Kentmere Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, Delaware.
- Location
- 1900 Lovering Avenue, Wilmington, Delaware 19806
- CMS Provider Number
- 085001
- Inspections on file
- 23
- Latest survey
- December 13, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Kentmere Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls was left unsupervised during care, resulting in a fall, head laceration, and a fractured femur, after which comfort care was initiated and the resident expired. Additionally, broken glass was left unaddressed in another resident's restroom on a dementia unit, despite staff awareness, creating a hazard for residents, including those who wander. Facility policy requiring hazard identification and adequate supervision was not followed in both cases.
Surveyors found multiple dietary deficiencies, including improperly stored and labeled food items in the walk-in refrigerator and freezer, such as opened products without dates, spoiled produce with mold, cracked eggs stored with intact eggs, and dry goods and frozen items left open to air. Staff failed to follow policy requiring all refrigerated and frozen foods to be covered, labeled, and dated. The dishwashing machine was operated at inadequate temperatures, with a low wash temperature and a “Probe Error” on the final rinse, and the dietary aide did not monitor or report these issues as required by policy. Hot foods on the tray line, including pureed vegetables and mechanically altered meat, were held below the required 135°F, and the hot holding unit lacked a thermometer for temperature monitoring at the time of observation.
The facility did not report allegations of abuse, including physical aggression and sexual abuse between residents, to the state survey agency within the required two-hour timeframe. In several cases, staff also failed to immediately notify the DON or Executive Director of abuse incidents, resulting in delayed reporting and investigation. Facility leadership acknowledged that these incidents were not reported in accordance with policy.
The facility did not interview all staff members with knowledge of or involvement in two separate incidents of resident injury and alleged abuse. In one case, a cognitively intact resident reported an LPN caused a finger injury, but the investigation omitted a statement from a therapist who was told about the event. In another case, a resident with severe cognitive impairment sustained a finger fracture of unknown origin, and the investigation did not include statements from the RN or LPN who cared for the resident at the time. Facility leadership acknowledged that not all relevant staff were interviewed as required by policy.
The facility did not maintain an effective pest control program, leading to ongoing rodent infestation on one floor. Multiple observations found rodent droppings in resident rooms and common areas, and a live mouse was seen in the dining room. Staff and leadership acknowledged the persistent rodent issue and described the use of sticky traps and reporting to pest control, but these measures did not resolve the problem.
The facility failed to ensure proper documentation of narcotic count sheets on medication carts, with missing initials from oncoming and off-going nurses across five carts. Staff interviews revealed awareness of the requirement, but no explanations for the omissions. An RN admitted to pre-signing a sheet, and the DON acknowledged the issue, noting previous reminders from the pharmacy.
The facility failed to ensure kitchen staff with beards wore beard guards during food preparation, as required by their policy. Observations over two days showed two male staff members without beard nets, despite the Dietary Manager and aides acknowledging the requirement. This oversight risked physical contamination of food for all 89 residents.
The facility failed to adhere to menu portion sizes for residents on mechanical soft and regular texture diets, affecting their nutritional intake. Observations revealed incorrect scoop sizes and serving methods were used, leading to smaller portions than specified. Interviews with staff highlighted a lack of standardization and understanding of portion sizes, with the RD stressing the importance of correct servings to maintain residents' weights.
A resident, severely cognitively impaired and dependent on staff for transfers, was involved in a fall when a CNA attempted to transfer them alone, contrary to the care plan requiring two staff members and a Hoyer lift. The resident's knees buckled, resulting in a fall onto a mat, but no injuries were sustained. The facility's policy mandates two staff members for mechanical lift transfers, which was not followed, increasing accident risk.
A facility failed to inform a resident of the risks and benefits of prescribed antidepressant medications, as required by their policy on resident rights. The resident, who was cognitively intact, was prescribed Escitalopram Oxalate and Trazadone for depression and insomnia. The DON could not provide documentation confirming that the resident had been informed about these medications.
A resident with chronic bronchitis and COPD was not allowed to self-administer cough drops as per physician's order, despite being cognitively intact. The cough drops were kept at the nurses' station, and the resident had to request them, with no self-administration assessment documented.
A resident experienced a fall from a wheelchair, resulting in a hospital visit. The facility failed to accurately reflect this incident in the resident's significant change MDS assessment, which was intended to address the fall. The MDS Coordinator confirmed the omission, despite the resident being severely cognitively impaired.
The facility failed to provide consistent ADLs for two residents. One resident with dementia and quadriplegia did not receive scheduled showers, with inadequate documentation of refusals or alternatives. Another resident with a stroke and vascular dementia had poor oral hygiene, despite being dependent on staff for assistance. Staff interviews revealed inconsistencies in monitoring and documentation of care plans.
A facility failed to notify a PCP about a new wound on a resident's ankle, leading to a lack of treatment orders. Additionally, a blood pressure medication was administered without obtaining the required blood pressure reading, as the MAR lacked necessary alerts. These deficiencies in communication and protocol adherence placed residents at risk.
A resident with mobility issues had uncut toenails extending beyond the toes, despite requesting a podiatry appointment. The facility's policy required podiatry care, but staff were unaware of the resident's need, leading to a lack of follow-up and communication. The DON confirmed the requirement for podiatry appointments to prevent infection.
A facility failed to provide necessary adaptive equipment and follow physician orders for two residents. One resident, with a leg fracture, was not consistently placed in a high back wheelchair with padded footrests as recommended, while another resident with right-sided paralysis did not consistently receive a physician-ordered splint for her arm and hand. Observations and interviews revealed inconsistencies in care, with staff confirming the lack of adherence to recommended equipment use and physician orders, leading to deficiencies in resident care.
A resident's high back wheelchair was found to be broken, specifically the removable armrest, and was not reported for repair. The facility's staff, including the DOR and RN, were unaware of the issue due to a breakdown in communication and reporting procedures. The Maintenance Director confirmed no report was received through the TELS system, highlighting a failure in maintaining essential equipment.
Three residents experienced abuse in a facility, including a cognitively impaired resident who was subjected to inappropriate treatment by a nurse, a hospice resident threatened by a CNA, and a resident who felt demoralized by another CNA. Investigations confirmed the abuse, leading to staff terminations.
Two residents experienced misappropriation of their credit cards by a CNA, leading to unauthorized charges. Both residents were moderately cognitively impaired, and the CNA was caught on video using the stolen cards. The facility's policy allowed for securing valuables, but this was not effectively utilized.
A facility failed to report a potential abuse allegation to the SSA within the required two-hour timeframe. A resident with dementia sustained a skin tear during care, which was identified as a potential mistreatment incident. The MDSC escalated the incident to the DON but did not report it to the SSA until four hours later, violating the facility's policy.
A resident with dementia sustained bruising and skin tears after a CNA failed to follow dementia care protocols during care provision. Despite being trained, the CNA held the resident's wrists, causing harm. The facility's investigation confirmed the injuries and led to the CNA's termination.
Failure to Prevent Resident Fall and Remove Environmental Hazard
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident with severe cognitive impairment and a history of repeated falls. During morning care, a CNA turned her back to the resident to obtain a washcloth, at which point the resident, known to have jerking movements, fell from the bed. The resident sustained a laceration to the forehead requiring sutures and, two days later, was found to have swelling and limited range of motion in the left leg. An x-ray revealed a displaced fracture of the left femur. The resident's responsible party, after consultation with the physician, opted for comfort care due to the resident's poor surgical candidacy and advanced dementia. The resident subsequently expired in the facility. The facility also failed to identify and remove an accident hazard in a resident's room on the dementia unit. Broken glass was observed in a picture frame in the restroom of a resident with severe cognitive impairment. Although a staff member observed the broken glass, no action was taken to remove it. The glass remained in the room, posing a risk to the resident and others, including wandering residents who could enter the room. Interviews confirmed that staff were aware of the hazard but did not report or address it in a timely manner. Facility policy required all staff to be involved in identifying and addressing environmental hazards and to provide adequate supervision to prevent accidents, taking into account each resident's unique needs. In both incidents, staff failed to follow these protocols: in the first case, by leaving a dependent resident unsupervised during care, and in the second, by not removing a known environmental hazard. These failures resulted in actual harm to one resident and the potential for harm to others.
Improper Food Storage, Dishwashing, and Hot Holding Temperatures in Dietary Services
Penalty
Summary
Surveyors identified deficiencies in the facility’s food storage practices in the walk-in refrigerator and freezer. Policy required all refrigerated and frozen foods to be covered, labeled, and dated with a use-by date, and for food to be received and stored according to safe food handling practices. During observation with the Dietary Director (DD), multiple items in the walk-in refrigerator were found without labels or dates, including opened horseradish sauce, minced garlic, chocolate syrup, leftover cooked carrots, and parsley. Employee water was stored on a shelf with resident food. Several items were spoiled or past the manufacturer’s best-by date, including flour tortillas, bell peppers with mold, celery that was brown and soft in brown liquid, and a box of tomatoes that were soft/mushy with mold. Cracked eggs were stored on a flat with other eggs, exposing contents onto surrounding eggs, and an opened box of yellow cake mix was left exposed to air. In the freezer, a bag of frozen omelets was stored open to air without being sealed or dated. Additional deficiencies were found in dishwashing machine use and monitoring. Facility policy required hot-water dish machines to maintain specific wash and rinse temperatures, and for the operator to check and record temperatures with each cycle, reporting inadequate temperatures immediately. During observation of Dietary Aide (DA) #10 operating the dish machine, the wash temperature registered only 118°F and the final rinse showed a “Probe Error, Final Rinse” message, with no temperature reading. DA #10 stated he did not check dish machine temperatures before or during the wash cycle and did not report the probe error to the DD. The DD later stated he was unaware of the probe error because it had not been reported, and that staff were expected to monitor wash and rinse temperatures and report concerns. Surveyors also found deficiencies in hot food holding on the tray line. Facility policy required hot foods to be held at 135°F or greater. During observation of the lunch tray line, the pureed green beans measured 111°F and the mechanically chopped pork measured between 127°F and 131°F, both below the required holding temperature. Staff member #11 acknowledged that hot foods should be held at 135°F or higher and noted that the hot holding unit typically had a thermometer for monitoring, but at the time of observation there was no thermometer in the unit. The DD confirmed that hot foods should be held at or above 135°F and that the thermometer used to monitor the hot holding unit temperature was not inside the unit, stating he had last seen it there a few days earlier.
Failure to Timely Report Allegations of Abuse and Notify Supervisory Staff
Penalty
Summary
The facility failed to timely report allegations of abuse to the state survey agency and did not ensure immediate notification of supervisory staff regarding abuse incidents involving multiple residents. According to facility policy, allegations of resident abuse must be reported to the appropriate state regulatory authority within two hours. However, documentation revealed that an incident involving physical aggression between two residents was reported to the state agency four and a half hours after it occurred, exceeding the required timeframe. The Director of Nursing (DON) confirmed that the report was not submitted within the mandated two-hour window. Additionally, the facility did not ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to the DON or Executive Director. In one case, a resident with severe cognitive impairment touched another resident inappropriately, but the incident was not reported to the DON or state agency until the following day. The DON and Executive Director both acknowledged that the incident should have been reported within two hours, and that the responsible LPN failed to follow the notification process. Another incident involved a resident who sustained bruising and swelling to the hand after allegedly having an inhaler forcibly removed by an LPN. The resident reported the injury to nursing leadership several days after the incident, and the state agency was not notified until hours after the injury was identified. The DON and Executive Director both acknowledged that the incident was not reported in a timely manner, as required by facility policy.
Failure to Interview All Relevant Staff in Abuse Investigations
Penalty
Summary
The facility failed to interview all individuals identified as involved or with knowledge of alleged abuse incidents for two of seven sampled residents. In the first case, a resident with intact cognition and a history of COPD, anxiety, traumatic brain injury, and asthma reported to the DON that an LPN caused a bruise and swelling to their finger by pulling an inhaler from their hand. The facility's investigation included interviews with the resident, the LPN, and statements from staff who worked with the resident, but did not include a statement from a therapist who was reported to have been told by the resident about the incident. The Speech Language Pathologist later confirmed having a vague recollection of the resident mentioning an incident with a staff member. In the second case, a resident with severe cognitive impairment and a history of dementia, osteoporosis, glaucoma, muscle weakness, and falls was found to have a bruised, swollen, and warm finger, later determined to be fractured with an unknown origin. The facility's investigation did not include statements from the RN or LPN who documented or provided care at the time of the injury. Interviews with facility leadership confirmed that not all staff who worked with the resident within the relevant look-back period were interviewed, contrary to facility policy and expectations.
Failure to Maintain Effective Pest Control Program Resulting in Rodent Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, resulting in an ongoing rodent infestation on the 3rd floor. Observations revealed multiple instances of rodent droppings in various locations, including the dining room, common room, and several resident rooms. A live mouse was also observed in the dining room. The facility's policy required a written agreement with an outside pest control service, regular and scheduled pest control services, safe use of chemicals, and a reporting system for pest issues between scheduled visits. Despite these requirements, evidence of rodent activity persisted in resident and common areas. Interviews with staff, including a CNA, the Director of Maintenance, the Executive Director, and the Director of Nursing, confirmed awareness of the rodent problem, with reports indicating that mice were frequently seen, especially at night. Staff described the use of sticky traps and acknowledged ongoing complaints about rodents. The Executive Director confirmed that the rodent issue had been a problem for the past year, and the Director of Maintenance described the process of reporting pest sightings and notifying the pest control company. However, these actions were insufficient to prevent or eradicate the infestation, as evidenced by continued rodent activity and staff reports.
Failure to Document Narcotic Counts on Medication Carts
Penalty
Summary
The facility failed to ensure proper documentation of narcotic count sheets on medication carts, which is a critical aspect of pharmaceutical services. The report highlights that the narcotic count sheets on each medication cart were not consistently initialed by the oncoming and off-going nurses, as required by the facility's policy and standard nursing practice. This issue was observed across five medication carts reviewed, affecting 40 sample residents. The absence of initials was noted on multiple occasions, indicating a pattern of non-compliance with the established procedures for controlled medication storage and accountability. Interviews with nursing staff, including LPNs and RNs, revealed an awareness of the requirement to initial the narcotic sheets when coming on and going off shift. However, the staff could not provide explanations for the missing initials. Additionally, one RN admitted to pre-signing the narcotic sheet, which is against standard practice, citing that she was the only one with the keys. The Unit Manager and Director of Nursing acknowledged the issue, with the latter stating that the pharmacy had previously reminded staff to sign in and out, but the problem persisted. The facility's pharmacist confirmed that reviewing narcotic sheets is part of their responsibility, although they had not yet reviewed the sheets for November. The pharmacist also stated that pre-signing narcotic sheets is not an acceptable practice. The report indicates a lack of oversight and monitoring of narcotic sheet documentation, which could potentially lead to drug diversion, although this risk is not explicitly stated in the report.
Failure to Enforce Beard Guard Policy in Kitchen
Penalty
Summary
The facility failed to ensure that beard guards were worn by kitchen staff during food production, which is a requirement according to their own policy titled 'Food Safety and Preparation.' This policy mandates that staff with facial hair must wear a beard net to prevent physical contamination of food. Observations were made during multiple meal preparations over two days, where two male kitchen staff members with beards were seen not wearing beard nets at the food preparation station. The Dietary Manager (DM) confirmed during an interview that staff with beards are required to wear beard nets, but admitted to not noticing the non-compliance until it was pointed out. Additionally, two Dietary Aides (DA3 and DA4) acknowledged their awareness of the requirement to wear beard guards but stated they had forgotten to do so. This oversight had the potential to affect all 89 residents who consumed food from the kitchen, as it could lead to physical contamination of the food served in the facility.
Failure to Follow Menu Portion Sizes
Penalty
Summary
The facility failed to ensure that menus were followed in terms of portion sizes for residents on mechanical soft diets and regular texture diets. This deficiency was observed in four residents who were on a mechanical soft diet and other residents receiving regular texture diets. The facility's Portion Control Chart specified scoop sizes for serving portions, but these were not adhered to during meal service, leading to incorrect portion sizes being served. During observations, it was noted that a dietary aide used incorrect scoop sizes and serving methods for meals, resulting in residents receiving less than the designated portion sizes. For instance, residents on mechanical soft diets were served with a light gray handled scoop instead of the required dark gray handled scoop, and tongs were used to serve sauteed onions and mushrooms instead of measuring the correct portion size. Additionally, residents on regular texture diets were served fewer raviolis than specified in the menu. Interviews with the Dietary Manager and Registered Dietician revealed a lack of standardization in serving tools and a misunderstanding of the correct portion sizes. The Registered Dietician emphasized the importance of serving the correct portion sizes to monitor residents' intake and maintain stable weights. The Director of Nursing expressed an expectation for kitchen staff to ensure correct portion sizes to prevent weight loss among residents.
Inadequate Assistance During Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate assistance to prevent accidents for a resident who was dependent on staff for transfers. The resident, who was severely cognitively impaired and had multiple diagnoses including dementia and muscle weakness, was care planned to be transferred with the assistance of two staff members using a Hoyer lift. However, a Certified Nurse Aide (CNA) attempted to transfer the resident alone, resulting in the resident's knees buckling and a fall onto a fall mat. Fortunately, the resident did not sustain any injuries from the fall. The facility's policy required two staff members to be present when using a mechanical lift, but this was not adhered to in the incident involving the resident. The Director of Nursing confirmed that the resident should have been transferred using a Hoyer lift with two staff members present. The incident was reported, and the CNA involved was suspended pending investigation and subsequently terminated for neglect. The failure to follow the care plan and facility policy increased the risk of accidents for the resident and potentially for other residents in the facility.
Failure to Inform Resident of Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure that a resident was fully informed of the risks versus benefits of using psychotropic medications, specifically antidepressants. This deficiency was identified during a review of the facility's adherence to its policy on resident rights, which mandates that residents be informed and participate in their treatment decisions. The resident in question, who was admitted with a diagnosis of major depressive disorder, was prescribed Escitalopram Oxalate and Trazadone for depression and insomnia, respectively. Despite having a cognitive status that indicated the resident was capable of making informed decisions, there was no documentation to confirm that the resident had been informed of the risks and benefits of these medications. During an interview, the Director of Nursing (DON) was unable to provide documentation that the resident had been informed about the risks and benefits of the prescribed antidepressant medications. The DON acknowledged the absence of such documentation and indicated that efforts were being made to locate it. This lack of documentation suggests a failure in the facility's process to ensure residents are informed about their treatment options, as required by their own policy on resident rights.
Failure to Allow Resident to Self-Administer Cough Drops
Penalty
Summary
The facility failed to allow a resident to self-administer cough drops as per the physician's order, which violated the resident's right to self-administer medication when clinically appropriate. The resident, who was admitted with chronic bronchitis and chronic obstructive pulmonary disease, had a physician's order permitting them to keep cough drops at their bedside and self-administer one every four hours. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS), and the care plan included the order for unsupervised self-administration of cough drops. Despite these provisions, the resident reported that the cough drops were kept in a cabinet at the nurses' station, and they had to request them from the nursing staff. The Unit Manager confirmed that the cough drops were stored in the cabinet and that the resident occasionally asked for them. However, there was no documentation of a self-administration assessment being conducted to allow the resident to keep the cough drops in their room, as required by the facility's policy on resident rights.
Inaccurate MDS Assessment Following Resident Fall
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, which could potentially lead to inaccurate federal reimbursements and care planning. The deficiency was identified through a review of the Resident Assessment Instrument (RAI) Manual and the resident's electronic medical records (EMR). The resident, who was admitted to the facility on an unspecified date, experienced a fall from her wheelchair on 07/18/24, resulting in swelling to her forehead. The incident was reported by a Certified Nurse Aide (CNA) and documented in the nursing Incident Report progress notes. The resident was subsequently transported to a local hospital for evaluation and treatment as per the physician's orders. Despite the fall being a significant event, the resident's significant change MDS with an Assessment Reference Date (ARD) of 08/08/24 did not reflect this incident. The MDS assessment indicated that the resident was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of zero out of 15. During an interview, the MDS Coordinator confirmed that the significant change MDS did not include the fall, even though the purpose of the assessment was related to the fall. This oversight highlights a failure in accurately coding the MDS, which is crucial for proper assessment and care planning.
Inconsistent ADL Provision and Documentation for Two Residents
Penalty
Summary
The facility failed to consistently provide activities of daily living (ADLs) according to the care plan for two residents. Resident 93, who was admitted with dementia and functional quadriplegia, did not receive showers as scheduled on multiple occasions. The Point of Care (POC) documentation did not indicate whether the showers were given or refused, and there was no record of bed baths being provided. Interviews with staff, including a Licensed Practical Nurse (LPN), a Certified Nurse Aide (CNA), and the Unit Manager (UM), revealed a lack of consistent monitoring and documentation of the resident's shower schedule, which was supposed to occur twice weekly. Resident 23, admitted with a stroke and vascular dementia, was found to have inadequate oral hygiene. Despite being cognitively intact, the resident was dependent on staff for oral care due to limited mobility. Observations showed a significant coating on the resident's teeth, and documentation indicated that the resident was often dependent on staff for oral hygiene. The Director of Nursing (DON) acknowledged the discrepancy in the documentation, which incorrectly stated the resident was dependent rather than requiring extensive assistance. This lack of proper oral care documentation and assistance was confirmed through interviews and observations.
Communication and Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper communication and treatment for a resident with a newly identified skin alteration. A Licensed Practical Nurse (LPN) identified a new wound on a resident's right ankle but did not notify the Primary Care Physician (PCP) or the wound care team, nor were any treatment orders obtained. The resident, who had an unstageable pressure ulcer on the right heel, was dependent on staff for activities of daily living and had memory problems. The wound was discovered during a visit by the wound doctor, who was unaware of the abrasion and decided to treat it as a wound. The Director of Nursing (DON) acknowledged that the LPN missed steps in notifying the physician and family and completing a wound alert form. The facility also failed to adhere to physician orders regarding medication administration for another resident. A blood pressure medication was administered without obtaining the required blood pressure reading, as per the physician's order to hold the medication if the systolic blood pressure (SBP) was below 120. The LPN administering the medication was unaware of the requirement due to the absence of an alert on the Medication Administration Record (MAR). The DON confirmed that the necessary documentation for blood pressure monitoring was missing from the MAR, and the pharmacist noted that the medication review for the new admission had not been completed. These deficiencies highlight lapses in communication and adherence to established protocols for resident care. The failure to notify the PCP and obtain treatment orders for the new wound, as well as the oversight in medication administration without proper monitoring, placed residents at risk for health complications. The facility's policies on provider notification and medication administration were not followed, leading to these deficiencies.
Failure to Provide Nail Care for Resident
Penalty
Summary
The facility failed to provide appropriate nail care for a resident, identified as R1, who was admitted with diagnoses of abnormalities in gait, muscle weakness, and lack of mobility. Despite being cognitively intact and requiring limited assistance for personal hygiene, R1's toenails were observed to be uncut and extended beyond the tips of the toes. R1 had requested a podiatry appointment from several staff members since admission but had not received one. The facility's policy required podiatry care for residents, as staff were not permitted to trim toenails themselves. Interviews with staff revealed a breakdown in communication and follow-up regarding R1's need for podiatry care. RN5, responsible for making podiatry appointments, was unaware of R1's need for nail care and had not received any complaints or referrals from staff. CNA17, who was informed by R1 that an appointment had been made, did not verify or communicate this information further. Other CNAs involved in R1's care were also unaware of the need for toenail trimming. The Director of Nursing confirmed that the facility required podiatry appointments for all residents and conducted frequent skin audits to prevent infection.
Failure to Provide Adaptive Equipment and Follow Physician Orders
Penalty
Summary
The facility failed to provide appropriate adaptive equipment and follow physician orders for two residents, leading to deficiencies in their care. One resident, who had a fracture of the right tibia/fibula, was recommended by the therapy department to use a high back wheelchair with padded footrests for proper positioning and to prevent further trauma. However, observations revealed that the resident was often placed in a standard wheelchair without the necessary padded footrests, which were found in the bathroom instead of being used. Interviews with staff confirmed the lack of adherence to the recommended equipment use, and the resident's care plan did not address the need for these specific positioning aids. Another resident, who had a history of a cerebral vascular accident resulting in right-sided paralysis, was not consistently provided with a physician-ordered splint for her right arm and hand. The splint was supposed to be applied during the day and at night, but observations and interviews indicated that it was not consistently used as ordered. The resident herself reported that the splint was only sometimes applied, and documentation in the Treatment Administration Record showed inconsistencies in the application of the splint. The facility's policies on repositioning and the use of splints and positioning devices were not followed, leading to these deficiencies. The lack of proper equipment and adherence to physician orders placed the residents at risk of improper support and positioning, potentially worsening their conditions. Interviews with the Director of Rehabilitation, Certified Nurse Aides, and the Director of Nursing highlighted the discrepancies between the expected care and the care provided, confirming the deficiencies identified by the surveyors.
Failure to Maintain Resident's Wheelchair
Penalty
Summary
The facility failed to ensure that a resident's wheelchair was functioning properly, which had the potential to affect the resident's comfort and safety. The resident, identified as R36, was observed using a high back wheelchair and later a standard wheelchair. It was discovered that the high back wheelchair, which was the resident's original equipment, was broken and had been placed in the resident's bathroom. A Certified Nurse Aide (CNA) confirmed that the wheelchair was broken, specifically noting that the removable armrest on the right side was damaged. The deficiency was further compounded by a breakdown in communication and reporting procedures. The Director of Rehabilitation (DOR) and a Registered Nurse (RN) were unaware of the issue, indicating a failure in the reporting process. The Maintenance Director also confirmed that no report of the broken wheelchair had been received through the TELS system, which is the facility's electronic program for reporting repairs. The CNA admitted to missing the report, although she typically reported such issues. This lack of communication and failure to follow established procedures led to the deficiency in maintaining essential equipment for the resident.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect three residents from abuse, as evidenced by incidents involving inappropriate actions by staff members. Resident 103, who had severely impaired cognition, reported that a male nurse, RN6, held a nebulizer mask too tightly on her face, causing pain and leaving red marks. Despite the resident's complaints, RN6 continued the treatment, leading to fear and distress for the resident and her daughter. The facility's investigation confirmed the abuse, and RN6 was suspended and later terminated. Resident 39, who was cognitively intact and receiving hospice care, experienced verbal threats from CNA12. The resident reported multiple altercations with CNA12, who was overheard threatening to punch the resident. The facility's investigation substantiated the allegations, and CNA12 resigned before disciplinary action could be taken. The resident expressed fear of the CNA and was informed of the investigation's outcome. Resident 105, also cognitively intact, reported feeling demoralized by CNA13, who allegedly threw clothing at her and used non-verbal gestures to communicate. The resident expressed concerns about her mental health and fear of retaliation. The facility's investigation confirmed verbal intimidation by CNA13, who was suspended and later terminated. The resident was informed of the investigation's findings.
Misappropriation of Resident Property by CNA
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their property, specifically their credit cards, by a Certified Nurse Aide (CNA). Resident 17, who was moderately cognitively impaired, discovered unauthorized charges on her credit card statement, which she reported to the state and police. The Director of Nursing (DON) confirmed that CNA16, who had received training on abuse and misappropriation, was responsible for stealing the credit card information. The resident had left her credit card bill on her dresser, which was likely where the CNA obtained the information. Similarly, Resident 95, also moderately cognitively impaired, reported a stolen credit card with unauthorized charges. The facility's investigation revealed that CNA16 used the resident's debit card to make purchases, which were captured on video. The DON confirmed the unauthorized use of the card on two occasions, and the incident was reported to the police. The facility's policy allowed residents to secure their valuables in their nightstands, but it appears this measure was not effectively utilized or enforced in these cases.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of potential abuse to the State Survey Agency (SSA) in a timely manner, as required by their policy. The policy mandates that any witnessed or suspected incidents of abuse must be reported immediately, and allegations of resident abuse should be reported to the appropriate state regulatory authority within two hours. In this case, a Certified Nurse Aide (CNA) informed the MDS Coordinator (MDSC) that a resident sustained a skin tear during care, which was identified as a potential allegation of mistreatment. The incident was reported to the SSA approximately four hours after it was determined to be a potential allegation of mistreatment, exceeding the two-hour reporting requirement. The resident involved, who was admitted with a diagnosis of dementia, had short-and-long-term memory problems and required assistance for toileting and hygiene. The MDSC, who conducted the initial skin assessment, escalated the incident to the Director of Nursing (DON) but failed to ensure the allegation was reported to the SSA within the required timeframe. The delay in reporting this potential abuse incident highlights a lapse in adhering to the facility's policy, which could potentially affect the timely reporting of other abuse or neglect allegations.
Inadequate Dementia Care Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that residents with dementia received appropriate care interventions, resulting in harm to a resident identified as R108. The resident, who had a history of becoming physically aggressive during care, sustained visible bruising and skin tears after an encounter with a Certified Nurse Aide (CNA1). The facility's policy required staff to be trained in dementia care and to provide person-centered care, but CNA1 did not adhere to these guidelines during the incident. R108 was admitted with diagnoses including dementia, mood disturbance, and anxiety, and had documented short-and-long-term memory problems. The resident's care plan included interventions for managing physical aggression, such as providing care at alternate times and using diversion techniques. However, during the provision of care, CNA1 held the resident's wrists, leading to skin tears and bruising. The resident reported being grabbed and hurt, and the injuries were confirmed by the MDS Coordinator and an LPN. The facility's investigation revealed that CNA1, who was hired in August 2023, admitted to causing the skin tear while attempting to clean the resident. Despite being trained in dementia care, CNA1 did not follow the facility's protocol to step away and reapproach the resident later if aggression occurred. The facility terminated CNA1's employment due to the failure to provide proper dementia care as directed by the training received.
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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