Excelcare At Lewes LLC

Based on record review, interview and review of other facility documentation, it was determined that for one (R3) out of one sampled residents reviewed for dialysis, the facility failed to monitor R3's dialysis catheter and failed to complete R3's before (pre) and after (post) dialysis assessments. Findings include: Review of R3's clinical record revealed:12/18/25 - R3 was admitted to the facility.12/19/25 - A care plan documented R3 needs dialysis related to renal failure with the following interventions: encourage resident to go for scheduled dialysis appointments; monitor/document/report any sign and symptoms of infection to the access site: redness, swelling, warmth or drainage; monitor/document/report signs and symptoms of renal insufficiency: change in level of consciousness, changes in skin turgor, change in heart or lung sounds; monitor/document/report signs and symptoms of the following: bleeding, hemorrhage, bacteremia or septic shock.12/25/25 - An admission MDS documented that R3 was receiving hemodialysis and dependent for ADL's. 12/26/25 - A physician's order documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, it was determined that for three (R11, R14 and R15) out of six residents reviewed for unnecessary medication review, the facility failed to ensure for the medication regimen review (MRR) that irregularities identified were reviewed by the attending/designee. Findings include:A facility policy titled, Pharmacy Services – Drug Regimen Review, dated 5/1/25, documented, . the pharmacist will report any irregularities to the attending physician, the facility's medical director and the director of nursing . The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it . 1. Review of R15's clinical record revealed: 8/26/25 – R15 was admitted to the facility with a diagnosis including, but not limited to, hypothyroidism. 12/8/25 – A medication regimen review for R15 documented that charting omissions are noted for levothyroxine for 11/21/25. A nursing comment documented, Omitted? Not sure why, and was signed by E27 (UM). There was a lack of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview it was determined that for one (R11) out of six residents reviewed for unnecessary medication review the facility failed to ensure that the resident was free from unnecessary medications. Findings include: Review of R11's clinical record revealed: 9/23/25 - A physician's order was written for R11 to receive Metoprolol, a blood pressure medication one time a day for hypertension, hold for systolic blood pressure greater than 130 or heart rate less than sixty. October 2025 - Review of R11's MAR revealed that nineteen out of thirty-one doses of Metoprolol were not given to R11 because of lower systolic blood pressure or heart rate. November 2025 - Review of R11's MAR revealed that twenty-five out of thirty doses of Metoprolol were not given to R11 because of lower systolic blood pressure or heart rate. December 2025 - Review of R11's MAR revealed that eleven out of thirty-one doses of Metoprolol were not given to R11 because of lower systolic blood pressure or heart rate. January 2026 - Review of R11's MAR revealed that nine out of thirty-one doses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interview and review of physician orders it was determined that for one (R11) out of six residents' sampled for unnecessary medication review the facility failed to ensure that R11's blood pressure medication was held when vital signs were below ordered parameters. Findings include:The facility policy on medication administration last updated 5/1/25 indicated, Medications are administered as prescribed in accordance with good nursing principles and practices.Review of R11's clinical record revealed:9/22/25 - A physicians' order was written for R11 to receive metoprolol daily for blood pressure; hold for systolic blood pressure (SBP) less than 130 or hear rate (HR) less than 60. October 2025 - R11 was administered metoprolol with below ordered parameters on the following dates:10/7 with a SBP of 11810/28 with a SBP of 125. November 2025 - R11 was administered metoprolol with below ordered parameters on the following dates:11/24 with a HR of 52.12/7/25 - An MRR irregularity report documented, metoprolol is not always held as required by the physician's order.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, it was determined that for one (R41) of one resident reviewed for grievance, the facility failed to promptly to initiate the replacement of lost dentures within three days after notification of loss.Findings include:5/14/25 - A facility-provided grievance form documented that FM1 reported R41's top dentures were missing. E14 (LPN) completed a room sweep and documented that the 11:00 PM - 7:00 AM shift would complete a second room sweep. The concern was reported to the Director of Nursing. The grievance included a note that a meeting with the Business Office to explore Medicaid eligibility for denture replacement.2/18/26 at 1:45 PM - During an interview, E15 stated she was unable to explain the extended timeframe for replacement of the dentures and was unsure why a meeting with the Business Office was required prior to proceeding with replacement. E15 further stated the events that occurred while she was on leave from the facility.2/18/26 at 1:53 PM - During a joint interview with E12 (Current Business Office Manager) and E15 (Social Worker), E12…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, it was determined that for two (R2 and R56) out of 2 sampled residents for dental services, the facility failed to assist the resident in obtaining routine dental services. Findings include:A facility policy and procedure titled, Dental Services, dated 5/1/25, documented, It is the policy of the facility to accommodate needed dental services, including routine dental services; to ensure the facility provides the assistance needed or requested to obtain these services. The facility will, if necessary or if requested, assist the resident: a. Making appointments . 1. Review of R2's clinical record revealed: 11/15/24 – R2 was admitted to the facility. 11/25/24 – A care plan was initiated for R2 with broken/carious teeth, including interventions to coordinate dental care and transportation as needed. 11/4/25 – The annual MDS assessment documented that R2 was cognitively intact and had obvious or likely cavity or broken natural teeth. 2/9/26 9:28 AM – During an observation and interview, R2 stated that they have had broken teeth and has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview it was determined that the facility failed to ensure food was stored, prepared, and served in a manner that prevents food borne illness to the residents. 02/09/2026 9:14 AM Sussex Hall nutrition refrigerator contained three (3) opened cartons of thickened water that were incorrectly dated to reflect the date of disposal as per manufacture recommendations. One container was dated February 3, 2026 and the other two cartons were dated January 31, 2026. The manufacturer's instructions on the cartons state that once opend, any remaining product should be discarded after four (4) days. 02/09/2026 10:08 AM Henelopen Hall Nutrition Refrigerator contained 1 carton of Thickened water that wereincorrectly dated

Based on record review and interview it was determined that the facility failed to the ensure the Medical Director fulfilled his/her responsibility of ensuring implementation of the Drug Regimen Review policy to be consist with current professional standards of care regarding provider documentation in response to identified irregularities. Findings include: Cross refer F756The facility job description for responsibilities of the medical director indicated, Provider Supervision and &Consultation: Provide guidance and education to physicians, nurse practitioners, and physician assistants regarding best practices in long-term care. Policy Development & Implementation: Ensure compliance with federal, state, and local healthcare regulations, including CMS and CDC guidelines.The facility policy on Drug Regimen Review last updated 5/1/25 indicated, The attending physician must document in the residents medical record that the identified irregularity has been reviewed and what, if any action has been taken to address it.2/18/26 8:52 AM - During an interview E2 (ROD) confirmed that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview it was determined that the facility failed to ensure accuracy of resident records for one (R41) out of six residents reviewed for falls when R41's fall incident report contained inaccurate information regarding an injury. Findings include:Review of R41's clinical record revealed; 12/15/25 1:09 PM - A progress note in R41's clinical record documented, At 1235, while this writer was at the meds cart giving out afternoon med, heard a bomb sound behind in the dining area, immediately turned and saw patient lying face down on the floor. Immediately assessed patient and a hematoma noted on patient forehead . 12/15/25 - The incident report for R41's fall documented, No injuries observed at time of incident in the injuries observed at time of incident section. 2/18/26 12:03 PM - During an interview E40 (R--) confirmed the finding and stated, they did write it in the other section. 2/18/26 3:40 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (ROD), and E3 (DON).

Based on record review and interview, it was determined that for two (R1 and R6) out of seven residents reviewed for abuse, the facility failed to report resident to resident abuse to the State Agency within two hours. Findings include:1.Review of R1's clinical record revealed:7/28/25 - R1 was admitted to the facility.11/4/25 - A review of facility reported incident documented that R1 experienced a psychotic episode and made contact with three residents (R3, R4, and R5) which occurred on 11/3/25 at 9:00 PM. The incident report documented that the report was submitted to the state agency on 11/4/25 at 2:39 PM.11/7/25 9:30 AM - During an interview, E6 (CNA) confirmed the incident occurred on 11/3/25 at approximately 9:00 PM.11/13/25 12:10 PM - During an interview, E3 (ADON) confirmed that she was made aware an incident occurred on 11/3/25 around approximately 9:00 PM and stated that when obtaining staff interviews on 11/4/25 was then informed of R1 having resident to resident physical contact with other residents. E3 stated the report was submitted late due to facility wanting to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, it was determined that for one (R2) out of seven (7) residents in the investigative sample, the facility failed to ensure the clinical record contained accurate documentation. Findings include:Review of R2's clinical record:7/1/25 - R2 was admitted to the facility.11/7/25 - A review of R1's clinical record lacked evidence of a progress note, consult, medication review, or visit summary after the incident on 11/2/25. 11/13/25 1:25 PM - The facility provided electronic communication from E16 (NP) documenting R2 was seen on 11/6/25 for a wellness check. 11/14/25 9:16 AM - During an interview, E12 (LPN) stated that R2 had not been seen by psychiatrist on 11/6/25 and confirmed no progress notes were not in the electronic medical record for the aforementioned date. The facility failed to ensure the clinical record contained accurate documentation. 11/14/25 - Findings were reviewed with E1 (Corporate NHA), E2 (DON) and E3 (ADON) during the exit conference.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure that one residents (Resident (R)79) in the sample of 46 received care and services in a manner and environment that maintained dignified dining experience. Findings include: Review of R79's admission Record located under the Profile tab in the Electronic Medical Record (EMR) revealed R79 was admitted on [DATE] with diagnoses that included generalized osteoarthritis and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 11/04/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R79 was cognitively intact. Review of the Care Plan located under the Care Plan tab dated 11/13/24 revealed R79 was to have assistance with activities of daily living (ADL) as needed due to identified self-care deficit. Observation and interview on 02/11/25 at 08:38 AM, R79 was seated in his wheelchair at the foot of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interviews, and review of facility policy, the facility failed to ensure one of three residents (Resident (R) 21) reviewed for abuse was free from abuse in the sample of 46 residents. This failure had the potential for psychosocial impairment from being verbally abused by a staff member. Findings include: A review of the facility reported incident revealed that on 11/26/24 at approximately 9:00 AM, the Social worker witnessed the involved staff (medical records clerk) having a verbal exchange with the resident in an argumentative tone and when the involved staff was advised to walk away from the altercation, the staff member turned around and confronted the R21 and used profanity. Review of R21's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/26/24 revealed an admission date of 05/17/17 and a Brief Interview for Mental Status (BIMS)score of 15 out of 15 indicating R21 was cognitively intact. On 02/13/25 at 12:10 PM during an interview R21 stated that he had already talked with someone from the state about this incident. Interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on document review, record review, interview, and policy review, the facility failed to ensure residents were free from misappropriation for one of one resident (Resident (R) 177) reviewed for misappropriation. Specifically, Licensed Practical Nurse (LPN) 3 took Resident (R)177's Percocet (pain medication) from the medication cart. The facility's failure to safeguard medication placed all residents at risk for their medications to be misappropriated. Findings include: Review of the facility's investigation summary revealed, On 12/4/24, [Licensed Practical Nurse (LPN)5's name] received 2 blister packs of Percocet packs from the pharmacy around 5AM. [LPN5] then handed the 2 packs of Percocet off to [Registered Nurse (RN)5's name] who was responsible for two carts on the unit (referred to as the odd and even carts). Both cards were mistakenly placed on the even cart, causing a discrepancy, the even cart had three cards of Percocet and the odd cart had two cards of Percocet. An adjustment was made and both…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and policy review, the facility failed to implement policies and procedures for the reporting of abuse to the State Survey Agency (SSA) for one of five residents (Resident (R) 77) reviewed for abuse out of a total sample of 46 residents. These failures had the potential to contribute to continued abuse in the facility for this resident and other residents. Findings include: Review of the facility's policy titled, Reporting of Reasonable Suspicion of a Crime & Alleged Violations provided by the facility and dated 06/15/24 indicated, The facility will develop and operationalize policies and procedures for .reporting of abuse, neglect, mistreatment, and misappropriation of property .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and policy review, the facility failed to complete a thorough investigation into an allegation of staff to resident abuse for one of five residents (Resident (R) 77) reviewed for an allegation of abuse out of a total sample of 46 residents. The failure to conduct a thorough investigation had the potential to place other residents at risk for abuse. Findings include: Review of the facility's policy titled, Reporting of Reasonable Suspicion of a Crime & Alleged Violations revised 06/15/24 revealed, .In response to allegations of abuse .or mistreatment, the facility will: a. Have evidence that all alleged violations are thoroughly investigated .c. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law .The administrator, Director of Nursing (DON) or Designee will be responsible for obtaining all statements/forms from staff member and will also be responsible for the investigation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to provide treatment to a wound in accordance with the physician's order and revise the care plan to reflect the change of wound treatment for one of six residents reviewed for quality of care (Resident (R) 17) in the sample of 46 residents. The failure created the potential to cause a negative outcome to the healing of R17's wound. Findings include: Review of the admission Record located in R17's electronic medical record (EMR) under the Profile tab indicated the resident was admitted on [DATE] with diagnoses including acquired absence of right and left legs above the knees, peripheral vascular disease, and type 2 diabetes mellitus with diabetic neuropathy. Review of the quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 11/20/24 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. During an observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (Resident (R) R46) of two residents reviewed for pressure sores in the sample of 46 residents was provided with all planned interventions related to an existing pressure sore. This failure created the potential for the resident to experience further unnecessary skin breakdown. Findings include: Review of R46's undated admission Record dated 02/13/25 in the Electronic Medical Record (EMR) under the Summary tab indicated admitted to the facility on [DATE] with diagnoses including dementia and type 2 diabetes. Review of R46's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/24 in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated the resident was moderately cognitively impaired. The assessment indicated the resident was at risk for developing pressure ulcers but did not have any current pressure ulcers at the time of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to prevent an injury during incontinence care for two of eight residents (Resident (R) 171 and R170) reviewed for accidents out of a total sample of 46 residents. Specifically, the facility failed to utilize a mechanical lift for assistance out of bed for R170 and failed to properly assist R171 with bed mobility during incontinence care which according to the care plan required the assistance of two staff members. This failure resultedR171 sustaining a laceration to her forehead when she rolled off the bed during incontinence care. Additionally, R170 sustained a skin tear to the abdomen during incontinence care related to improper transfer. Findings include: 1. Review of R171's admission Record located in the Electronic Medical Record (EMR) under the Resident tab indicated she was admitted to the facility on [DATE] with diagnosis of cerebral infarction. Review of R171's Care Plan located in the EMR under the Care Plan tab initiated 09/01/20 included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure two Residents (R) R28 and R65) out of three residents reviewed for urinary function/catheters had appropriate orders in place related to the use of their indwelling urinary catheters in the sample of 46 residents. This failure created the potential for the residents to go without appropriate catheter related care. Findings include: Review of R65's admission Record, dated 02/13/25 in the Electronic Medical Record (EMR) under the Admissions tab indicated the resident was admitted to the facility on [DATE] with diagnoses included quadriplegia following a spinal cord injury and urinary retention. Review of R65's admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 11/05/24 and in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. The assessment indicated the resident had an indwelling urinary catheter in place in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review, observation, and interviews, the facility failed to ensure one (Resident (R) R65) out of seven residents reviewed for accidents in the sample of 46 resident was appropriate for the use of side rails on his bed. This failure created the potential for the resident to be injured related to potentially unnecessary side rails installed and in use on his beds. Findings include: Review of the facility's policy titled, Bed Rails/Grab Rails dated 05/03/24 indicated, The facility will attempt to use appropriate alternatives prior to installing a side or bed rail .The use of side rails will require a physicians order; .The use of bed rails will be included in the residents' plan of care .The nursing department will evaluate the resident for the use of bed/side rails upon admission, readmission, quarterly and as needed. Review of R65's admission Record, dated 02/13/25 and found in the Electronic Medical Record (EMR) under the Admissions tab, indicated the resident was admitted to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure one of six sampled residents (Resident (R) 176) whose medications were reviewed was free from significant medication error in the sample of 46 residents. Specifically, R176 was administered Ativan, an anxiolytic medication, and morphine, a narcotic pain medication, without a physician order for the medications. This medication error had the potential to cause the resident to become over sedated and experience respiratory depression. Findings include: Review of the summary provided by the facility revealed on 07/26/24 at approximately 9:35 PM, Registered Nurse (RN)4 started the medication pass for the hall she was assigned to on the evening shift. She took out medications for a hospice resident including 0.5 milligrams (mg) of Ativan and 15 mg of Morphine and proceeded to the room. RN4 did not check R176's armband or ask her name before administering the medications. After R176 swallowed the medication she realized she had given…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to implement an effective infection control program to ensure personal protective equipment (PPE) was used for one resident of one resident (Resident (R) 320) who was on contact isolation, and failed to identify COVID from the weekend to weekday for R80 who was not placed on contact isolation in a timely manner to prevent the potential spread of an infection. Findings include: Review of the facility's policy titled, Enteral Feeding Medication Administration dated 05/01/24 and provided by the facility stated, .Universal precautions and clean technique will be utilized when stopping, starting, flushing, and giving medications through the feeding tube. PPE [personal protective equipment] will be used as needed .The personal protective equipment worn will vary by task being performed and likelihood of exposure to body fluid .Enhanced Barrier Precautions will be used in the facility as extra level of protection for some residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

5. Review of R5's clinical record revealed: 12/29/15 - R5 was admitted to the facility. 11/14/17 - A PASARR 1.5 was completed for R5 with an outcome stating The individual does not have a serious mental illness (SMI) but further review of level of impairment, recent treatment history, or other circumstances demonstrates that a full II is not required . 1/18/22 - A new diagnoses of schizophrenia, anxiety disorder unspecified, and major depressive disorder, recurrent, moderate were identified. 10/24/22 - A new diagnosis of unspecified dementia, unspecified severity, with other behavioral disturbance was identified. 12/16/22 - A new diagnosis of bipolar disorder, unspecified, was identified. 1/25/23 - A new diagnosis of unspecified psychosis not due to a substance or know physiological condition was identified. 3/14/24 12:40 PM - In a telephone interview, S1 (PASARR State Authority) confirmed there should have been a resident review in 2022 as the PASARR 1.5 from 2017 is not a true reflection of R5's current clinical status. 3/15/24 11:41 AM - In an interview, E6 (SW) a second level…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that for one room out of five rooms reviewed for environmental concerns the facility failed to provide a clean and homelike environment. Findings include: Random observations of room [ROOM NUMBER] revealed: 3/11/24 10:37 AM - An observation of room [ROOM NUMBER] revealed the following: -A substantial amount of dirt and food crumbs scattered throughout the bedroom. -The bathroom revealed a substantial amount of small, circular black debris scattered throughout the floor. Also, next to the toilet had a circular area, brown in color approximately 12 inches by 6 inches in size. -There was approximately 3 feet of baseboard peeling off the wall and onto the floor. During this observation, an interview with the resident stated that (baseboard) has been that way for a year. The resident stated he told maintenance about it. 3/12/24 10:58 AM - An observation of room [ROOM NUMBER] revealed that there continued to be dirt and food crumbs scattered throughout the bedroom…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, it was determined that for one (R255) out of three residents reviewed for abuse, the facility failed to report a bruise of unknown origin. Findings include: 9/26/23 - An admission MDS assessment documented R255 had a BIMS score of 3 (severe cognitive impairment). 10/10/23 6:20 AM - A skin and wound note documented, resident noted with left upper arm bruise of unknown origin while care was being provided. 10/10/23 - A facility incident report documented that R255 had a bruise to the left upper arm. No measurements or description was documented in R255's clinical record. R255 was unable to explain what happened. 10/11/23 12:10 AM - An order note documented, monitor left upper arm bruise until resolved every shift. 10/12/24 2:07 AM - An order note documented, monitor right upper arm and chest bruise until resolved every shift for monitoring. The facility lacked evidence that a bruise of unknown origin was reported to the state agency within the required eight-hour time frame. 3/20/24 12:34 PM - During an interview, E2 (DON) confirmed that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and review of the clinical record, it was determined that for one (R309) out of two residents reviewed for admission, the facility failed to ensure that R309 had physician orders for the resident's immediate care. Findings include: 1 a. Review of R309's clinical record revealed: 3/6/24 - R309 was admitted to the facility. 3/6/24 6:30 PM - An admission assessment was completed for R309 indicating an indwelling urinary catheter in place. 3/6/24 - A care plan was initiated for indwelling urinary catheter. 3/9/24 - An admission MDS indicated R309 had an indwelling urinary catheter. 3/11/24 11:02 AM - An observation of R309 revealed an indwelling catheter in place and bag in a privacy bag. An interview with R309 confirmed use of indwelling urinary catheter related to neurogenic bladder (retention of urine). 3/12/24 9:32 AM - A physician's order revealed R309 use of indwelling urinary catheter related to neurogenic bladder. 3/13/24 2:22 PM - An interview with E19 (CNA) confirmed R309 was admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined that for one (R313) out of one residents reviewed for bowel and bladder incontinence care, the facility failed to ensure that R313 received treatment and care in accordance with professional standards of practice and physician orders. Findings include: 1. Review of R313's clinical record revealed: 6/19/23 - The EMR diagnosis page documented that R313 was admitted to the facility with a diagnosis of chronic idiopathic constipation. 6/19/23 Review of the physician's orders included medications for constipation: - Milk of magnesia (MOM)- give 30 ml by mouth every 24 hours as needed for constipation If no BM x 9 shifts. -Bisacodyl suppository- insert 1 suppository rectally every 24 hours as needed for constipation. Administer if MOM is ineffective or NO bowel movement x 10 shifts. -Bisacodyl oral tablets- give 10 mg by mouth every 24 hours as needed for Constipation. -Senna s tablets- give 2 tablets by mouth in the evening every other day for constipation. -Miralax powder- give 17 grams by mouth one time a day every other day for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, it was determined for one (R309) out of one resident reviewed for physician visits, the facility failed to ensure the physician reviewed the total program of care, including medications and treatments. Findings include: Review of R309 clinical record revealed: 3/6/24 - R309 was admitted to the facility. 3/6/24 6:30 PM - An admission assessment was completed for R309 indicating an indwelling urinary catheter was in place. 3/9/24 - An admission MDS indicated R309 had an indwelling urinary catheter. 3/9/24 0:00 AM - A physician's progress note revealed a history and physical completed for R309. The progress note assessed the genitourinary system and lacked evidence of an indwelling urinary catheter in place. 3/11/24 11:02 AM - An observation of R309 revealed an indwelling catheter in place and a bag in a privacy bag. An interview, R309 confirmed use of an indwelling urinary catheter related to neurogenic bladder (retention of urine). 3/12/24 9:32 AM - A physician's order revealed R309's use of an indwelling urinary catheter related to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, document review and interview it was determined that the facility failed to ensure that a qualified person in charge was present in the kitchen during all hours of food service operation. Findings include: 3/11/24 10:24 AM - During interview, E27 (Dietary Aide), disclosed that only one (1) staff member in the food service department possessed a valid Food Protection Manager certificate from an Accredited Food Safety Program. 3/20/24 2:40 PM - Findings reviewed with E1 (NHA), E2 (DON) and E3 (ADON) and E4 (Corporate) during the exit conference.

Based on observation and interview it was determined that for one (R14) out of one residents reviewed for food the facility failed to prepare food in a form designed to meet the individuals needs. Findings include: Review of R14's clinical record revealed: 6/19/18 - R14 was admitted to the facility. 2/28/24 - A physician's order stated that R14 was on a regular diet with ground meats/mechanical soft texture, regular/thin consistency liquids. (mechanical soft texture are foods that are moist, soft texture, and easily swallowed. Meats are ground or finely cut to equal size no bigger than 1/4 inch). 3/8/24 - A swallow study completed by an outside provider revealed R14 required ground solids and regular liquids. 3/11/24 approximately 12:30 PM - An observation of lunch with R14 revealed whole cauliflower florets. R14's meal ticket stated, 1/2 cup - Ground Parslied Cauliflower. R14 attempted to eat the cauliflower and spit out the stem and stated, I can't eat this, it's too hard. R14 does not use his dentures and has no other natural teeth. 3/11/24 1:10 PM - During an interview, E16 (RN)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview it was determined that the facility failed to ensure food was stored, prepared, and served in a manner that prevents food borne illness to the residents. Findings include: 3/11/24 10:34 AM - During the initial tour of the kitchen, there was a partially uncovered container of stuffed peppers in the walk-in refrigerator with the plastic cling film peeled back exposing the food to dirt, debris, and other contaminants. 3/11/24 10:38 AM - During a tour of the kitchen, the reach-in refrigerator contained a plate of unlabeled undated liverwurst. 3/11/24 11:07 AM - An observation of the nourishment refrigerator in the Henlopen hallway revealed a carton of Nutritional Shake that was undated. The instructions on the carton indicate that once opened, any remaining product should be discarded after four (4) days. 3/11/24 11:55 AM - During a tour of the kitchen, the surveyor observed E27 (Dietary Aide) test the sanitizer level of the solution in two red sanitizing buckets. When E27 tested the sanitizing solution, the test strips from each of the two buckets…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a random observation and interview, it was determined that the facility failed to ensure that two call bells (room [ROOM NUMBER]) in the facility was functioning properly. Findings include: 3/11/24 approximately 10:15 AM - During a random observation of room [ROOM NUMBER] the call bell box on the wall was taken apart and the wires were exposed. Both A and B bed call bells were unable to be plugged in thus were not functioning. Further observation revealed there wasn't any alternate equipment for the residents to call for help. 3/11/24 10:25 AM - During an interview E7 RN confirmed the call bell box was taken apart, the wires were exposed therefore the call bells were unable to be plugged in and there wasn't a bell or any kind of alternate means for the two residents to call for help. E7 was then asked if she knew how long the call bells were not functional? E7 stated she thought last week but wasn't sure. 3/11/24 10:42 AM - During an interview E1 (NHA) and E2 (DON) were asked if they were aware that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.