Director of Nursing stated that the hospital arranges transport for the first two weeks post-discharge, after which it becomes the dialysis center social worker's responsibility. However, the facility's Long Term Facility Outpatient Dialysis Services Coordination Agreement clearly states that the long-term care facility is responsible for arranging suitable and timely transportation for dialysis. This discrepancy led to the failure to ensure timely transportation for the resident's dialysis treatment.
Failure to Disinfect Glucometer
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program as evidenced by the improper disinfection of a glucometer. During a medication observation, an LPN obtained a blood glucose level on one resident using a glucometer and did not clean or disinfect the device after use. Shortly after, the same LPN used the uncleaned glucometer on another resident. The LPN confirmed the failure to disinfect the glucometer after use. The facility's policy and the manufacturer's guidelines both require the glucometer to be cleaned and disinfected after each use to prevent cross-contamination.
Failure to Provide Nephrostomy Care Training
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for staff, as evidenced by the absence of nephrostomy care on the Nursing Orientation Check List. A resident with kidney cancer and chronic kidney disease, who had a nephrostomy tube placed, required daily saline flushes. Despite a physician's order for this procedure, an LPN admitted to performing the flush without receiving specific training from the facility, relying instead on prior experience from another facility. The Staff Developer confirmed that nephrostomy tube flush education had not been provided to the nursing staff. These findings were reviewed with the Nursing Home Administrator, Director of Nursing, Corporate Clinical Operations, Regional Clinical Specialist, and representatives from the Ombudsman office.
Failure to Provide Comprehensive Medication Regimen Review Policy
Penalty
Summary
The facility failed to provide a Medication Regimen Review (MRR) policy with specific time frames for response from the provider for identified irregularities and a complete process for following up on urgent action irregularities. The policy, dated 4/1/20, lacked stated time frames for provider response to pharmacist-identified irregularities and did not include a complete process for urgent action irregularities, such as time frames for informing the provider of the urgent finding and steps to take if the provider fails to respond within a designated time frame. This deficiency was identified through record review and interviews with facility staff, including the Nursing Home Administrator (NHA), Director of Nursing (DON), Corporate Clinical Operations, Regional Clinical Specialist, and representatives from the Ombudsman office. The surveyor reviewed the MRR policy and found that while the policy required the pharmacist to communicate recommendations and identified irregularities within 10 working days and to inform the DON or designee verbally for urgent action irregularities, it did not specify the time frames for provider response or the complete process for urgent action follow-up. The facility was unable to provide evidence of these critical components in their MRR policy, leading to the determination that the facility failed to ensure a comprehensive and timely response to medication regimen review irregularities, particularly those requiring urgent action to protect residents.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to provide a clean and sanitary environment in two shower rooms and multiple resident rooms. During an observation of the East and [NAME] wings shower rooms, several large areas of a blackened substance were observed where the walls met the tiles, along with multiple areas of chipped and broken floor and wall tiles. Additionally, an environmental tour revealed that the floors in rooms E101 through E122 and W101 through W122 were coated with a thick, blackened, greasy substance. These findings were confirmed with the Corporate Resource Manager and the Maintenance/Housekeeping Director, and were reviewed with the Nursing Home Administrator, Director of Nursing, Corporate Clinical Operations, Regional Clinical Specialist, and representatives from the Ombudsman Office.
Failure to Maintain and Safeguard Medical Records
Penalty
Summary
The facility failed to maintain and safeguard medical records information on six residents, resulting in incomplete, inaccurately documented, and not readily accessible records. For Resident 98, the facility lacked evidence of the admission agreement upon admission. For Residents 42, 63, 76, 107, and 108, the electronic medical records (EMRs) did not have readily accessible documentation of urine culture results, including the organism and sensitivities, which are crucial for identifying the appropriate antibiotic treatment. The facility was able to produce printouts from the laboratory's website upon the surveyor's request, but these results were not uploaded into the EMRs, and only a limited number of people had access to the laboratory's website. This lack of documentation in the EMRs was confirmed through interviews with facility staff, including the Nursing Home Administrator (NHA) and other clinical operations personnel. The surveyor's review revealed that the facility's failure to upload urine culture results into the EMRs led to incomplete medical records for the affected residents. This deficiency was observed in multiple cases where urine cultures indicated the presence of Klebsiella species, including Klebsiella oxytoca ESBL and Klebsiella pneumoniae ESBL. The surveyor noted that the facility's practice of not uploading these results into the EMRs hindered the accessibility and completeness of the residents' medical records. The findings were reviewed with the NHA, Director of Nursing (DON), Corporate Clinical Operations, Regional Clinical Specialist, and representatives from the Ombudsman, who acknowledged the issue.
Latest citations in Delaware
Three residents who were dependent on staff for bed mobility and transfers did not receive adequate supervision and safe handling during care and transfers, resulting in serious injuries. A resident who was totally dependent for bed mobility slid from the bed to the floor while a CNA focused on gathering supplies during care, later being found to have an ankle fracture. Another resident with a prior brain bleed, craniotomy, and left-sided paralysis, requiring a mechanical lift with two staff, sustained a head injury when a Hoyer lift was improperly positioned or controlled during transfer from a shower bed to a wheelchair, causing the lift bar to strike the top of the head and leading to ongoing head and neck pain. A third resident needing extensive assistance fell between a shower bed and her regular bed when a CNA attempted to transfer her without locking the shower bed wheels, resulting in acute L2–L3 compression fractures confirmed by CT.
A resident who required set-up assistance for eating spilled coffee onto bare upper thighs while being prepared for morning care, initially resulting in nonblanchable redness with intact skin and no reported pain. During later incontinence care, staff identified a broken blister on the resident’s right upper thigh, cleansed the area, and applied skin prep, but did not notify the MD until more than a day after the blister was first noted. An NP confirmed that although she had been informed of the coffee spill itself, there was no documentation that the subsequent change in skin condition had been communicated to a provider, resulting in a failure to promptly notify the on-call provider of the new skin alteration.
A resident with significant neurologic impairment and multiple contractures slid from bed and was assisted to the floor during the night shift, but an RN did not complete the initial post-fall assessment until the following day shift. An LPN documented that the resident was seated after the event, denied pain, had ROM and VS assessed, and was assisted back to bed with a CNA. The DON later reported that the CNA and LPN did not report the event as a fall because the resident was assisted down, and the LPN stated she relied on the CNA’s account when completing the incident report and was unsure if the RN had been notified.
A resident reported an allegation of physical abuse by a CNA during the night shift, which was documented in the clinical record. Facility policy required that all alleged violations be reported to the Administrator, state agency, APS, and other required agencies immediately but no later than two hours after the allegation. Instead, the allegation was reported to the state agency approximately nine hours after it was made. An RN acknowledged not reporting the allegation right away and waiting for the day shift, and the DON confirmed that the reporting timeframe was not followed.
A resident with dementia and a care plan for false accusations alleged physical abuse by a CNA. Facility policy required staffing or room changes to protect residents from an alleged perpetrator, but the CNA remained on duty providing care to other residents for the rest of the shift. An LPN and an RN confirmed that the CNA continued working with residents, with the CNA only being stopped from caring for the accusing resident’s room, resulting in a failure to fully implement the abuse protection policy.
A resident with CHF and kidney disease requiring dialysis was admitted and assessed as having congestive heart failure, but the baseline care plan lacked CHF-related interventions and there was no timely physician order for fluid restriction despite a nutrition assessment referencing a 1500 mL limit. A physician note identified the resident as high risk for rehospitalization and called for strict I&O and daily weights, yet a formal fluid restriction order was not entered until several days later, only after the responsible party requested it. The next day, the resident was sent to the hospital from dialysis for chest pain and shortness of breath. In interviews, the MD, RN, and DON all confirmed the resident should have been placed on fluid restriction and monitoring upon admission and that this was not done in a timely manner.
Surveyors found that dietary staff repeatedly failed to wear required hair and beard restraints while preparing food, washing dishes, and serving meals, and the Dietary Manager acknowledged that restraints should be worn at all times but that the facility had run out of them. These unsanitary practices occurred during routine kitchen operations and affected nearly all residents who received meals from the kitchen, with only two residents receiving nutrition via feeding tubes.
Surveyors found that medication carts were left unlocked and unattended in two separate locations. One cart on a hall outside a resident room was left unlocked while an LPN was inside the room with the privacy curtain pulled and unable to see the cart, with only a CNA present further down the hall. Another cart at the nurses’ station, shared by nurses on two halls, remained unlocked while the ADON walked past it twice and then left the area, leaving no one at the station until returning several minutes later to lock it. Facility policy required all medication and treatment carts to be locked when not in use and not left unattended while unlocked.
The facility did not provide required written information on advance directives and the right to accept or refuse medical and surgical treatment to two residents, one cognitively intact and one with moderately impaired cognition, as confirmed by EMR review showing no such documentation. The SSD reported having no written materials explaining types of advance directives or any signature page confirming verbal explanations or resident understanding. The AD stated the admission packet only asked whether a resident had or wanted an advance directive and did not include written definitions or explanations. The Administrator acknowledged being unaware of regulatory requirements and of the facility policy, which states that residents have the right to formulate an advance directive and to accept or refuse treatment, and that written information must be provided in an easily understood manner.
A cognitively intact resident with mild cognitive impairment reported to her son that a male CNA entered her room at night to provide incontinent care, which she refused, and that he returned and made an inappropriate sexualized remark when she again refused care. The son called the facility to report the concern, and the Admissions Director stated she immediately informed the DON, in line with protocol to notify leadership of abuse-related grievances. However, the DON reported she did not recall receiving the grievance and only became aware of the allegation when law enforcement arrived several days later after receiving a family complaint. The DON confirmed that the SSA was not notified of the abuse allegation until four days after the initial grievance, despite facility policy and leadership acknowledging that alleged abuse must be reported to the SSA within two hours.
Failure to Provide Adequate Supervision and Safe Transfers Resulting in Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate assistance and supervision to prevent accidents for three residents who were dependent on staff for mobility and transfers. One resident with anoxic brain injury, multiple contractures, abnormal posture, and idiopathic progressive neuropathy was documented on multiple MDS assessments as requiring substantial/maximal assistance for bed mobility and was described by nursing and therapy staff as totally dependent and unable to move or roll in bed without physical assistance. During nighttime care, a CNA entered the room in response to a call light, found that the resident had vomited, and focused on looking for towels while standing on one side of the bed. The CNA reported that the resident then began sliding off the opposite side of the bed; the CNA ran around the bed but was unable to prevent the resident from sliding off, and instead lowered the resident to the floor in a seated position. Subsequent imaging confirmed a stable right ankle fracture, and interviews with the NP, OT, LPN, and other CNAs confirmed that the resident was dependent for bed mobility and could not independently roll or slide out of bed, indicating that the resident did not receive the level of hands-on assistance and supervision consistent with their documented needs. A second resident with a history of brain bleed, seizure disorder, craniotomy, and left-sided paralysis had a care plan and therapy determination requiring a mechanical (Hoyer) lift with two staff for all transfers and was completely dependent on staff for bathing and transfers. During a transfer from a shower bed back to a wheelchair using a mechanical lift, the resident reported that the hooks of the lift were not properly attached to the bars, causing the front of the lift to become unbalanced and tilt backward, dropping the resident into the chair and allowing the lift bars to strike the top of the resident’s head at the craniotomy site. The resident stated that the lift was not moving when staff attempted to place him in the chair and that this type of incident had not occurred during prior showers, when he was typically returned to his room on the shower bed and transferred in bed. One CNA described that while assisting with the transfer, the lift appeared stuck and positioned sideways over the wheelchair; when she voiced concern and attempted to correct the position, the lift rose and the bar hit the resident’s head. The other CNA involved stated that as she operated the lift controls, the resident’s weight shifted, the lift tipped back, and the bar struck the top of his head. The physician documented a head strike from the Hoyer lift with subsequent head and neck pain, and the resident required repeated PRN pain medication for ongoing head and neck pain. A third resident with cerebral infarction and rheumatoid arthritis had orders and MDS documentation indicating a need for extensive to maximal assistance with bed mobility and dressing. After receiving a shower, this resident was brought back to the room on a shower bed. The facility’s incident report documented that the CNA lowered the side rail of the shower bed, pushed the shower bed against the resident’s bed, turned the resident on her side, removed the bath sheet, and began pushing the Hoyer pad underneath. During this process, the resident rolled and fell between the two beds to the floor, becoming very anxious and crying. A subsequent CT scan at the hospital revealed acute L2 and L3 vertebral compression fractures. In a later interview, the CNA acknowledged that she must have forgotten to lock the wheels on the shower bed before attempting the transfer, and described that when she rolled the resident to place the Hoyer pad, the shower bed separated from the resident’s bed, allowing the resident to fall between them. These events demonstrate that the resident did not receive adequate supervision and safe handling during the transfer process, despite her documented need for extensive assistance with mobility.
Failure to Timely Notify Provider of New Skin Blister After Coffee Spill
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a provider of a change in a resident’s skin condition following a coffee spill incident. The resident was admitted earlier in the month, and the admission MDS documented that the resident required set-up assistance for eating. On the morning of 3/30/26, a nurse documented that the resident placed a cup of coffee on the bed railing, and when he let go, the cup fell onto his lap, spilling hot coffee onto his bilateral upper thighs while he was not wearing pants and was about to receive morning care. At that time, the nurse documented nonblanchable redness on both upper thighs with all skin intact, and later that day a wound care RN documented that there was no scalded skin present and the resident denied pain. A late entry nurse’s note documented that during incontinence care on 3/31/26, a broken blister on the resident’s right upper thigh was identified, cleansed with saline, patted dry, and skin prep applied. Review of incident documentation showed that the physician was not notified of this blister until 4/1/26 at 8:38 AM, more than 24 hours after the blister was first identified. During interview, the NP stated she had been notified of the coffee spill on 3/30/26 but, upon reviewing the physician binder, confirmed there was no evidence that the change in skin condition noted on 3/31/26 had been communicated to a provider at that time. The facility therefore failed to notify the on-call provider when the resident experienced a change in skin condition after the coffee spill incident.
Failure to Obtain Timely RN Post-Fall Assessment After Assisted Descent to Floor
Penalty
Summary
The facility failed to ensure that an RN performed and documented an initial post-fall assessment for a resident who slid off the bed and was lowered to the floor during the 11 PM–7 AM shift. The resident had significant medical conditions including anoxic brain injury, abnormal posture, multiple contractures of the upper and lower limbs, and idiopathic progressive neuropathy. A facility-reported incident documented that the resident sustained a fall with later complaint of ankle pain, with an X-ray obtained and results unclear, and a repeat film obtained two days later. The clinical record showed that the initial post-fall assessment was not completed by an RN until 8:34 AM on the 7 AM–3 PM shift by the ADON, and there was no evidence of an RN assessment during the overnight shift when the fall occurred. A witness summary completed by an LPN documented that the resident was in a seated position after the fall, denied pain, had range of motion assessed, denied pain again, had vital signs taken, and was assisted by a CNA back to bed. During interviews, the DON stated that the fall was not reported by the CNA and the LPN because they did not consider it a fall since the resident was assisted to the floor. In a phone interview, the LPN confirmed being called by the CNA about the fall, stated that care and an assessment were provided, and indicated uncertainty about whether the RN was notified, noting that the written incident report was based on what the CNA reported and that the LPN was not present at the time of the fall.
Failure to Timely Report Allegation of Staff-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure immediate reporting of an allegation of staff-to-resident physical abuse in accordance with its abuse policy and regulatory time frames. The facility’s abuse policy, last updated January 2026, required that all alleged violations be reported to the Administrator, state agency, adult protective services, and other required agencies immediately but no later than two hours after the allegation is made. On 6/12/25 at 3:31 AM, an incident note in the clinical record documented that resident R83 alleged physical abuse by a CNA (E8). However, the allegation was not reported to the State Agency until 11:21 AM the same day, approximately nine hours after the allegation was made, exceeding the required reporting timeframe. During an interview on 4/23/26 at 11:06 AM, an RN (E6) confirmed that the allegation was not immediately reported and stated that the DON later informed her it should have been reported right away rather than waiting for day shift. In a separate interview at 11:14 AM, the DON (E2) confirmed these findings. The deficiency centers on the delayed reporting of the abuse allegation to the State Agency despite clear policy requirements for immediate notification. The survey findings were reviewed with the Nursing Home Administrator (E1), the DON (E2), and others at the exit conference on 4/23/26 at 3:00 PM.
Failure to Remove Accused Staff From Resident Care After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from further potential abuse by not immediately removing an accused staff member from resident care following an allegation of physical abuse. The facility’s abuse policy, updated January 2026, states that room or staffing changes are to be made as necessary to protect residents from the alleged perpetrator. On 6/12/25 at 11:21 AM, the facility reported an allegation of staff-to-resident physical abuse involving resident R83 and CNA E8. Record review of E8’s timesheet showed that after this allegation, E8 remained in the facility working with residents until 7:05 AM. During interview, LPN E7, who was assigned to R83’s unit at the time, confirmed that E8 continued caring for residents after R83’s accusation and stated that R83 had dementia and a care plan for false accusations, and that E8 was only stopped from caring for R83’s room for the rest of the shift. RN E6 also confirmed that E8 continued caring for residents after the allegation and stated that she instructed E8 to care for other patients. These findings were reviewed with the NHA (E1) and DON (E2) during the exit conference. The resident involved, R83, had dementia and a documented care plan for false accusations, which influenced staff’s decision to limit E8’s contact only with R83 rather than removing E8 from all resident care. Despite the facility’s written policy requiring protective staffing or room changes to safeguard residents from an alleged perpetrator, E8 remained on duty providing care to other residents for the remainder of the shift after the allegation of physical abuse was made.
Failure to Implement Timely Fluid Restriction and Monitoring for Resident With CHF and Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and monitoring consistent with professional standards of practice for a resident admitted with congestive heart failure and kidney disease requiring dialysis. The resident was hospitalized for multiple conditions, including heart failure, and then admitted to the facility with diagnoses of congestive heart failure and kidney disease. An admission assessment by an RN documented congestive heart failure, but the baseline care plan did not include any interventions related to this diagnosis. A nutrition assessment documented that the resident was on a therapeutic meal plan with a 1500 mL fluid restriction and indicated ongoing monitoring of oral intake, weight, skin integrity, and labs, yet the physician’s orders and dietary intake records did not contain an order for fluid restriction. A physician progress note documented that the resident had multiple complex comorbidities, including heart failure, and was at high risk for rehospitalization without proper care, specifying a plan for strict intake and output and daily weights. An admission MDS later confirmed that the resident was cognitively intact, experiencing shortness of breath, and had an active diagnosis of heart failure. A physician’s order for a 1500 mL fluid restriction was not written until several days after admission, at the request of the resident’s responsible party. The following day, nursing documentation showed the resident was sent to the hospital from dialysis for chest pain and shortness of breath. In interviews, the MD, the admitting RN, and the DON all confirmed that the resident should have been placed on a fluid restriction and monitoring upon admission, and the DON acknowledged that the fluid restriction order was not implemented in a timely manner.
Failure to Ensure Dietary Staff Used Required Hair and Beard Restraints During Food Service
Penalty
Summary
The deficiency involves failure to maintain sanitary conditions in the kitchen, specifically related to staff not using required hair and beard restraints during food service activities. During an observation and interview with the Dietary Manager (DM) on 03/29/26 from 9:25 AM to 10:28 AM, two Dietary Aides (DA1 and DA2) were seen engaged in food preparation and dishwashing without wearing beard or hair restraints, which the DM confirmed. In a subsequent observation and interview with the DM on 03/31/26 from 8:55 AM to 11:36 AM during the meal serving line, DA1 and DA3 were again observed not wearing beard or hair restraints, and the DM stated that such restraints should be worn at all times and acknowledged the facility was out of beard/hair restraints. These conditions affected 78 residents who received meals from the kitchen, out of a total census of 80 residents, with 2 residents receiving nutrition via feeding tubes. The observations document that multiple dietary staff members repeatedly failed to use required protective restraints while handling food and dishes, and that the facility lacked an adequate supply of beard/hair restraints, as confirmed by the DM. The report specifies that this failure occurred during both food preparation and meal service times and applied to nearly all residents receiving meals from the kitchen.
Unattended, Unlocked Medication Carts Left Accessible in Two Locations
Penalty
Summary
The deficiency involves the facility’s failure to keep medication carts locked and secured when not in use, as required by facility policy and professional standards. During an early morning observation on 04/01/26 at 4:53 AM, a medication cart on the [NAME] Hall in front of room W102 was found unlocked while an LPN was inside the resident’s room with the privacy curtain pulled. The medication cart was not visible from inside the room, and the only other staff member in the area, a CNA, was further down the hall delivering linen to another room. At 4:59 AM, the LPN returned to the cart and locked it, confirming that it had been left unlocked and out of her line of sight. A second unsecured cart was observed on 04/01/26 at 5:56 AM at the nurses’ station, where the medication cart shared by nurses on the [NAME] and East Halls was left unlocked. The ADON walked past this unlocked cart twice and then left the nurses’ station to go down the East Hall at 6:00 AM, leaving the cart unattended and still unlocked. At 6:05 AM, the ADON returned and locked the cart. In an interview at that time, the ADON stated that it was the expectation that all medication and treatment carts be kept locked when not in use. Review of the facility’s “Storage of Medication” policy, revised November 2020, confirmed that compartments containing drugs and biologicals are to be locked when not in use and that unlocked carts should not be left unattended.
Failure to Provide Required Written Information on Advance Directives and Treatment Rights
Penalty
Summary
The facility failed to provide written information regarding advance directives and the right to accept or refuse medical and surgical treatment to two residents reviewed for advance directives. One resident was admitted with hemiplegia and hemiparesis following cerebrovascular disease and major depressive disorder and had a BIMS score of 15/15, indicating intact cognition. Review of this resident’s EMR, including the admission record and MDS, showed no evidence that written information on advance directives had been provided. A second resident was re-admitted with heart failure, stage three chronic kidney disease, malignant neoplasm of the upper lobe of the left bronchus, and pain, and had a BIMS score of 12/15, indicating moderately impaired cognition. Review of this resident’s EMR also revealed no evidence that written information regarding advance directives had been provided. During interviews, the SSD stated she did not have any written information to provide residents about the distinct types of advance directives and that there was no signature page to indicate a verbal explanation was provided or that residents understood their right to accept or refuse medical and surgical treatments. The AD reported that the admission packet contained only one page asking if a resident had an advance directive or wished to formulate one, and that she did not have written information defining the types of advance directives to give residents on admission. The Administrator stated she was not aware of the regulatory guidance requiring written information on advance directives and the right to accept or refuse medical and surgical treatment, and was unaware that the facility’s own policy required this. The facility’s “Advanced Directives” policy, revised November 2025, stated that residents have the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment, and that written information must be provided in a manner easily understood by the resident or representative.
Failure to Timely Report Allegation of Sexual Abuse to SSA
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of sexual abuse to the State Survey Agency (SSA) within the required two-hour timeframe. A cognitively intact resident, admitted with cognitive communication deficit and mild cognitive impairment and having a BIMS score of 15/15, was the subject of an allegation reported by her son. On a grievance/concern form dated 09/18/25, the son reported that a male aide entered the resident’s room in the middle of the night stating he needed to check if she was wet; the resident refused, and the aide returned later, at which time the resident again refused. The facility’s investigation report dated 09/22/25 documented that the assigned CNA made an inappropriate verbal remark to the resident, stating, “you don’t know what you are missing,” when she refused incontinent care. An incident tracking form dated 09/22/25 at 8:21 PM showed that a police officer came to the facility and informed staff that they had received a complaint from the resident’s family alleging the resident had been spoken to in a manner that made her uncomfortable, and that the male staff assigned to her care made the same remark when she refused care. The Admissions Director stated she received the telephone call from the resident’s son on 09/18/25 describing the male staff entering the room, the resident’s refusals of care, and the uncomfortable comment, and that she immediately informed the DON of the concern, consistent with facility protocol to notify the Administrator and DON of all grievance and abuse concerns. The DON stated she did not remember receiving the grievance/concern form and reported that she first learned of the alleged abuse on 09/22/25 when a police officer came to the facility after receiving an allegation of abuse. The DON confirmed that the SSA was notified of the abuse allegation on 09/22/25, four days after the son’s grievance, and acknowledged that the SSA should have been notified on 09/18/25. The Administrator/Abuse Coordinator, who was out on leave at the time and unaware of the grievance, confirmed that alleged violations involving abuse should be reported to the SSA within two hours after the allegation is made. The facility’s written policy on abuse, neglect, exploitation, mistreatment, and misappropriation of property, dated 06/15/25, states that alleged violations involving abuse are to be reported to the SSA within two hours after the allegation is made, which did not occur in this case.
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