DELAWARE VETERANS HOME
Government - State
144 Beds
Independent
Data: November 2025
Trust Grade
70/100
#3 of 43 in DE
Photo by Wayne Skinner
Photo by Delaware Veterans Home
Photo by Delaware Veterans Home
1 / 10 photos
Last Inspection: April 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Delaware Veterans Home in Milford has a Trust Grade of B, which indicates it is a good choice, falling in the 70-79 range. It ranks #3 out of 43 facilities in Delaware and is the top facility in Sussex County, showing it is among the better options available locally. However, the facility is experiencing a worsening trend, with the number of reported issues increasing from 3 in 2024 to 5 in 2025. Staffing is a strength here, boasting a 5-star rating and more RN coverage than 95% of Delaware facilities, though turnover is at 48%, which is average. The facility has incurred $31,837 in fines, which is concerning and suggests ongoing compliance issues. Recent inspections revealed significant incidents, such as a resident experiencing hallucinations without adequate intervention and failures in care plan meetings where necessary team members were not present. While the facility has strong ratings in overall quality and staffing, these concerns highlight the importance of careful consideration.
- Trust Score
- B
- In Delaware
- #3/43
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 48% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $31,837 in fines. Higher than 77% of Delaware facilities, suggesting repeated compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 132 minutes of Registered Nurse (RN) attention daily — more than 97% of Delaware nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 28 deficiencies on record. Higher than average. Multiple issues found across inspections.
70/100
Top 6%
Needs review
3 → 5 violations
★★★★★
5.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 3 issues
2025: 5 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
Staff Turnover: 48%
Near Delaware avg (46%)
Higher turnover may affect care consistency
Federal Fines: $31,837
Below median ($33,413)
Moderate penalties - review what triggered them
The Ugly 28 deficiencies on record
1 actual harm
Mar 2025
5 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
2. Review of R9's clinical record revealed:
1/16/24 - R9 was admitted to the facility.
12/18/24 6:43 PM - A nursing progress note documented that R9 had contacted 911 services due to having hallucina...
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2. Review of R9's clinical record revealed:
1/16/24 - R9 was admitted to the facility.
12/18/24 6:43 PM - A nursing progress note documented that R9 had contacted 911 services due to having hallucinations. Due to the resident having a history of the behaviors, a note was left in the physician communication log and R9 had continued to be monitored.
12/19/24 9:30 AM - A physician's order was written for a urinalysis with a culture and sensitivity to be collected on 12/20/24.
12/20/24 - A urine sample was collected and sent to the lab for analysis and culture.
12/20/24 - A provider note by E13 (NP) documented, . Was asked to see patient [R9] today due to complaints of intermittent hallucinations unit manager reports patient having intermittent visual hallucinations. Today's urinalysis results showed 2+protein and trace of leukocytes . Urinalysis review. Will await urine culture and sensitivity .
12/23/24 12:26 PM - The lab results revealed the urine culture was positive for a urinary tract infection with a positive growth of greater than 100,000 colony forming units of Serratia Marcescens (a type of bacteria).
12/23/24, 12/24/24 and 12/25/24 - The clinical record lacked evidence that R9's UTI was addressed.
12/26/24 1:28 PM - A progress note by E14 (RN) documented, Provider onsite and reviewed UA C&S results. New order for gentamicin 40mg/ml - administer 7 mls BID x 5 days for UTI. Probiotic to be ordered BID for 10 days.
12/26/24 1:35 PM - A physician's order was written for gentamicin sulfate (antibiotic) 40mg/mL, inject 3.5 mL in the muscle two times a day for urinary tract infection for 5 days.
There was a delay of two days before the urine results were reviewed and R9 received antibiotics.
3/4/25 2:20 PM - An interview with E15 (RN) stated that if the unit manager is working, they will keep track of results for labs. Otherwise, the supervisor will be available to keep track of lab results. If a lab result is critical, the result can be called to the on-call provider if a provider is not present.
3/4/25 2:29 PM - An interview with E14 stated that lab results automatically populate in the resident's chart. E14 stated that positive results also get faxed to the facility where the fax is monitored each shift for any results. E14 stated, If there was a positive urinary culture result, we try to let the provider know immediately so the medication can be ordered for the resident since the provider does not order anything until the culture results are completed.
3. Review of R35's clinical record revealed:
8/17/22 - R35 was admitted to the facility.
4/30/24 - A physician's order for lisinopril 10 mg give one tablet by mouth one time a day for hypertension (high blood pressure). Hold for systolic blood pressure less than 100 and hold if heart rate is less than 60.
7/10/24 - The July MAR documented R35 had a blood pressure listed 120/77 and heart rate of 56 and a signature indicating lisinopril medication was administered.
7/1/24 - 7/23/24 - A pharmacist's medication regimen review documented that for R35, recommendation to the facility: [R35] is receiving lisinopril 10mg with parameters to hold is systolic blood pressure (SBP) is less than 100 or heart rate (HR) less than 60 and was the medication was given (per MAR).
9/20/24 - A physician's order for lisinopril 10 mg give 0.5 tablet by mouth one time a day for hypertension (high blood pressure). Hold for systolic blood pressure less than 100 and hold if heart rate is less than 60.
12/27/24 - The December MAR documented R35 had a blood pressure listed 114/75 and heart rate of 55 and a signature indicating lisinopril medication was administered.
1/1/25 - 1/13/25 - A pharmacist's medication regimen review documented that for R35, recommendation to the facility: [R35] is receiving lisinopril 10mg with parameters to hold is systolic blood pressure (SBP) is less than 100 or heart rate (HR) less than 60 and was the medication was given (per MAR).
3/6/25 10:30 AM - An interview with E18 (RN) confirmed that if a resident has vitals outside the parameters medication should be held and notification to the provider if an ongoing pattern. E18 confirmed that R35 received the lisinopril on 12/27/24 per the MAR.
4. Review of R41's clinical record revealed:
3/3/22 - R41 was admitted to the facility.
12/4/24 - A physician's order for cozaar 25 mg give 50 mg tablet by mouth one time a day for hypertension (high blood pressure). Hold for systolic blood pressure less than 120.
12/5/24- The December MAR documented R41 had a blood pressure of 119/68 and a signature indicating cozaar medication was administered.
12/9/24 - The December MAR documented R41 had a blood pressure of 110/70 and a signature indicating cozaar medication was administered.
12/14/24 - The December MAR documented R41 had a blood pressure of 112/76 and a signature indicating cozaar medication was administered.
12/15/24 - The December MAR documented R41 had a blood pressure of 116/83 and a signature indicating cozaar medication was administered.
12/1/24 - 12/19/24 - A pharmacist's medication regimen review documented that for R41, the pharmacist recommendation to the facility: [R41] is receiving cozaar with parameters to hold is systolic blood pressure (SBP) is less than 120. On 12/5, 12/9, 12/14, and 12/15 SBP was less than 120 and the medication was given (per MAR).
3/6/25 10:30 AM - An interview with E18 (RN) confirmed that if a resident has vitals outside the parameters medication should be held and notification to the provider if an ongoing pattern. E18 confirmed that R41 received the lisinopril on the aforementioned dates per the MAR.
3/6/25 2:35 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON).
Based on record review and interview, it was determined that for four (R422, R9, R35 and R41) out of four residents reviewed for quality of care, the facility failed to ensure care/treatment in accordance with professional standards of practice. For R422 the facility failed to provide treatment for a urinary tract infection for four days causing a change in condition that required a transfer to the hospital. This delay in care resulted in harm to R422. For R9, the facility failed to provide treatment for a urinary tract infection for two days. For R35 and R41, the facility failed to follow a doctor's order. Findings include:
Cross Refer F773
1. Review of R422's clinical record revealed:
5/23/24 - R422 was admitted to the facility with a history of a stroke affecting his right dominant side, Parkinson's disease and dementia.
6/13/24 - A nursing progress note documented that E16 (MD) was notified that R422 was getting confused, disoriented and drowsy.
6/13/24 - A physician's order was written by E16 for a urinalysis and urine culture.
6/14/24 - A nursing progress note documented the urine sample was collected and sent to the lab for analysis and culture.
6/16/24 - A review of the lab results revealed a urine culture with a positive growth of enterococcus casseliflavous greater than 100,000 CFU /ml, indicating R422 had a urinary tract infection.
6/16/24 - The clinical record lacked evidence that R422's positive urine culture was treated.
6/17/24 and 6/18/24 - The clinical record lacked evidence that the UTI was being addressed.
6/19/25 3:30 PM - A change in condition evaluation performed by E23 (RN) documented, resident noted with increasing lethargy, altered mental status .increased lethargy.
6/19/24 4:50 PM - A physician progress note documented a change in condition: altered level of copiousness, increased confusion, disorientation, altered mental status .with increased lethargy, send patient to the ER (emergency room) for further evaluation and possible admission.
6/19/24 6:32 PM - Hospital records documented R422 was admitted with altered mental status. A urinalysis was positive for a large number of leucocytes and many bacteria. Awaiting urine culture and sensitivity. R422 was immediately treated with IV antibiotics.
7/13/24 10:18 AM - Hospital records documented that R422 was treated for encephalopathy likely in the setting of a UTI. Upon admission, all tests performed ruled out a stroke and the principal diagnosis was a UTI.
7/8/24 - R422 was discharged from the hospital and chose not to return to the facility.
3/5/25 10:50 AM - During an interview, E2 (DON) stated that lab results are faxed to the nurse supervisor's office. If a lab result is critical and requires immediate attention, the nurse supervisor or the nurse who is assigned to the resident will call the on-call provider, if the provider is not present.
3/6/25 9:25 AM - During an interview, E16 confirmed that she was unaware of the critical lab value for R422 E16 stated that her NP would have been on-call that weekend. In addition, E16 confirmed there were no progress notes and no antibiotic orders for R422. E16 also confirmed she ordered the urine analysis and culture, but did not follow up on the results.
3/6/25 9:48 AM - During an interview via telephone E13 (NP) confirmed that she was not notified of R422's positive urinary tract infection results.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Transfer
(Tag F0626)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that for one (R47) out of two residents reviewed for hospitalization, th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that for one (R47) out of two residents reviewed for hospitalization, the facility lacked evidence that R47 was allowed to return timely to the facility.
11/26/24 - R47 was admitted to the facility.
12/6/24 - R47 was admitted to the hospital for altered mental status and for a psychiatric evaluation. The admission history and physical also reflected that R47 had recently been diagnosed with a urinary tract infection.
12/8/24 - A hospital progress note revealed Barriers: Patient is medically cleared for discharge. VA home is not taking patient on weekends .
12/9/24 - A discharge summary revealed that His mental status has improved, he has been pleasantly confused during the hospital stay, which appears to be his baseline. He is medically stable for discharge.
12/10/24 - A daily medical progress report revealed Barriers to discharge: medically cleared. Discharge disposition: placement issues.
12/12/24 - A daily progress report revealed Disposition hospital issue: Patient was already discharged by prior provider, but VA home refused to take him. They think he needs to go to inpatient psych or memory unit . If they think he needs to go to memory unit then he can go back to the same VA then they can start the process. Psych recommended no need for inpatient psych.
12/13/24 - R47's discharge instructions revealed Disposition hospital issue: Patient was already discharged by prior provider, but VA home refused to take him. They think he needs to go to inpatient psych or memory unit . If they think he needs to go to memory unit then he can go back to the same VA then they can start the process. Psych recommended no need for inpatient psych.
12/13/24 - R47 returned to the facility.
3/5/25 1:20 PM - In an interview, E2 stated that the facility wanted to send R47 to a specific behavioral health facility, but R47 was declined due to needing assistance with activities of daily living. E2 stated that the facility would not have refused R47 re-entry back to the facility but acknowledged that there concerns about the safety of the resident and staff due to his behaviors. E2 further stated that residents can return on the weekend although they prefer that they return during the week because leadership is also in the facility. E2 stated they would not refuse a resident to return.
3/6/25 12:33 PM - In an interview, E1 (NHA) and E2 stated they were not aware of any reason that R47 should not have returned to the facility on [DATE], which was a Monday. Both noted that they do not refuse weekend readmissions.
3/6/25 2:35 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on interviews and record review, it was determined that for one (R4) out of three residents reviewed for accidents, the facility failed to implement the correct assistant device to transfer the ...
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Based on interviews and record review, it was determined that for one (R4) out of three residents reviewed for accidents, the facility failed to implement the correct assistant device to transfer the resident to prevent accidents. Based on review of the facility's evidence to correct the non-compliance and the facility's substantial compliance at the time of the current survey, the deficiency was determined to be past non-compliance as of 12/20/24. Findings include:
Review of R4's clinical record revealed:
7/11/23 - R4 was admitted to the facility.
11/20/23 - A new diagnoses for R4 included, but was not limited to, peripheral autonomic neuropathy, lack of coordination, generalized muscle weakness and unsteadiness on the feet.
10/16/24 - A care plan documented that R4 was high risk for falls related to impaired gait/balance.
11/15/24 - A new order documented R4 was a total assist for transfer and to be transferred with two staff using a Hoyer lift.
12/4/24 - R4's annual MDS documented a BIMS score of 15, revealing an intact cognitive state. R4 was documented with impairments on both sides for upper and lower extremities and was dependent on staff for transferring.
12/14/24 12:35 AM - A facility progress note by E6 (RN) documented, Resident in shower room getting ready for a shower. When lowering resident into shower chair resident started to sit himself down, even after staff (CNA and RN) repeatedly told him not to sit yet. Resident started slipping out of sling and he was gradually lowered to the ground. once resident was sitting on the ground, we repositioned the sling and was able to hoyer lift him into the chair. Resident had no c/o pain during or after the entire process. Resident and RN report no injuries .
12/16/24 10:46 AM - A facility incident report revealed that R4 had a witnessed fall while being transferred using a sit-to-stand transfer and the resident was a Hoyer lift for transferring. R4 slipped out of the sling and was lowered to the floor by the staff where no harm occurred to the resident.
3/4/25 9:53 AM - During an interview E6 stated that E7 (CNA) and her, were transferring R4 to a shower chair using the sit-to-stand transfer. E6 stated that R4 was already in a sling for a sit-to-stand transfer when she came to assist and did not stop to check if that was the correct mode of transfer for R4. When R4 was being lifted in the sit-to stand method, R4 was trying to sit and could not get his legs back up. E6 stated that they lowered him to the floor and assessed him and he had no injuries.
3/4/25 10:47 AM - During an interview E7 stated that they used a sit-to stand transfer of R4 to the shower chair. When R4 was lifted, he began to wiggle and then he was lowered to the floor. E7 stated R4 was supposed to be a Hoyer lift transfer and R4 did not have any injuries after the incident.
3/5/25 9:32 AM - During an interview E8 (DOT) stated R4 was changed from a sit-to-stand transfer to a Hoyer lift because R4's participation would not allow him to do the sit-to-stand safely. E8 stated that R4 would not hold on and let go during the sit-to-stand causing him to be a safety risk.
3/6/25 9:05 AM - During an interview E9 (ADON) stated that after the incident re-education was completed that included: lift and transfer competencies, chain of command notification for resident refusals, how to access the transfer status of residents, how to access the Kardex for transfer status of residents, the appropriateness of providing more assistance. The facility audited the evaluations on the Hoyer lift for the residents. In addition, on-going audits are reviewed weekly. The facility created a subcommittee for falls where they are planning to implement additional appropriate signage such as stars for residents at risk.
Based on the review of the facility's thorough investigation, documented response, completion of in-service training and audits, staff interviews and no further incidents related to injuries using a Hoyer lift, R4's accident was determined to be past non-compliance. The plan of correction was initiated on 12/14/24 and completed on 12/20/24.
3/6/25 2:35 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0773
(Tag F0773)
Could have caused harm · This affected 1 resident
2. Review of R9's clinical record revealed:
1/16/24 - R9 was admitted to the facility.
12/19/24 9:30 AM - A physician's order was written for a urinalysis with a culture and sensitivity to be collect...
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2. Review of R9's clinical record revealed:
1/16/24 - R9 was admitted to the facility.
12/19/24 9:30 AM - A physician's order was written for a urinalysis with a culture and sensitivity to be collected on 12/20/24.
12/20/24 - A urine sample was collected and sent to the lab for analysis and culture.
12/23/24 12:26 PM - The lab results revealed the urine culture was positive for a urinary tract infection with a positive growth of greater than 100,000 colony forming units of Serratia Marcescens (a type of bacteria).
12/26/24 1:28 PM - A progress note by E14 (RN) documented, Provider onsite and reviewed UAC&S results. New order for gentamicin (antibiotic) 40mg/ml - administer 7 mls BID x 5 days for UTI. Probiotic to be ordered BID for 10 days.
There was a delay of two days before the provider was notified and reviewed the urine results.
3/4/25 2:20 PM - An interview with E15 (RN) stated that if the unit manager is working, they will keep track of results for labs. Otherwise, the supervisor will be available to keep track of lab results. If a lab result is critical, the result can be called to the on-call provider if a provider is not present.
3/4/25 2:29 PM - An interview with E14 stated that lab results automatically populate in the resident's chart. E14 stated that positive results also get faxed to the facility where the fax is monitored each shift for any results. E14 stated, If there was a positive urinary culture result, we try to let the provider know immediately so the medication can be ordered for the resident since the provider does not order anything until the culture results are completed.
3/6/25 2:35 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2.
Based on record review and interview, it was determined, for two (R442 and R9) out of three residents sampled for laboratory services, the facility failed to promptly notify the ordering medical practitioner of abnormal laboratory results. Findings include:
Cross refer F684
1. Review of R422's clinical record revealed:
5/23/24 - R422 was admitted to the facility with diagnoses that included Parkinson's disease, history of a stroke affecting the right dominent side and dementia.
6/13/24 - A physician's order was written for a urinalysis with a culture and sensitivity.
6/16/24 - The results were faxed to the facility supervisor's office which revealed R422's urine culture had a positive growth of enterococcus casseliflavous (a type of bacteria) greater than 100,000 cfu/ml, indicating a urinary tract infection.
3/5/25 - A review of R422's clinical record revealed lacked evidence of the laboratory results and notification of provider.
3/5/25 10:34 AM - During an interview, E2 (DON) stated that all lab results are faxed to the nurse supervisor's office. If a lab result is positive the supervisor or the nurse assigned to the resident notifies the on-call provider if a provider is not present.
3/6/25 9:25 AM - During an interview, E16 (MD) confirmed that there was no evidence of provider notification, progress notes. E16 confirmed the lab results were positive and she was not notified.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
Based on record review and interview, it was determined that for five (R1, R11, R64 and R66) out of nineteen sampled residents, the facility failed to have input from all required interdisciplinary te...
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Based on record review and interview, it was determined that for five (R1, R11, R64 and R66) out of nineteen sampled residents, the facility failed to have input from all required interdisciplinary team (IDT) members at the residents' care plan meetings. Findings include:
1. 2/11/08 - R1 was admitted to the facility.
1/15/25 - A quarterly MDS was completed.
1/28/25 - A quarterly care plan meeting note lacked evidence of input from the physician.
10/16/24 - A quarterly MDS was completed.
10/29/24 - A quarterly care plan meeting note lacked evidence of input from the physician.
7/17/24 - An annual MDS was completed.
7/30/24 - An annual care plan meeting note lacked evidence of input from the physician.
2. 6/11/24 - R11 was admitted to the facility.
6/17/24 - An admission MDS was completed.
7/9/24 - A quarterly care plan meeting note lacked evidence of input from the physician.
9/11/24 - A quarterly MDS was completed.
9/24/24 - A quarterly care plan meeting note lacked evidence of input from the physician.
12/11/24 - A quarterly MDS was completed.
12/26/24 - A quarterly care plan meeting note lacked evidence of input from the physician.
3. 6/6/24 - R64 was admitted to the facility.
6/12/24 - An admission MDS was completed.
9/11/24 - A significant change MDS was completed.
9/24/24 - A quarterly care plan meeting note lacked evidence of input from the physician.
12/11/24 - A quarterly MDS was completed.
12/26/24 - A quarterly care plan meeting note lacked evidence of input from the physician.
4. 8/1/24 - R66 was admitted to the facility.
8/7/24 - An admissions MDS was completed.
11/16/24 - A significant change MDS was completed.
11/19/24 - A quarterly care plan meeting note lacked evidence of input from the physician.
2/5/25 - A significant change MDS was completed.
2/18/25 - A quarterly care plan meeting note lacked evidence of input from the physician.
3/5/25 1:20 PM - In an interview, E2 (DON) stated that while the charting system does not reflect that providers have direct input in the care plan meetings, all residents are seen and assessed by them on a consistent basis. E2 stated that he will ensure that the process is revised to include input from the provider specifically at the time of the care plan meeting.
3/6/25 2:35 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON).
Apr 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to protect two of three residents (Resident (R) 51, R6...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to protect two of three residents (Resident (R) 51, R63), reviewed for abuse, when facility nursing staff, a Certified Nurse Aide (CNA)4 used profanity toward R51 during care. In addition, when R39 sat on R63's bed and pushed down on R63's chest with his hands. Failure to protect residents from abuse has the potential to result in injury to residents.
Findings include:
1. Review of R51'sadmission Record located in electronic medical record (EMR) under the Profile tab indicated R51 was admitted on [DATE] with diagnoses which included unspecified dementia, unspecified severity with agitation, and generalized anxiety.
Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/03/23, found in the EMR under the MDS tab indicated a Brief Interview for Mental Status (BIMS) score of five out of 15, indicating a severe cognitive deficit.
Review of the Investigation File, dated 01/19/24 indicated a written statement by Assistant Director of Nurses (ADON) 1 indicated he was informed that CNA2 witnessed CNA4, during resident care, using profanity toward R51. The statement indicated CNA4 was removed from the unit, asked to write a statement, questioned by ADON1, suspended, and terminated following investigation of the incident.
Further review of the Investigation File indicated a Root Cause Analysis indicated the following: at approximately 6:00 AM on 01/19/24, staff (CNA2) witnessed another staff (CNA4) make inappropriate verbal remarks towards a resident (R51) during care. CNA4 stated that she became frustrated with the resident who was not being compliant with care and admitted that her tone was firm, and she may have used profanity words under her breath. CNA2, who came in to assist with care, overheard CNA4 using words of profanity toward R51.
Review of CNA2's written statement indicated that while she was helping CNA4 provide care to R51 on 01/19/24, CNA4 was becoming verbally aggressive to him. The statement indicated CNA told R51 he was pissing her off. CNA2 said CNA4 wanted R51 to hold onto the sit to stand device, R51 was not being cooperative, and CNA4 told R51 to hold onto the fucking thing. CNA2 said CNA4 said, within earshot of R51. that he was fucking annoying her.
During an interview, by telephone, with CNA2 on 04/24/24 at 7:47 PM, CNA2 said she witnessed CNA4 using foul language with R51. She said they were providing care, and he was not being cooperative, and CNA4 got frustrated with him. CNA2 said CNA4 was using the words fuck and fucking toward R51.
During an interview, by telephone, with CNA4 on 04/25/24 at 2:19 PM, she said she was assigned to R51's unit that evening and was already mad because she had been floating and working different units all the time. She said she was providing care to R51 and providing peri care. She said he kept trying to pull up his pants before she was done, and she said she might have gotten loud because he was not hearing her but denied using profanity or being able to recall using profanity. She said she was accused of using profanity towards R51. She said she was removed from the unit and facility and has not been back.
Review of CNA4's Personnel File indicated she received training on Abuse, Neglect and Exploitation on 09/12/23, and Dementia Care with the Hand in Hand program on 09/13/23.
During an interview, by telephone on 04/25/24 at 10:04 AM, Registered Nurse (RN) 4 said she did not recall anyone reporting this incident of abuse to her because she would have reported it to ADON1. She said CNA2 did tell her that CNA4 was not applying R51's ted stockings so she told her R51 needed to have them, it was ordered so it must be done. RN4 said CNA2 told her that CNA4 told R51 you are making it hard for me to turn you or something, and had exhibited an attitude in general that night.
During an interview on 04/25/24 at 9:39 AM, ADON1 said CNA2 reported that CNA4 became frustrated while providing care to R51 and used profanity toward R51. ADON1 said he interviewed staff that were on duty, removed CNA4 from the unit, asked her to write a statement, placed her on administrative leave and had her leave the facility. He said the abuse was substantiated and CNA4 was terminated. He said all staff were re-trained related to abuse. ADON1 said R51 exhibited no behavior changes and did not recall the incident.
Review of the Social Worker (SW)3's statement dated 01/19/24 indicated she spoke with R51 and when asked how his day was going, R51 stated it was going great because he had been able to sleep late. The statement indicated that when asked if anything unusual happened, R51 said no, and denied anyone yelling at him or speaking to him in a mean way. The statement indicated R51 did not appear upset.
2. Review of R39's admission Record in the EMR under the Profile tab indicated R39 was admitted on [DATE] with diagnoses including Alzheimer's early onset, restlessness and agitation, major depressive disorder, and bipolar disorder.
Review of R39's quarterly MDS with an ARD of 11/09/23 in the EMR under the MDS tab indicated a BIMS score was four out of 15, indicating a severe cognitive deficit.
Review of R39's Care Plans in the EMR under the Care Plan tab indicated care plans in place at the time of the incident included R39's behaviors: aggressiveness, towards others, hallucinations, delusions, easily agitated, tearful episodes, purposeful intentions of sitting self on the floor related to dementia included the following intervention: when resident becomes agitated with staff and other residents encourage resident to go for a walk off the unit.
Review of R63'sadmission Record in R63's EMR under the Profile tab indicated R63 was admitted on [DATE] with diagnoses including anxiety, neurocognitive disorder with Lewy bodies, and post-traumatic stress disorder (PTSD).
Review of the admission MDS with an ARD of 11/28/23 in the EMR under the MDS tab indicated the BIMS score was a six out of 15 indicating a severe cognitive deficit.
Review of R39's Health Status Note, dated 01/23/2024 at 4:06 AM in the EMR under the Progress Note tab indicated staff heard a commotion and found R39 kneeling on R63's bed with one knee while his hands were around R63's crossed wrists, pressing against R63's chest. The Health Status Note indicated R63 remained lying in bed as if in shock, unable to defend himself. Staff removed R39 from the area and re-directed him.
During an interview on 04/24/24 at 4:34 PM, the Unit Manager (UM) 1 stated that R39 has periods when he is up at night, and it was not unusual for him to be in the hallway where R63's room was located.
During an interview on 04/25/24 at 9:41 AM, the ADON1 said R39 thought that it was his room and R63 was in his bed. ADON1 said R63 did not realize what was going on and R39 was removed and easily re-directed. ADON1 said R39 was placed on 1:1 supervision and transferred to an inpatient psychiatric facility on 01/26/24.
The Investigation File indicated that when R39 was asked what he was doing, he stated that R63 was in his bed.
Review of the facility's policy titled Abuse and Neglect dated 12/03/20 and recently revised on 04/04/24 indicated incidents of abuse will be investigated, reported, facility staff will be educated and trained, and incidents could be cause for immediate termination.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, policy and procedure review, the facility failed to follow infection control pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, policy and procedure review, the facility failed to follow infection control procedures during a dressing change for one of three residents (R)4 reviewed. Specifically, the Registered Nurse (RN)1 failed to clean the over the bed table or place a barrier on the table before placing clean wound supplies on the table. Also, RN1 failed to perform hand hygiene when she returned to the room after obtaining a dressing from the treatment cart. The failure created the potential for an infection to develop in R4's wounds.
Findings include:
Review of the facility's policy titled Skin Integrity/Wound Care dated 03/08/23, revealed .A resident with skin impairment will receive treatment and services, consistent with professional standards of practice, to promote healing .
Review of the facility's procedure titled Wound Treatment Competency Audit provided by the Administrator on 04/25/24 revealed the following criteria for all nurses to utilize .7. Assembles necessary equipment &[and] places on clean, accessible surface 8. Places date, time, and initials on dressing. 9. Hand hygiene performed prior to and after the treatment of each wound .
10. Puts on gloves . 12. Soiled dressing gently removed & placed in a small waste bag. 13. Removes gloves and places in trash receptacle 14. Hand hygiene I 5. Prepares dressing, without contamination 16. Hand hygiene, put on clean gloves and cleanse site 17. Applies treatment as ordered .21. Hand hygiene prior to returning equipment to cart .STEPS MUST BE FOLLOWED FOR THE TREATMENT OF EACH WOUND
Review of R4's admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R4 was admitted on [DATE] with diagnoses that included chronic atrial fibrillation, unspecified cardiovascular and coagulations; post-traumatic stress disorder, chronic; idiopathic progressive neuropathy, and acute neurologic.
Review of the quarterly Minimum Data Set (MDS) assessment with an assessment reference date of (ARD) of 04/03/24 revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating R4 was unable to participate in the assessment due to severe cognitive impairment.
Review of the Progress Notes located in the EMR under the Clinical tab revealed R4 was identified to have two open areas on 04/16/23 which indicated, Nurse notified by aid in reference to two open areas noted behind resident's left knee with measurements of 5.5 centimeters (cm) x 1.3 cm and 1.0 cm x 1.0 cm .
Review of the Physician's Orders dated 04/18/24, located under the Clinical tab in the EMR, revealed a treatment order for wound care left posterior knee: cleanse with Normal Saline Solution (NSS), pat dry. Apply calcium alginate and cover with .dry dressing as needed.
On 04/24/24 at 9:13 AM, RN1 was observed to perform R4's dressing change to the left posterior knee. RN1 obtained the required materials from the treatment cart and proceeded to R4's room. RN1 placed the items on an overbed table and performed hand hygiene. RN1 did not clean the table or place a clean covering over the table before placing the items on the table. RN1 performed hand hygiene, donned gloves and removed the dressing from the resident's left posterior knee. RN1 doffed the gloves, donned clean gloves and cleaned the wounds with a sterile saline wipe. RN1 dropped the calcium alginate dressing in the trash, left the room to retrieve another calcium alginate from the treatment cart located down the hall from R4's room. RN1 returned to R4's room, without performing hand hygiene donned a new pair of gloves, placed the calcium alginate on the left posterior knee and then a dry dressing.
During an interview with RN1 and Unit Manager (UM2) on 04/24/24 at 10:35 AM, RN1 confirmed that she did not perform hand hygiene when she returned to the room after obtaining a calcium alginate from the treatment cart before donning a clean pair of gloves. RN1 confirmed that she did not date the dressing per facility protocol. UM2 stated, the expectation would be to clean the overbed table and wash hands again when returning to the room.
In an interview on 04/25/24 at 10:28 AM, the Administrator stated, I retrained everyone on handwashing on 04/24/24 and I personally retrained RN1 on wound care criteria as well.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure resident, and resident's representatives wer...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure resident, and resident's representatives were notified at time of discharge of the location and reason for the discharge for a sample of four of four residents (Resident (R)13, R19. R12 and R39) reviewed for hospitalization. As a result of this deficient practice, residents had the potential for location of residents not known to families or resident representatives.
Findings include:
1. Review of R13's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 04/26/22 and readmission on [DATE] with medical diagnoses that included chronic obstructive pulmonary disease and adult failure to thrive.
Review of R13's Significant Change Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 01/17/24, revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating R13 was severely cognitively impaired.
Review of the Misc tab in the EMR revealed a bed hold agreements dated 12/02/23 and 12/17/23 as date of transfer and lacked information about the reason or destination of the transfer of the resident.
Review of the Progress Notes tab in the EMR documented Social Services entry on 12/04/23 and 12/18/23 revealed Note Text: Bed hold notice to Ombudsman/MCO/Family/POA [Power of Attorney] and lacked documentation of where the resident was transferred to or why transfer was needed,
2. Review of R19's undated admission Record, located in the Profile tab of the EMR revealed R19 was initially admitted to the facility on [DATE] with diagnoses of chronic kidney disease, stage 3, diabetes mellitus, essential hypertension, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.
Review of a quarterly MDS located in the EMR under the MDS tab, with an ARD of 01/21/24 indicated R19 had a BIMS score of 10 out of 15 which indicated R19 was moderately cognitively impaired.
Review of a document titled DVH Bed Hold Notice at Time of Transfer dated 03/06/24, located in the EMR under the Misc tab, revealed R19's representative received a bed hold notice upon R19's transfer. The document did not indicate where R19 was transferred too.
Review of R19's Social Services progress notes located in the EMR under the Progress Notes tab, dated 03/05/24 indicated social services had sent a bed hold notice to R19's power of attorney (POA). Review of a Social Services progress note dated 03/06/24 indicated the facility had received a signed bed hold notice from R19's POA. Neither note indicated the POA had received written notice of the location of R19's transfer.
Review of a document titled DVH Bed Hold Notice at Time of Transfer dated 04/23/24, located in the EMR under the Misc tab, revealed R19's representative received a bed hold notice upon R19's transfer. The document did not reveal where R19 was transferred too.
Review of R19's Social Services progress notes located in the EMR under the Progress Notes tab, dated 04/23/24 indicated social services had sent a bed hold notice to R19's POA. The note did not indicate the POA had received written notice of the location of R19's transfer.
3. Review of R12's admission Record, located in the EMR under the Profile tab revealed R12 was initially admitted on [DATE] and most recently readmitted on [DATE] with diagnoses that included chronic atrial fibrillation, asthma, atherosclerotic heart disease of natural coronary artery without angina pectoris, and retention of urine.
Review of the quarterly MDS with an ARD of 02/27/24 revealed a BIMS score of nine out of 15 indicating R12 was moderately cognitively impaired.
Review of the Census located in the EMR under the Clinical tab revealed R12 was hospitalized from [DATE] to 12/13/23.
Review of the Progress Notes located in the EMR under the Clinical tab revealed no written evidence a Bed Hold notification with the location or reason for the transfer/discharge was provided to the resident and resident's representative for the two identified hospitalizations.
4. Review of the admission Record, found in R39's EMR under the Profile tab indicated R39 was admitted on [DATE]. The admission Record indicated diagnoses included Alzheimer's disease, depression, restlessness and agitation, and bipolar disorder.
Review of the MDS with an ARD of 11/09/23, found in R39's EMR under the MDS tab indicated R39's BIMS score was four out of 15, indicating a severe cognitive deficit.
Review of the Health Status Note, found in R39's EMR under the Progress Notes tab, dated 01/23/24 at 4:06 AM indicated R39 was seen physically aggressing another resident while that resident was in bed asleep. The Health Status Note indicated R39 was discovered kneeling on the other resident's bed with one knee while his hands were around the other resident's crossed wrists, pressing against the chest of the other resident.
Review of R39's Health Status Note, found in the EMR under the Progress Notes tab, dated 01/26/24 at 3:04 PM indicated R39 left the facility, accompanied by a unit manager, and was transported to Meadowood (an inpatient psychiatric facility).
Review of R39'sSocial Service note found in EMR under the Progress Notes tab, dated 01/29/24 at 3:00 PM indicated the Bed-hold Notice at Time of Transfer was sent to the Responsible Party.
Review of R39'sBed-Hold Notice at Time of Transfer, found in the EMR, under the Misc tab dated 01/26/24, indicated the Bed-Hold Notice at Time of Transfer, did not include the name of the facility that he was being transferred to and did not include in writing the reason for the transfer/discharge.
During an interview on 04/24/24 at 2:26 PM, the Social Work Consultant (SW2) explained the process was to notify family or resident representative within 24 hours with the bed hold information. A note was made in the EMR progress note to indicate the notification was made and the bed hold information was mailed out.
During an interview on 04/25/24 at 10:44 AM, the Administrator confirmed the bed hold information sent out to the resident or resident's representatives lacked information about the reason or location where the resident was discharged to and confirmed the information was missing on the form sent to the resident or resident's representative.
Review of the facility policy titled Bed Hold Policy dated 01/04/24 revealed, At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. When a Transfer/Discharge policy was requested, the Bed Hold Policy was provided and lacked information about the reason or location of the transfer of the resident to be provided to the family or resident representative.
Apr 2023
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
2. Review of R19's clinical record revealed:
3/21/23 - R19's Quarterly MDS Assessment documented R19 required extensive assist of two for bed mobility and had an impairment to one side of the upper an...
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2. Review of R19's clinical record revealed:
3/21/23 - R19's Quarterly MDS Assessment documented R19 required extensive assist of two for bed mobility and had an impairment to one side of the upper and lower body.
4/19/23 12:54 PM - During an initial observation and interview, R19 was observed lying in bed and the call device was on the far-right side of the nightstand next to the bed. R19 revealed he had weakness from a stroke and could not reach the call bell.
The facility failed to place the call light within reach for a resident who required extensive assist for ADL's (Activities for Daily Living).
4/25/23 1:15 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (Interim DON).
Based on observation and record review it was determined that for two residents (R19 and R49) out of two residents reviewed for accommodation of needs, the facility failed to ensure that the residents' call device were within reach. Findings include:
1. Review of R39's clinical record revealed:
3/21/23 - An annual MDS reflected R39 was totally dependent on staff for performance of ADL's, except for bed mobility that required extensive assistance.
4/21/23 8:54 AM - An observation of R39 in their room after returning from breakfast. R39 was seated in the wheelchair and the call device was on the nightstand and not within reach.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that for one (R56) out of four residents reviewed for activities of daily living (ADL's), the facility failed to complete a significant change M...
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Based on record review and interview, it was determined that for one (R56) out of four residents reviewed for activities of daily living (ADL's), the facility failed to complete a significant change MDS (Minimum Data Set) assessment when R56 had a significant decline in functional and mental status. Findings include:
Review of R56's clinical record revealed:
10/26/22 - R56 was admitted to the facility with dementia.
11/1/22 - R56's admission MDS documented that R56 required supervision of one staff member for bed mobility, transfers, eating, ambulation (walking) and required limited assist of two staff members for toileting. R56's BIMS (Brief Interview for Mental Status) assessment documented three out of fifteen correct answers during the interview.
1/31/23 - R56's quarterly MDS documented that R56 required extensive assistance of two staff members for bed mobility, transfers and toileting, supervision of one staff member for eating, and was non-ambulatory (unable to walk). R56's was not able to complete the BIMS interview due to a decline in his cognition. R56 required a significant increase of staff assistance for his ADL's related to a decline in functional and mental status since his 11/1/22 admission assessment.
4/25/23 12:10 PM - During an interview, E7 (RNAC) confirmed that a significant change in status MDS assessment should have been completed 1/31/23 related to R56's decline in functional and mental status.
4/25/23 12:21 PM - During an interview, E1 (Interim DON) confirmed that a significant change MDS assessment should have been completed.
4/25/23 at 1:15 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (Interim DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, it was determined that for one (R44) out of one resident reviewed for dental, the facility failed to have a MDS (Minimum Data Set) assessment that ac...
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Based on observation, record review and interview, it was determined that for one (R44) out of one resident reviewed for dental, the facility failed to have a MDS (Minimum Data Set) assessment that accurately reflected R44's missing teeth. Findings include:
Review of R44's clinical record revealed:
9/21/22 - R44 admitted to facility.
2/28/23 - A significant change MDS assessment documented that R44 had no broken or loosely fitting full or partial denture.
4/19/23 10:11 AM - During a random observation R44 had missing upper, front teeth.
4/21/23 10:03 AM - During an interview, E5 (RN, unit manager) stated they (the facility) knew about the resident's missing partial denture plate since his admission. In addition, E5 confirmed that the oral assessment section for R44's MDS was a mistake.
4/25/23 at 1:15 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined that for one (R31) out of five residents reviewed for unnecessary medications the facility failed to provide evidence that the attending physicia...
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Based on interview and record review it was determined that for one (R31) out of five residents reviewed for unnecessary medications the facility failed to provide evidence that the attending physician reviewed irregularities/recommendations documented on the monthly Medication Regimen Review (MRR). Findings include:
The facility policy for MRR last updated 1/2023, indicated that, all recommendations shall be acted upon within 30 calendar days. For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale of why the recommendation is rejected in the residents medical record.
Review of R31's clinical record revealed:
6/14/22 - The MRR documented the following recommendation in a pharmacy consultant note, to the physician. This resident has been taking an antidepressant at a dosage of 150 milligrams daily. Please evaluate the current dose and consider a dose reduction. The signature line for the attending physician acknowledgement was blank, and the clinical record lacked evidence that R31's attending physician reviewed the recommendation.
4/24/23 11:15 AM - During an interview, E2 (Interim DON) confirmed the facility lacked evidence that R31's attending physician reviewed/responded to the 6/14/22 MRR. E2 did provide an order of a dose reduction for R31's antidepressant medication written by the facility's psychiatric NP dated 6/30/22.
4/25/23 1:15 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (Interim DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0943
(Tag F0943)
Could have caused harm · This affected 1 resident
Based on interview and review of facility documentation as indicated, it was determined that the facility failed to ensure that the required trainings on abuse, neglect and exploitation were completed...
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Based on interview and review of facility documentation as indicated, it was determined that the facility failed to ensure that the required trainings on abuse, neglect and exploitation were completed as required for one (E8) out of ten randomly sampled staff members. Findings include:
Review of the facility submitted staff training records revealed:
11/8/20 - E8 (CNA) began working at the facility. E8 had no documented date of completion of abuse training.
4/24/23 12:25 PM - During an interview, E1 (NHA) confirmed the findings.
4/25/23 1:15 PM- Findings were reviewed during the Exit Conference with E1 (NHA), and E2 (Interim DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
Based on interview and review of facility documentation as indicated, it was determined that the facility failed to provide required in-service training (12 hours per year) for three (E8, E9, and E10)...
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Based on interview and review of facility documentation as indicated, it was determined that the facility failed to provide required in-service training (12 hours per year) for three (E8, E9, and E10) out of three CNA's reviewed additionally the facility failed to ensure these three CNA's had trainng on dementia management and care of the cognitively impaired. Findings include:
4/24/23 12:18 PM - Review of the facility submitted staff training worksheet revealed a lack of evidence of dementia training for the CNA's sampled. The space for CNA dates of training and hours had a line drawn through the space for E8, E9 and E10. Indicating that none of the 12 hours were completed.
4/24/23 12:25 PM - During an interview with E1 (NHA), it was reported that the facility was unable to provide evidence of dementia training and the hours completed because that information was unable to be located after the prior human resources staff was released from the facility's employment.
4/25/23 1:15 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (Interim DON).
Sept 2021
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that for one (R45) out of six residents reviewed for medica...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that for one (R45) out of six residents reviewed for medications the facility failed to assess the ability to self-administer a medication when requested by a resident. Findings include:
Cross refer F655
[DATE] (date of last revision) - The facility's Self-Administration of Medications policy included If a resident requests to self-administer drugs, the interdisciplinary team will determine if it is safe for that resident to do so before the resident may exercise that right.
Review of R45's clinical record revealed the following:
[DATE] - R45 was admitted to the facility with heart disease and several psychiatric disorders.
[DATE] - An order was written for R45 to receive nitroglycerin under his tongue every five minutes as needed for angina or chest pain and to notify medical staff if no relief after three doses.
[DATE] - An admission MDS (Minimum Data Set) Assessment documented that R45 had BIMS of 15 (cognitively intact).
[DATE] - A Quarterly MDS Assessment documented that R45 had BIMS of 15 (cognitively intact).
[DATE] - A Significant Change MDS Assessment documented that R45 had BIMS of 15 (cognitively intact).
[DATE] 4:50 PM - During an interview, R45 stated, I asked to have my nitroglycerin in my room so I can take it right away when I need it. I can feel it when my blood pressure goes up. If I put on my call bell, I have to wait 15 minutes for someone to answer. I could be dead by then. I would have died if I did not have my nitroglycerin to take when I had my last heart attack a year or so ago. I don't want to die. I told [E4, ADON] I want my nitroglycerin in my room, and he said I would not have another heart attack because of the blood pressure medicines I'm on. I don't know if I even have nitroglycerin ordered. I don't know what the hell they are giving me.
[DATE] 12:30 PM - During an interview, E2 (DON) provided a copy of the facility's Self-Administration of Medications policy and stated she would look for any documentation that the interdisciplinary team evaluated E45 after his request to self-administer nitroglycerin.
[DATE] 3:15 PM - During an interview, E9 (RN, UM) stated that R45 would not be safe to have nitroglycerin in his room because of his upper extremity tremors and his blood pressure has been low at times, but there is no documentation that the interdisciplinary team evaluated him after his request to self-administer nitroglycerin.
Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Deputy Director) during the Exit Conference on [DATE] at approximately 3:15 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that for one (R45) out of one resident reviewed for baseline care planning the facility failed to provide the medication list to the resident. F...
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Based on record review and interview, it was determined that for one (R45) out of one resident reviewed for baseline care planning the facility failed to provide the medication list to the resident. Findings include:
Cross refer F554
5/20/19 (date of last revision) - The facility's Care Plan Development, Implementation and Timing policy included, [the facility] must provide the resident and the responsible party, if applicable, with a written summary of the baseline care plan .no more than 21 days after admission .The summary must include:
a. Initial goals for the resident;
b. A list of current medications and dietary instructions, and
c. Services and treatments to be administered by the facility .the medical record must contain evidence that the summary was given to the resident .
Review of R45's clinical record revealed the following:
4/28/21 - R45 was admitted to the facility with heart disease and several psychiatric disorders.
5/4/21 - An admission MDS (Minimum Data Set) Assessment documented that R45 had BIMS of 15 (cognitively intact).
5/11/21 2:19 PM - E11 (SW) documented a note that R45's initial care plan meeting from admission was held and E45 was present.
9/2/21 4:50 PM - During an interview, R45 stated, I don't know if I even have nitroglycerin ordered. I don't know what the hell they are giving me. When asked if he received a copy of a list of his medicines, R45 said No.
9/10/21 8:15 AM - During an interview, E11 (SW) stated after E45's baseline care plan meeting she gave him a copy of his care plan, but not his medication list. When asked if she normally gives residents / representative party a copy of their medication list she said, No. Just a copy of the care plan.
A baseline plan of care was developed and implemented. However, the clinical record lacked evidence that the baseline plan of care summary included that R45's medication list was provided to him.
Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Deputy Director) during the Exit Conference on 9/10/21 at approximately 3:15 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation and interview it was determined that for one (R28) out of 29 sampled residents the facility failed to develop a comprehensive care plan for the communication needs of a hearing ai...
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Based on observation and interview it was determined that for one (R28) out of 29 sampled residents the facility failed to develop a comprehensive care plan for the communication needs of a hearing aid, including it's use and care. Findings include:
Cross Refer F676
1. The following was reviewed in R28's clinical record:
6/20/19 - R28 was admitted to the facility with dementia.
6/20/19 - A care plan, last updated 9/2/21, for Impaired Communication lacked evidence of the use and care of R28's hearing aids.
3/18/20 - The Treatment Administration Record included a task to clean the hearing aid and change the battery weekly. This was last signed off as completed on 9/2/21.
6/22/21 - The annual MDS assessment indicated that R28 had adequate hearing with the hearing aids.
9/8/21 8:30 AM - 10:00 AM - During an observation of morning care, R28 did not have hearing aids in during morning care. E12 (CNA) and E30 (CNA) directed R28 during care, speaking louder and repeating directions several times when R28 didn't comply with a request or did not perform the task correctly. When R28 was dressed, E12 took the resident to breakfast where he was observed eating without his hearing aides in.
9/8/21 4:52 PM - In a interview, E6 (Gold UM) acknowledged that having hearing aids inserted prior to care would improve resident/staff communication. E6 stated she would update this in the resident's care plan.
Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Deputy Director) during the Exit Conference on 9/10/21 at approximately 3:15 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview it was determined that for one (R28) out of three residents investigated for hearing/vision, the facility failed to provide care and services to prom...
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Based on observation, record review, and interview it was determined that for one (R28) out of three residents investigated for hearing/vision, the facility failed to provide care and services to promote communication in the area of hearing. Findings include:
Cross refer F656
1. The following was reviewed in R28's clinical record:
6/20/19 - R28 was admitted to the facility with dementia.
12/16/19 - R28's care plan for impaired communication problem lacked approaches for the use and care of his hearing aids.
3/18/20 - R28's Treatment Administration Record showed that the hearing aids should be cleaned and the battery replaced on Thursday's.
6/22/21 - The annual MDS assessment states R28 had adequate hearing with hearing aids and was usually understood, he missed some parts or the intent of messages, but comprehended most conversations.
9/2/21 - The TAR revealed R28's hearing aids were cleaned.
9/2/21 12:40 PM - During an interview, FM3 (R28's family/POA) stated that staff were not caring for resident's hearing aids properly and showed a picture of the hearing aids that were caked with ear wax.
9/7/21 12:08 PM - During a random observation, R28 was taken to the dining room by E12 (CNA) with the left hearing aid not in R28's ear canal properly. After the surveyor pointed this out, E12 repositioned the aid, so it was in the ear correctly.
9/8/21 8:30 AM - During an observation of morning care, R28 did not have his hearing aids inserted. E12 (CNA) and E30 (CNA) assisted R28 during care, speaking louder and repeating directions several times when he didn't comply with a request or did not perform the task correctly.
9/8/21 9:15 AM - During an interview, E12 (CNA) reported that the hearing aides were only inserted by the nurse. E12 told E13 (RN) that R28's hearing aids needed to be inserted. E12 then took the resident to breakfast, without his hearing aids.
9/8/21 10:00 AM - During a random observation, R28 was observed in the dining room without his hearing aids, eating breakfast.
9/8/21 4:52 PM - In an interview, E6 (Gold UM) acknowledged that having R28's hearing aids inserted prior to personal care would improve resident/staff communication.
9/9/21 9:30 AM - During an interview, E6 confirmed that she spoke with FM3 (Family/POA) today and FM3 raised a concern over the wax build up in R28's hearing aids. E6 stated she would revise nursing orders to include inserting hearing aids prior to care and to increase cleaning to twice weekly.
Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Deputy Director) during the Exit Conference on 9/10/21 at approximately 3:15 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, it was determined that, for one (R48) out of six residents sampled for skin conditions, the facility failed to provide dandruff shampoo treatment as ...
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Based on observation, record review and interview, it was determined that, for one (R48) out of six residents sampled for skin conditions, the facility failed to provide dandruff shampoo treatment as ordered. Findings include:
Review of R48's clinical record revealed the following:
8/9/19 - R48 was readmitted to the facility.
9/13/19 - R48's care plan for the potential for self care deficit was updated to include that R48 often refused showers and needed extra cueing and support.
6/29/21 - Physician's orders included dandruff shampoo (for dry, flaky scalp and itch relief) to be applied directly to the scalp once daily for dry scalp.
July 2021 - September 2021 - R48's treatment administration record showed R48's dandruff shampoo treatment was held (declined) on multiple occasions: 15 out of 31 times in July; 28 out of 31 times in August; and 7 out of 7 times as of September 7, 2021.
8/3/21 at 2:03 PM - An email correspondence from FM1 (POA) addressed to E1 (NHA) revealed concerns about R48 including, worst case of cradle cap .did show it to the nurse .she said she would order Head and Shoulders shampoo .
8/3/21 at 3:30 PM - A facility grievance form was initiated for concerns including R48's cradle cap to scalp.
8/3/21 at 6:13 PM - A nursing progress note documented, .There was a scant amount of cradle cap noted on the resident's scalp .resident has refused shampoo consistently. MD is aware and will assess .
8/3/21 at 6:35 PM - A reply email correspondence from E1 addressed to FM1 documented that, . aware that he (R48) refuses care and we are not always able to convince him to allow us to groom him as much as he would prefer. He is the resident and has the right to refuse care. This has been discussed during his care plan meetings and interventions are in place to try to convince him to allow us. R48 has a few small dry patches on his scalp. The physician is going to assess him in the a.m. (morning) to determine what treatment will be appropriate. The unit manager will update you after the assessment has been completed.
There was no evidence in the record that the physician assessed the resident on or around 8/4/21.
9/10/21 at 9:39 AM - In an interview, E2 (DON) confirmed the lack of evidence that the physician assessed and/or revised the treatment orders to address R48's scalp condition since he had been refusing the dandruff shampoo treatment.
9/10/21 at 10:26 AM - In an interview, E8 (RN Supervisor) stated that she was not aware of R48's cradle cap issue.
9/10/21 at 10:35 AM - In an interview, E14 (Nurse Practitioner) stated that she reviewed R48's physician progress notes and confirmed that the facility lacked evidence that a physician assessment was done to evaluate R48's scalp. E14 added that there was no evidence that the medical team was notified of R48's consistent refusals of the dandruff shampoo treatment.
9/10/21 at 10:55 AM - In an interview, E9 (RN, UM) confirmed there was no evidence that the medical team was notified about R48's consistent refusal of the dandruff shampoo treatment or that a physician assessment was done to evaluate R48's scalp.
Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Deputy Director) during the Exit Conference on 9/10/21 at approximately 3:15 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that for two (R26 and R33) out of three residents sampled for hearing/vision, the facility failed to ensure that R26 received proper treatment a...
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Based on record review and interview, it was determined that for two (R26 and R33) out of three residents sampled for hearing/vision, the facility failed to ensure that R26 received proper treatment and assistive device to maintain vision abilities. For R33, the facility failed to ensure R33 received proper treatment and assistive devices to maintain hearing abilities. Findings include:
1. Review of R26's clinical record revealed:
6/21/21 - R26 was admitted to the facility.
9/2/21 at 1:11 PM - In an interview, R26 told the surveyor that he requested a pair of eyeglasses from the facility. R26 added that he was not seen by the eye doctor since he was admitted to the facility in June of this year.
9/7/21 at 3:28 PM - E10 (Social Worker) gave the surveyor a written note documenting that R26 had no eye appointment scheduled at this time.
9/8/21 at 8:35 AM - In an interview, E2 (DON) stated that R26 did not have any specific eye consult physician order but will check.
9/8/21 at 9:19 AM - In an interview, FM2 (POA/Family Member) stated that she participated in the care plan meeting a few weeks ago and requested the facility to set up an eye doctor appointment for R26.
9/8/21 at 11:11 AM - Review of R26's record revealed a new physician's order for POA requested an eye evaluation.
9/8/21 at 11:37 AM - E2 confirmed that R26's eye doctor appointment was only ordered after the surveyor brought it to the facility's attention.
2. Review of R33's clinical record revealed:
1/20/12 - R33 was admitted to the facility with diagnoses including hearing loss to both ears.
11/26/14 - A care plan was developed for R33's potential for self care deficit with approaches including Hearing aids in AM out HS (bedtime), left ear very HOH (hard of hearing).
7/28/21 - Resident Council meeting minutes documented that R33 had expressed concern about audiology (hearing) appointments being made.
8/24/21 - Physician's orders included an audiology consult as hearing aids were not effective.
8/25/21 - Resident Council meeting minutes documented that R33's audiology appointment was being addressed.
9/2/21 at 11:11 AM - In an interview, R33 stated that he requested an audiology appointment to check on his broken hearing aids. R33 added that both hearing aids were not functioning well even when the batteries were replaced and stated It's taking them (facility) a long time to get this appointment scheduled.
9/7/21 at 3:30 PM - E10 (Social Worker) gave the surveyor a written note documenting that R33 had an audiology consult order written on 8/24/21, Audiology to be scheduled.
9/8/21 at 2:45 PM - When asked for the recommendation from the audiology consult ordered on 8/24/21, E2 (DON) confirmed that the facility lacked evidence that R33 had an audiology consult and recommendation after 8/24/21 to address R33's complaints of broken hearing aids.
Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Deputy Director) during the Exit Conference on 9/10/21 at approximately 3:15 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observations it was determined that for one (R29) out of four sampled residents reviewed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observations it was determined that for one (R29) out of four sampled residents reviewed for dementia care, the facility failed to ensure that the resident received adequate supervision to prevent accidents and failed to ensure the environment was free of accident hazards. Findings include:
Review of R29's clinical record revealed:
8/23/18 - R29 was admitted to the facility with dementia.
2/24/21 - A physician note revealed R29 was found with white material at the corner of his mouth, identified as barrier cream (a skin protectant). Poison control was notified, no change in condition was noted.
2/25/21 - R29's care plan was updated to include - nurses and nursing assistants - keep all non-edible objects out of reach including condiment wrappers, food wrappers, offer snacks, diversions.
6/9/21 3:30 PM - A care plan note revealed R29 was found with a disposable razor and had cuts to his right thumb.
9/2/21 10:15 AM - A cracked toilet seat was observed in R29's bathroom and a tube of barrier cream ointment was found on the back of the toilet.
9/7/21 10:45 AM - R29 was observed walking in the Gold Unit and he entered another residents room without staff redirection. The stop gate banner was not fastened across the doorway.
9/7/21 12:49 PM - Denture paste and liquid body wash were observed on R29's bathroom sink.
9/8/21 8:10 AM - R29 was observed in room [ROOM NUMBER] (not his room). The fabric STOP banner was not across the door frame. No staff were in the immediate area to redirect E29.
9/8/21 11:51 AM - R29 was observed walking and was carrying a STOP banner in his hand. He was re-directed by staff, who removed the banner from the resident.
9/8/21 4:00 PM - In an interview, E16 (Security Director) confirmed a work order was not received to repair/replace the cracked toilet seat.
9/10/21 12:05 PM - An observation of R29's bathroom revealed the toilet seat had been replaced. At this time, a bottle of liquid soap was observed on R29's bathroom sink and was confirmed with E6 (Gold UM) immediately.
Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Deputy Director) during the Exit Conference on 9/10/21 at approximately 3:15 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on record review, observation, and staff interview, it was determined that for one (Red Unit, Cart 3) out of three medication carts inspected, the facility failed to accurately reconcile the tra...
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Based on record review, observation, and staff interview, it was determined that for one (Red Unit, Cart 3) out of three medication carts inspected, the facility failed to accurately reconcile the transfer of controlled drugs from one shift to another. Findings include:
10/25/18 (date of last revision) -The facility policy for Narcotics: Physician orders, Counting, Discontinued, Documentation stated that Controlled Substances must be counted at the change of shifts .Two (2) nurses must verify drug and count for each controlled medicine and verify the count is the some on the Controlled Substance Record form for each medicine .If count is correct, on the Narcotic count Sheet [the nurses will sign the sheet] .If count is incorrect, the nurse receiving the medication keys will NOT accept the narcotic keys. Instead the nurse: will notify the shift supervisor of the discrepancy immediately and initiate a Medication Error Report .
9/9/21 9:45 AM - A narcotic count of Cart 3 on the Red Unit with E31 (RN, UM), it was discovered that one tablet of a controlled substance was missing. The documentation on the facility's Controlled Drug Record Individual Patient's Narcotic Record indicated there should be 18 tablets, but there were only 16 tablets in the narcotic box. The last narcotic counts were signed by two nurses as correct at 7:00 PM on 9/8/21 and at 5:45 AM on 9/9/21. The last time a tablet of this medication was signed out by a nurse was at 2:00 PM on 9/8/21 indicating that there should be 17 tablets left in the narcotic box. The nurse assigned to this cart, E32 (LPN), stated he has not given this medication this shift. Both E31 and E4 (ADON) confirmed this finding. E4 stated he would begin an investigation.
9/9/21 12:45 PM - During an interview, E2 (DON) and E4 confirmed that there was a missing controlled substance tablet and E4 stated he was continuing to investigate.
Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Deputy Director) during the Exit Conference on 9/10/21 at approximately 3:15 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
2. The facility's policy for Drug Regimen Reviews (last revised 11/17/17) included that findings and recommendations should be noted on the monthly drug regimen review report and that this written rep...
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2. The facility's policy for Drug Regimen Reviews (last revised 11/17/17) included that findings and recommendations should be noted on the monthly drug regimen review report and that this written report would be provided to the attending physician and the director of nursing.
The policy did not specify the time frames for the different steps in the process (time frame for pharmacist to provide the report to the facility and for the attending physician to act upon irregularities, including the rationale when not following the recommendation). The policy also did not include the steps the pharmacist must take when an irregularity requiring urgent action was identified.
Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Deputy Director) during the Exit Conference on 9/10/21 at approximately 3:15 PM.
Based on record review and interview, it was determined that for one (R13) out of six residents reviewed for medication review, the facility failed to ensure the provider reviewed irregularities and failed to ensure the Drug Regimen Review policy included all of the time frame requirements. Findings include:
1. Review of R13's clinical record revealed:
7/19/21 - Review of R13's drug regimen reviews found the pharmacist identified an irregularity and requested an order for a baseline and annual blood tests to monitor R13's liver function and lipid panel since R13 was receiving a medication to control cholesterol. There was no evidence that the physician reviewed this pharmacy concern.
8/31/21 - The pharmacy consultant drug regimen review repeated the same irregularity for a baseline and annual blood tests to monitor liver function and lipid panel. E15 (Medical Director) responded and agreed to order the lipid panel.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0790
(Tag F0790)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for one (R26) out of one resident reviewed for dental services the facility failed to ensure assistance was provided to obtain dental care. ...
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Based on record review and interview it was determined that for one (R26) out of one resident reviewed for dental services the facility failed to ensure assistance was provided to obtain dental care. Findings include:
Review of R26's clinical record revealed:
6/21/21 - R26 was admitted to the facility.
9/2/21 at 1:15 PM - In an interview, R26 told the surveyor that he requested a dental appointment and that he was not seen by the dentist since he was admitted at the facility in June.
9/7/21 at 3:30 PM - E10 (Social Worker) provided the surveyor with a note documenting that R26 had no dental appointment scheduled at this time.
9/8/21 at 8:36 AM - In an interview, E2 (DON) stated that R26 did not have a dental consult order, but she will check.
9/8/21 at 9:20 AM - In an interview, FM2 (POA/Family Member) stated that she participated in the care plan meeting a few weeks ago and requested the facility to set up a dental consult appointment for R26.
9/8/21 at 10:57 AM - R26's record revealed a new physician's order for POA requested to resume routine dental appointments.
9/8/21 at 11:38 AM - E2 confirmed that R26's physician order for a dental appointment was only obtained after the surveyor brought it to the facility's attention.
Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Deputy Director) during the Exit Conference on 9/10/21 at approximately 3:15 PM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
Based on record review and interview it was determined that the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for five (5) out of 29 sampled residents in the areas of sk...
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Based on record review and interview it was determined that the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for five (5) out of 29 sampled residents in the areas of skin conditions (R41, R45, R47 and R48) and restraints/alarms (R35). Findings include:
1. Review of R41's clinical records revealed the following:
8/6/21 - Quarterly MDS (Minimum Data Set) assessment documented the presence of MASD (Moisture Associated Skin Damage).
7/1/21 - 8/30/21 - Review of R41's nurse skin assessments revealed no skin problems or lesions present.
9/10/21 at 9:00 AM - During an interview, E2 (DON) confirmed that R41 did not have MASD and that the MDS will be corrected.
2. Review of R47's clinical records revealed the following:
8/13/21 - Quarterly MDS (Minimum Data Set) assessment documented the presence of MASD (Moisture Associated Skin Damage).
7/1/21 - 8/30/21 - Review of R47's weekly skin assessments revealed no skin problems, tears/breaks, or lesions observed.
9/10/21 at 9:00 AM - During an interview, E2 (DON) confirmed that R47 did not have MASD and that the MDS will be corrected.
3. Review of R45's clinical records revealed the following:
5/4/21 - A Comprehensive admission MDS (Minimum Data Set) assessment documented the presence of MASD (Moisture Associated Skin Damage).
4/28/21 - 5/25/21 - Review of R45's nurse skin assessments revealed no skin problems or lesions, except scattered moles.
9/10/21 at 9:00 AM - During an interview, E2 (DON) confirmed that R45 did not have MASD and that the MDS will be corrected.
4. Review of R48's clinical records revealed the following:
5/14/21 - A quarterly MDS assessment documented the presence of MASD (Moisture Associated Skin Damage).
June 2021 - 8/25/21 - Review of R48's weekly skin assessments revealed no new skin issues noted and intact skin (no sores).
8/13/21 - A significant change MDS assessment documented that R48 had MASD.
9/10/21 at 8:43 AM - An interview with E2 (DON) confirmed that R48 did not have MASD and the MDS would be corrected.
9/10/21 at 10:40 AM - In an interview, E7 (RNAC) confirmed the inaccurate MASD coding on the MDS assessment.
5. Review of R35's clinical records revealed the following:
4/20/21 - R35 was admitted to the facility with diagnoses including dementia with behaviors.
5/4/21 - A care plan was developed for R35's potential for elopement with interventions including to monitor placement of the wanderguard (small electronic device that triggers an alarm when close to sensors at the exit doors).
5/4/21 - A physician order included to check placement of the wanderguard on the resident's left wrist and to assess skin on the left wrist for redness or irritation every shift.
7/1/21 - 9/8/21 - R35's Treatment Administration Record revealed that nursing staff documented the placement of R35's wanderguard on his left wrist every shift.
7/16/21 - R35's quarterly MDS assessment documented that a wanderguard was not used.
9/2/21 - 9/8/21 at varying times - R35 was observed wearing a wanderguard on his left wrist.
9/8/21 at 9:08 AM - Interview with E2 (DON) confirmed that R35 wore a wanderguard on his wrist and that the MDS would be corrected.
9/10/21 at 10:45 AM - Findings of the inaccurate alarm coding was discussed and confirmed by E7 (RNAC).
Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Deputy Director) during the Exit Conference on 9/10/21 at approximately 3:15 PM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
Based on record review, observation and interview it was determined that, for four (R26, R37, R45 and R48) out of six residents sampled for medication review, the facility failed to ensure that psycho...
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Based on record review, observation and interview it was determined that, for four (R26, R37, R45 and R48) out of six residents sampled for medication review, the facility failed to ensure that psychotropic medications were appropriately ordered and monitored. Findings include:
5/22/18 - The facility policy entitled Behavior Monitoring/Psychotropic drugs included, A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior .These drugs include, but are not limited to, drugs in the following categories: Anti-psychotic; Anti-depressant; Anti-anxiety; and Hypnotic (for sleep) . [The purpose of this policy includes] to provide guidelines to accurately record monitoring of behavioral symptoms and side effects for residents taking psychoactive medications . PRN [as needed] orders for psychotropic are limited to 14 days . if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.
The policy did not include that PRN antipsychotic medications are always limited to 14 days and that the physician must physically evaluate the resident prior to reordering for another 14 days, if the medication is still needed.
Side Effect Monitoring
1. Review of R45's clinical record revealed the following:
4/28/21 - R45 was admitted to the facility with several psychiatric disorders including chronic PTSD (post-traumatic stress disorder) from serving in combat and bipolar (manic - depression) disorder.
4/28/21 - An order was written for R45 to receive an antipsychotic medication daily.
5/4/21 - An admission MDS Assessment documented that R45 received an antipsychotic medication daily since admission to the facility.
5/11/21 - A care plan was initiated for potential for adverse side effects related to use of antipsychotic medication and interventions included to monitor for adverse effects.
8/20/21 - An AIMS (Abnormal Involuntary Movement Scale that identifies serious motion side effects of antipsychotic medication) was completed for R45 and documented no abnormal movements in the upper extremities.
9/2/21 4:57 PM - An observation during the resident interview revealed that R45 had noticeable arm tremors (shakiness).
9/9/21 3:30 PM - During an interview, E2 (DON) confirmed that R45 had abnormal involuntary movements of his upper extremities at the time the 8/20/21 AIMS scale was completed (and since admission to the facility) and that the AIMS scale was incorrect. When asked for a policy/procedure for the AIMS, E2 stated the facility did not have any. In addition, E2 confirmed the 8/20/21 AIMS was the only one completed since R45 was admitted to the facility.
There was no evidence that a baseline AIMS scale was performed when R45 was admitted to the facility on daily antipsychotic medications. An inaccurate AIMS scale was completed on 8/20/21. The facility failed to ensure that periodic monitoring for side effects of antipsychotics was completed for R45 according to current standards of practice (on admission and every 6 months).
NIH 2014: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4062734/
PRN Orders
2. Review of R48's clinical record revealed:
8/9/19 - R48 was admitted to the facility with diagnoses including anxiety disorder.
8/31/21 - Review of R48's physician orders showed an order for a medication for anxiety to be given every 2 hours as needed for anxiety. This order did not have an end date.
9/9/21 9:00 AM - Findings were discussed and confirmed with E2 (DON).
3. Review of R26's clinical record revealed:
6/21/21 - R26 was admitted to the facility with diagnoses including anxiety disorder.
Review of R26's physician orders showed two different medications that could be administered every 2 hours as needed for anxiety without end dates.
a. 6/22/21: gel medication containing an anti-anxiety (Ativan) and an anti-psychotic (Haldol) to be placed on the skin PRN (as needed). Since this medication contained an antipsychotic, every PRN order must be limited to 14 days and the provider must evaluate the resident with each new order.
b. 6/29/21: an oral medication for anxiety (Ativan). The initial order for this medication should be limited to 14 days.
9/8/21 11:00 AM - Findings were discussed and confirmed with E2 (DON).
4. Review of R37's clinical record revealed:
4/7/21 - R37's physician orders included Haldol (an antipsychotic drug to treat mental disorders) to be given three times a day as needed (PRN) for delusions, hallucinations, throwing objects, striking and unable to redirect, without a stop date.
5/11/21 - A Physician order for a gel medication containing anti-anxiety and anti-psychotic medications to be placed on the resident's skin every six hours as needed for anxiety or agitation had a stop date of 12/30/21.
These as needed (PRN) orders contained an anti-psychotic which required a stop date of 14 days.
5/18/21 - Drug regimen review included No new recommendations at this time.
The drug review by a pharmacist failed to identify the missing or incorrect stop dates for both PRN anti-psychotic medications.
6/8/21 1:59 PM - A pharmacy review of medications identified R37's order for the PRN gel from 5/11/21 was subject to a stop date order per policy.
The drug review did not address the PRN Haldol which had been ordered since 4/20/21.
6/9/21 - Physician orders included the addition of a stop date of 12/30/21 to the 5/11/21 PRN gel order.
9/9/21 2:30 PM - An interview to review findings was conducted with E2 (DON). E2 said that the process for renewing anti-psychotic medication should be every fourteen days and E2 was not sure why the physician did not write the order to include a fourteen day discontinuation and renewal as recommended in the pharmacy review.
Findings were reviewed with E1 (NHA), E2 and E3 (Deputy Director) during the Exit Conference on 9/10/21 at approximately 3:15 PM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Supervisor's office medication refrigerator
[DATE] 5:00 PM - During an inspection of the Supervisor's office medication room,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Supervisor's office medication refrigerator
[DATE] 5:00 PM - During an inspection of the Supervisor's office medication room, E4 (ADON) and E8 (RN Supervisor) were unable to locate the medication refrigerator (containing several vaccines and other medications that need to be refrigerated) temperature logs for the months of June and [DATE]. In addition, the logs for January, February, and [DATE] had many days when the temperatures were not recorded:
- January missing 5 of 31 days (16%)
- February missing 10 of 28 days (36%)
- March missing 14 of 31 days (45%)
[DATE] 12:45 PM - During an interview, E4 (ADON) confirmed the above finding and stated the facility does not have a policy for medication refrigerator temperature checks, but it is the night supervisor's responsibility to check and record medication refrigerator temperatures every night.
4. Red Unit medication room
[DATE] 8:30 AM - An inspection of the Red Unit's medication room with E31 (RN, UM), revealed a tube of an ointment medication that was opened and partially used in the drawer with unopened stock medications. The tube was not labeled with a resident's name or the date it was opened. E31 disposed of the medication.
[DATE] 12:45 PM - During an interview, E4 (ADON) confirmed that when the nurse used this tube medication for a resident, it should have been removed from the stock medication drawer, labeled, and put in the resident's med cart.
Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Deputy Director) during the Exit Conference on [DATE] at approximately 3:15 PM.
Based on observation and interview, it was determined that for one (Gold Unit) out of three medication carts and two (Gold and Red Units) out of three medication rooms inspected, the facility failed to ensure medications were labeled with the resident name and not expired. In addition, in one (Supervisor's office) out of three medication rooms inspected, the facility failed to ensure that all refrigerated drugs and biologicals were stored under proper temperature controls. Findings include:
1. [DATE] 9:45 AM - During an inspection of the Gold Unit medication cart contents, one box of a liquid medication was found open in the top drawer and not labeled with a resident name or dosage instructions. This finding was immediately confirmed by E13 (RN) who stated that the medication came in a bag with several boxes of medication and only the bag was labeled, not the individual boxes.
[DATE] 4:50 PM - In an interview, E6 (Gold UM) confirmed that the medication should be individually labeled with a patient identifier and dosage instructions.
2. [DATE] 11:49 AM - An inspection of the Gold Unit medication room, found a bottle of liquid medication with an expiration date of [DATE]. E13 (RN) immediately discarded the medication.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations and interviews it was discovered that the facility failed to ensure food was stored, distributed and prepared in a sanitary manner in accordance to FDA food standards. Findings i...
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Based on observations and interviews it was discovered that the facility failed to ensure food was stored, distributed and prepared in a sanitary manner in accordance to FDA food standards. Findings include:
The following was revealed during the initial kitchen tour and nourishment rooms on 9/2/21 from 8:30 AM to 10:00 AM:
- The walk-in refrigerator had moldy blueberries and a cardboard box storing purple cabbage and bacon;
- The hand washing sink in the dish room was blocked by carts;
- The ice machine scoop was stored within the hand washing sink splash zone;
- The dining room had unlabeled spray bottles;
- The nourishment room on the Red Unit refrigerator was dirty with unlabeled sandwiches;
- The nourishment room on the Gold Unit refrigerator was dirty on the bottom.
Findings were reviewed and confirmed with E1 (NHA) and E2 (DON) on 9/2/2021 at approximately 3:00 PM.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • 28 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $31,837 in fines. Higher than 94% of Delaware facilities, suggesting repeated compliance issues.
Bottom line: Mixed indicators with Trust Score of 70/100. Visit in person and ask pointed questions.
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About This Facility
What is Delaware Veterans Home's CMS Rating?
CMS assigns DELAWARE VETERANS HOME an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Delaware, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Delaware Veterans Home Staffed?
CMS rates DELAWARE VETERANS HOME's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 48%, compared to the Delaware average of 46%.
What Have Inspectors Found at Delaware Veterans Home?
State health inspectors documented 28 deficiencies at DELAWARE VETERANS HOME during 2021 to 2025. These included: 1 that caused actual resident harm and 27 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Delaware Veterans Home?
DELAWARE VETERANS HOME is owned by a government entity. Government-operated facilities are typically run by state, county, or municipal agencies. The facility operates independently rather than as part of a larger chain. With 144 certified beds and approximately 69 residents (about 48% occupancy), it is a mid-sized facility located in MILFORD, Delaware.
How Does Delaware Veterans Home Compare to Other Delaware Nursing Homes?
Compared to the 100 nursing homes in Delaware, DELAWARE VETERANS HOME's overall rating (5 stars) is above the state average of 3.3, staff turnover (48%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Delaware Veterans Home?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Delaware Veterans Home Safe?
Based on CMS inspection data, DELAWARE VETERANS HOME has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in Delaware. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Delaware Veterans Home Stick Around?
DELAWARE VETERANS HOME has a staff turnover rate of 48%, which is about average for Delaware nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Delaware Veterans Home Ever Fined?
DELAWARE VETERANS HOME has been fined $31,837 across 1 penalty action. This is below the Delaware average of $33,397. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Delaware Veterans Home on Any Federal Watch List?
DELAWARE VETERANS HOME is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.