DOVER, DE - Federal inspectors documented significant deficiencies in basic care services at Bay Terrace Rehabilitation and Health Center during a February 2025 inspection, finding failures in pain management, personal hygiene assistance, and medication administration that affected multiple residents.
Critical Pain Management Failures Documented
The most serious violations involved inadequate pain management for three residents, with inspectors finding the facility failed to follow physician orders for pain medication and used inconsistent assessment methods. One resident experiencing chronic leg pain rated their discomfort at 7-8 out of 10 but received only ineffective Tylenol instead of prescribed Tramadol.
During a wound care treatment observation, inspectors documented a resident reporting pain levels of 5 out of 10 before treatment, escalating to 10 out of 10 during and after the procedure. The resident was observed "yelling out every time" the nurse touched affected areas and stated the acetic acid treatment was "burning and stinging." Despite physician orders requiring Tramadol administration 30 minutes before wound care, staff administered only Tylenol.
The facility's pain management documentation revealed systemic problems with assessment consistency. Medication administration records showed staff used different pain scales for pre- and post-treatment evaluations, documenting responses as "effective," "ineffective," or "unchanged" rather than using standardized numerical scales. This inconsistency prevents accurate pain tracking and appropriate treatment adjustments.
Pain management protocols are critical in nursing facilities because uncontrolled pain can lead to depression, decreased mobility, poor sleep, and reduced quality of life. Proper pain assessment requires using the same measurement scale consistently to track treatment effectiveness and adjust interventions accordingly. The American Geriatrics Society emphasizes that effective pain management requires appropriate assessment, regular reassessment, and data collection to monitor treatment effectiveness.
Basic Hygiene Care Deficiencies Affect Dependent Residents
Inspectors found multiple residents dependent on staff for personal care were not receiving adequate hygiene assistance. A legally blind resident requiring maximum assistance with hygiene was observed with "significant unkempt facial hair" over multiple days, despite having a new razor available. The resident stated, "I have a brand new razor and they have used it once. I can't see and need help to shave."
Two other residents requiring total assistance with personal hygiene were consistently observed with "uncombed, unmanaged, greasy hair" throughout the inspection period. Staff documentation indicated hygiene tasks were completed, contradicting visual observations. A CNA acknowledged the inconsistency and explained that "typically the floor has limited staff and it is difficult to complete twelve residents per CNA, especially on shower days."
Proper hygiene maintenance is essential for preventing infections, maintaining dignity, and ensuring resident comfort. For dependent residents, inadequate personal care can lead to skin breakdown, increased infection risk, and psychological distress. Professional nursing standards require facilities to provide necessary assistance based on each resident's individual needs and limitations.
Medication Order Compliance and Safety Issues
The inspection revealed failures to follow physician orders for both pain medication and bowel management protocols. For a resident with constipation, staff failed to implement prescribed interventions when the resident had no bowel movements for 12 shifts, despite having specific orders for progressive treatments including milk of magnesia, suppositories, and enemas.
Another resident received wound care treatment that differed from current physician orders in the electronic medical record. A nurse confirmed administering treatment based on a verbal order that wasn't documented, creating potential safety risks and compliance issues.
Medication order compliance is fundamental to patient safety in healthcare settings. Deviations from prescribed protocols can result in treatment delays, symptom progression, and potential complications. Healthcare facilities must maintain accurate, up-to-date order documentation and ensure all staff follow current prescriptions precisely.
Care Planning and Assessment Deficiencies
Inspectors found care plans that failed to address residents' current needs and conditions. A resident with incontinence issues who could communicate toileting needs was not placed on a toileting program despite assessment data showing awareness of urges and ability to request assistance. Documentation showed increasing incontinence rates over several months without corresponding interventions.
Another resident's care plan lacked appropriate pain management goals and non-pharmacological interventions, despite admission for chronic pain conditions. Care plans are required to be comprehensive, person-centered, and regularly updated to reflect changing resident needs and conditions.
Additional Issues Identified
The inspection documented several other deficiencies affecting resident care and safety. Respiratory care violations included failure to change oxygen tubing according to physician orders and improper storage of nasal cannulas. Kitchen sanitation problems included expired milk, uncovered food items in refrigeration, food debris on floors and equipment, and possible mold growth on refrigerator shelving.
Dental service provision was inadequate, with residents requesting dental care who had not been offered these services since admission. One resident without dentures reported difficulty chewing and specifically requested to see a dentist. Medical equipment issues included failure to properly apply and maintain orthotic splints for contracture prevention, despite active physician orders requiring their use.
Policy deficiencies were noted in medication regimen review procedures, which lacked required timeframes for pharmacist responses to urgent recommendations. These administrative gaps can delay important medication adjustments and potentially compromise resident safety.
The facility has 60 days to submit a plan of correction addressing all identified deficiencies and demonstrating how similar violations will be prevented in the future.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Courtland Manor from 2025-02-19 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.