New Castle Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY R2 was admitted to the facility on [DATE], according to the resident's admission Record, found in the Electronic Medical Record (EMR) under the Profile Tab. The resident's diagnoses included Anoxic Brain Damage and Persistent Vegetative State. Observations of R2 on 12/09/25 at 2:38 PM, on 12/10/25 at 9:04 AM, 10:03 AM, 11:59 AM and 1:18 PM, and 12/11/25 at 10:31 AM, revealed grab bars raised on both sides of the resident's bed. The resident was laying in her bed in a vegetative state and unable to move her body. Observations of R2 laying in her bed in a vegetative state and unable to move her body were conducted on 12/09/25 at 2:38 PM, on 12/10/25 at 9:04 AM, 10:03 AM, 11:59 AM and 1:18 PM, and 12/11/25 at 10:31 AM. Grab bars were raised on both sides of the resident's bed during all of the observations. During an observation of R2 conducted along with Licensed Practical Nurse (LPN5) on 12/10/25 at 1:30 PM, LPN5 confirmed 1/4 grab bars were in the raised position on both sides of R2's bed. Review of R2's…

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 review of a clinical record and other documentation as indicated, it was determined that for one (R5) out of five residents reviewed for accidents, the facility failed to have evidence of a thorough investigation for a cognitively impaired resident who was identified at the hospital with multiple injuries of unknown origin. Findings include: Cross refer to F658 example 1 and F689 example 2 Review of R5's clinical record revealed: 3/20/25 - E4 (LPN) documented in a nurse's note that R5 fell while trying to sit on his chair in his room and had no injury. It should be noted that R5's 3/20/25 fall was witnessed and reported to the nurse by the assigned 1:1 CNA. R5's clinical record revealed that there were no other falls reported and documented after the 3/20/25 fall. 3/25/25 at 1:34 PM - The facility reported the following to the State Agency: On 3/24/25 [R5] was noted with a blood and tissue in his ear and he stated that he had scratched his ear. He was also noted with a change of condition, slurred speech with increased weakness. He was assessed by the NP [E5,…

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 interview, it was determined that for one (R5) out of three residents reviewed for discharge, the facility failed to allow R5 to return to the facility and also failed provide a 30 day discharge to his family representative. Findings include: The facility's Bed Hold Letter Policy - It is the policy of the facility to track Medicaid bed hold days and notify appropriate parties via Medicaid Bed Hold letter. Updated [DATE] The facility's admission Agreement- N. Bed Hold and Leave of Absence- . If Resident's primary pay source is Medicaid, and if the State within which the facility is located provides for paid hold/ leave days, the facility will hold the bed for the Resident up to ____________. If the resident's absence from the facility exceeds the days provided during a calendar year or the State does not provide for paid hold/leave days, the facility shall not hold the bed and the Resident will be discharged from the facility effective the first day following the last paid Medicaid…

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 two (R1 and R5) out of five residents sampled for accidents, the facility failed to meet professional standards of the Delaware Board of Nursing Scope of Practice by failing to have a registered nurse (RN) complete and document an RN admission assessment and post-fall assessment. Findings include: Delaware State Board of Nursing - RN, LPN and NA/UAP Duties 2024 . RN . admission Assessments . Post Fall Assessment & Documentation . updated 10/11/24. 1. Review of R1's clinical record revealed: 11/6/24 - R1 was admitted to the facility with diagnosis including dementia. 11/6/24 11:35 AM - E10 (LPN) initiated R1's admission observations in the EMR. 11/6/24 12:30 PM - E10 (LPN) completed R1's admission observations in the EMR. 11/6/24 12:31 PM - E10 (LPN) completed R1's functional abilities assessment in the EMR. 11/6/24 12:39 PM - E10 (LPN) completed R1's TB (tuberculosis) screen in the EMR. 11/6/24 1:05 PM - E6 (LPN) completed R1's baseline care plan checklist in the EMR. 5/2/25 11:40 AM- A review of the EMR admission…

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 (R1) out of four residents reviewed for accidents, the facility failed to have his advanced directive and copy of his DPOA (Durable Power of Attorney) readily accessible on his EMR during his 11/6/24 admission. Findings include: Review of R1's clinical record revealed: 6/21/23 - During a previous Facility admission, E5 (NP) completed the DMOST (Delaware Medical Orders for Scope of Treatment) form with R1, which stated Do not attempt resuscitation/DNAR. 11/6/24 - R1 was admitted to the facility with diagnosis including dementia. 11/6/24 11:48 AM - E6 (LPN) entered into R1's EMR a DNR (do not resuscitate) order. 11/7/24 9:44 AM - E11 (MD) signed the DNR order in R1's EMR. 11/7/24 1:56 PM - R1's admission Minimum Data Set (MDS) assessment documented a Basic Inventory of Mental Status (BIMS) score of 9, which was reflective of moderate cognitive impairment. 4/30/25 9:10 AM - A review of R1's EMR revealed no evidence of the DMOST form or the financial power of attorney document in R1's EMR. 4/30/25 10:35 AM - During an…

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 facility policy review, the facility failed to ensure foods were labeled, dated, sealed, and stored according to professional standards for food service safety in one of one kitchen. This failure had the potential to cause the spread of foodborne illness to all 115 census residents. Findings include: Review of the facility's policy titled, Equipment Cleaning and Sanitation Policy, dated 08/25/20, revealed The food and nutrition services staff will maintain a clean and sanitary environment in food service areas. The policy did not address food storage policies and procedures. During initial observations of the kitchen on 11/24/24 beginning at 8:47 AM, the following was observed: -In the dry storage, there was a box with a plastic bag inside containing powdered thickener. The bag was sealed at the top; however, there was a large hole ripped in the bag. Pieces of debris and food wrappers were observed inside the box. There was no date to indicate when the package had been opened. -In the dry storage, there was a package of prepared tart crusts that…

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, the facility failed to ensure all pureed foods on the menu were served to the seven residents who received pureed diets out of a total census of 115 residents. This failure placed the residents on pureed diets at risk for hunger, dissatisfaction with meals, unplanned weight loss, and malnutrition. Findings include: Review of the undated Diet Counts (Census), provided by the facility, revealed there were seven residents who received a pureed diet. Review of the undated Fall Winter 24125 Diet Guide Sheet, provided by the facility, revealed lunch meal for a pureed diet on 11/26/24 consisted of pureed roast beef, pureed creamed spinach, pureed egg noodles, pureed bread, and pureed spice cake. During observations of meal service in the kitchen on 11/26/24 beginning at 11:44 AM, there were no pureed noodles or pureed bread observed on the tray line. All seven residents who received a pureed diet were served a meal of only pureed roast beef, pureed creamed spinach, and pureed cake. During an interview on 11/26/24 at 11:59 AM, 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 observation, record review, and interviews, the facility failed to assess a resident for self-administration of medication for one of one resident (Resident (R) 7) reviewed for self-administration of medication of 37 sample residents. This had the potential to affect resident medication safety at the facility. Findings include: Review of R7's admission Record in the Profile tab of the electronic medical record (EMR) revealed an admission date of 05/26/23. The admission Record also revealed a diagnosis of chronic obstructive pulmonary disease, cognitive communication deficit, and dementia. Review of R7's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/26/24 and located in the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated the resident was severely cognitively impaired. Review of a completed Self-Administration of Meds Assessment located under the Observations tab of the EMR and with observation date of 11/12/24, revealed that the resident made the determination of not 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure residents had access to call lights when needing assistance from staff for one of three residents (Resident (R) 73) reviewed for call lights out of 37 sample residents. This failure had the potential to affect resident safety. Findings include: Review of the quarterly Minimum Data Set (MDS) located under the Resident Assessment Instrument (RAI) tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 11/04/24 revealed a Brief Interview for Mental Status (BIMS) of nine out of 15 which indicated the resident was moderately cognitively impaired. The resident was admitted on [DATE] with diagnoses which included atrioventricular block, muscle weakness, and osteoarthritis. During an observation and interview on 11/24/24 at 2:05 PM, the call light was observed on the opposite side of the bed. The call light was not within R73's reach. When R73 was asked if she needed to call for assistance, how would she…

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, interviews, record review, and facility policy review, the facility failed to protect two of four residents right to be free from physical abuse, Resident (R) 218 from physical abuse by R26, and R316 from physical abuse by R42 of 37 sample residents. This failure could lead to the potential of physical abuse towards other residents throughout the facility. Findings include: Review of the facility's policy titled, Delaware Resident Abuse policy: Abuse, Neglect and Exploitation, revised [DATE], indicated, under the section Policy: This Facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. The section Definitions: Abuse - includes actions such as the willful infliction of injury unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain…

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 review, and review of the facility's policy, the facility failed to report allegations of abuse to the appropriate reporting authority for two of four residents (Residents (R) 316 and R216) reviewed for abuse of 37 sample residents. This failure had the potential to affect resident safety at the facility. Findings include: Review of the facility's policy titled, Delaware Resident Abuse, revised on 09/28/22, revealed facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator would immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy. 1. Review of R316's Face sheet located under the Resident tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses to include dementia, anxiety disorder, major depressive disorder, and unspecified lump in the right breast. Review of R316's…

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, interviews, and facility policy review, the facility failed to ensure a thorough investigation was completed related to an allegation of physical abuse for one of four residents (Resident (R) 216) reviewed for abuse of 37 sample residents. This failure created the potential for R216 to experience further abuse. Findings include: Review of the facility's policy titled, Abuse, Neglect, Mistreatment, Exploitation of Resident Property, dated 09/28/22, read in part, The Facility will not tolerate abuse, neglect, mistreatment, exploitation, of residents, and misappropriation of resident property by anyone. It is the facility's responsibility to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown source. The facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator will immediately being…

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, record review, interview, and facility policy review, the facility failed to ensure the care plan was updated to reflect the use of a palm guard to address contractures for one of two residents (Resident (R) 89) reviewed for contractures of 37 sample residents. This failure placed R89 at risk for inconsistent use of the palm guards which could lead to pain and skin breakdown related to hand contractures. Findings include: Review of the facility's policy titled, Splint Issuance Policy, dated 03/11/22, revealed Patient splint schedule will be communicated to the multidisciplinary team and documented in the care plan. Review of the facility's policy titled, Comprehensive Care Planning Policy, dated 03/02/21, revealed The MDS [Minimum Data Set] Coordinator develops the current care plan .by addressing all unresolved problems from the previous care plan and/or noting on the care plan all new problems, approaches and target dates as they are identified in the: (1) current Resident Assessment…

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, interviews, and record reviews, the facility failed to ensure proper nephrostomy tube care for one of three residents (Resident (R) 367) reviewed for ostomy care of 37 sample residents. This failure has potential to cause residents to have urine back flow and cause blockage and infection. Findings include: Review of the Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses which included dysphagia, gastric ulcer disease, immobility, incontinence, colostomy, and sepsis. Review of R367's EMR Orders tab revealed an order, dated 11/21/24, Monitor output from nephrostomy. During an observation and interview on 11/24/24 at 12:24 PM, R367 was unable to speak. R367's unidentified Family Member (FM) 1 was visiting her and sat at the bedside. FM1 stated R367 was admitted for kidney stone that was not passing at the hospital. She stated they put in a stint for R367, but it (kidney stone) had not passed yet. At…

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, interviews, record review, and review of the facility's policy, the facility failed to ensure personal protective equipment (PPE) was utilized properly with proper hand hygiene during wound care for one of one resident (Resident (R) 92) reviewed for transmission-based or enhanced barrier precautions of 37 sample residents. This failure had the potential to contribute to the spread of infection among staff and residents. Findings include: Review of the facility's policy titled, Infection Prevention and Control Program, revised 05/11/23, revealed employees participated in performance improvement activities related to infection prevention (i.e., improved hand hygiene, respiratory hygiene/cough etiquette protocols, use of PPE) and participated in performance improvement activities by promoting enhanced hand hygiene. Review of the facility's policy titled, Transmission-Based Precautions and Isolation, revised 04/15/24, revealed Enhanced Barrier Precautions (EBP) - EBP were intended to prevent the transmission of multi-drug-resistant organisms (MDROs) via…

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 six (R25, R29, R31, R43, R56 and R119) out of six residents reviewed for advance directive, the facility failed to offer the opportunity to formulate an advance directive for each resident. Findings include: 1. R25's clinical record revealed: 5/4/23 - R25 was admitted to the facility. 5/11/23 - R25's admission MDS assessment documented the resident's BIMS as 11. While R25's initial mental status upon admission to the facility was moderately impaired, R25's BIMS was re-evaluated as a 14 on 8/1/23, 14 on 10/24/23 and 13 on 1/3/24, which reflected the resident was cognitively intact. Review of R25's clinical record lacked documented evidence that the resident was offered to formulate an advance directive. 1/25/24 at 10:58 AM - During an interview with E6 (Regional) and E7 (SW), E6 stated that they (the facility) are not doing it (offering residents to formulate an advance directive). 2. R29's clinical record revealed: 5/19/23 - R29 was admitted to the facility. 5/24/23 - R29's admission MDS assessment documented 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 for three (R29, R43 and R99) out of six residents reviewed for physician services, the facility failed to ensure each resident was seen for the required physician visits. Findings include: 1. R29's clinical record revealed: 5/19/23 - R29 was admitted to the facility. 5/25/23 - R29 was seen by E4 (Physician) for the initial comprehensive visit. Review of R29's physician visits revealed that the resident was seen on 7/26/23 by E5 (NP) and the next documented visit was on 11/8/23 by E5 (NP), approximately 104 days later. The nineth day visit was missed. 1/29/24 at 12:01 PM - During an interview with E4 (Physician), E5 (NP) and E1 (NHA), E4 stated that they are catching up on their visits and that going forward they are going to keep a log to ensure that the required visits are completed. 2. R43's clinical record revealed: 1/5/18 - R43 was admitted to the facility. 12/14/22 at 4:28 PM - A progress note documented that R43 was seen by E17 (Physician) for a routine visit. This was the last documented Physician visit until…

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 five (E19, E22, E23, E24 and E25) out of five CNAs (certified nurse's aides) reviewed, the facility failed to provide proof of annual performance reviews. Findings included: 1. E19 was hired on 6/27/22. The facility lacked evidence of a yearly performance evaluation. 2. E22 was hired on 8/1/22. The facility lacked evidence of a yearly performance evaluation. 3. E23 was hired on 7/12/22. The facility lacked evidence of a yearly performance evaluation. 4. E24 was hired on 8/1/18. The facility lacked evidence of a yearly performance evaluation. 5. E25 was hired on 8/3/22. The facility lacked evidence of a yearly performance evaluation. 1/26/24 3:45 PM - During an interview, E1 (NHA) and E2 (DON) confirmed the findings. 1/29/24 2:37 PM - Findings were reviewed E1 (NHA) and E2 (DON).

Based on observation, interview and record review, it was determined that the facility failed to ensure that the start dates were documented when over the counter medications (bottles) were opened in four out of four medication carts reviewed during medication administration. 1/22/24 8:25 AM - During the medication administration observations, this surveyor observed multiple opened bottles of over-the-counter medications in the medication drawers. The bottles lacked the dates when they were opened. During an interview, E56 (LPN) stated, I did not know we had to put start dates on the medications. 1/23/24 11:30 AM - During a phone interview E53 (pharmacist) stated, I reviewed the medications carts this month, and gave the report to the administration to take care of. A review of E53's report revealed documentation of medications without start dates on all four medication carts. 1/29/24 2:37 PM - Findings were reviewed E1 (NHA) and E2 (DON).

Based on record review and interview, it was determined that for eight (R25, R29, R31, R50, R56, R99, R123 and R276) out of thirty (30) residents clinical records reviewed, the facility failed to ensure that each residents' record was complete, accurately documented and readily accessible. Findings include: 1. R25's clinical record revealed: 8/21/23 at 11:20 AM - E4 (Physician) documented in a note, Patient seen and examined. Progress note to follow. As of 1/29/24, R25's clinical record lacked documented evidence of E4's 8/21/23 Physician completed progress note. 1/29/21 at 12:01 PM - During an interview with E4 (Physician), E5 (NP) and E1 (NHA), findings were reviewed regarding the incomplete and inaccurate clinical record. 2. R29's clinical record revealed: 12/8/23 at 11:14 AM - E4 (Physician) documented in a note, Patient seen and examined. Progress note to follow. As of 1/29/24, R29's clinical record lacked documented evidence of E4's 12/8/23 Physician progress note. 1/29/21 at 12:01 PM - During an interview with E4 (Physician), E5 (NP) and E1 (NHA), findings were reviewed…

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 record review, it was determined that the facility failed to promote R2's dignity by keeping R2's urinary collection bag in a privacy bag. Findings include: 7/1/15 - R2 was admitted to the facility. 10/12/23 - R2 's care plan documented, Requires urinary catheter for the diagnosis of retention with incomplete bladder emptying and obstructive uropathy. 12/28/23 - R2's physicians orders documented, Ensure the Foley bag (urinary collection bag) is covered every shift. 1/17/24 - R2 was observed lying in her bed at 8:30 AM, 10:30 AM, 12:30 PM. The urinary collection bag was not in the privacy bag and was visible from the hallway. 1/17/23 12:45 PM - Findings were confirmed with E52 (UM). 1/29/24 2:37 PM - Findings were reviewed E1 (NHA) and E2 (DON).

Based on interview and record review it was determined that for one (R474) out of one resident reviewed for choices, the facility failed to ensure the right to self-determine when R474's preference for showers were not completed. Findings include: 1. Review of R474's clinical record revealed: 8/2/22 - A significant change MDS assessed R474 as cognitively intact and the preference to choose type of bathing as very important. Review of facility shower schedule revealed that R474 was scheduled to receive two showers a week initially on Tuesdays/Fridays then a change to Monday/Thursday on evening shift. Review of CNA Point of Care [POC] record revealed R474 had the following: June 2022 - Three showers received. July 2022 - One shower received. August 2022 - Two showers received. During an interview on 1/25/24 at 3:18 PM, E2 (DON) explained that residents are supposed to receive two showers a week based on their room location. E2 then confirmed that R474 had not received at least two showers a week. 1/29/24 2:37 PM - Findings were reviewed E1 (NHA) and E2 (DON).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to ensure that R106 was free from side rails that were not required to treat the resident's medical condition. A facility policy titled, Bed rail policy, dated 3/10, and revised 4/24/23 documented, The use of bed rails will be limited to circumstances where they are used to treat a medical condition and enhance the residents' functional abilities. 11/7/22 - R106 was admitted to the facility with diagnoses including muscles weakness, and seizure disorder. 11/7/22 - R106's admission side rail assessment documented, No medical needs, and resident does not benefit from the use of side rails. 4/27/23 - R106's quarterly nursing side rail assessment documented, No medical needs for bed rails, and resident does not benefit from side rails. 12/27/23 - R106's quarterly MDS assessment documented that R106 was completely dependent on staff for bed mobility and transfers. 1/1/24 R106's quarterly MDS documented, No bed rails.…

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 for one (R106) out of three residents review for resident assessment the facility failed to accurately document R106's side rails on the MDS assessments. 11/7/22 - R106 was admitted to the facility with diagnoses including muscles weakness, and seizure disorder. 1/24/23 11:29 AM - R106's medical records documented, .[R106's] sister requested that side rails be placed on the bed .care plan updated, nurse practitioner made aware. 1/24/24 9:00 AM - A review of R106's MDS assessments for the dates of 2/7/23, 2/24/23, 5/23/23, 7/25/23, 10/19/23, and 1/1/24 documented, No bed rails. During an interview E52 (UM) stated, I have been working here for about one and a half year, and he [R106] has had those side rails. During an interview with the E53 (LPN RNAC) stated, I did not know that he [R106] had side rails. 1/29/24 2:37 PM - Findings were reviewed E1 (NHA) and E2 (DON).

Based on interview and record review it was determined that for one (R84) out of three residents reviewed for PASARR, the facility failed to ensure a referral for a new PASARR screening after changes to R84's mental health diagnoses. Findings include: Review of R84's clinical record revealed: 10/8/20 - A Level II PASARR was completed for R84. 10/2/22 - A progress noted documented that R84 was being seen by psych for new mental health diagnoses including adjustment disorder with depressed mood, major depressive disorder severe with recurrent symptoms and delusional disorders. 1/24/24 1:00 PM - In an interview, E7 (SW) stated that R84 did not have an updated PASARR evaluation. 1/24/24 1:30 PM - During an interview, E1 (NHA) stated that E7 just started doing her PASARR audits. 1/24/23 4:03 PM - In an email correspondence, P1 (PASARR State Authority) confirmed that the facility should have submitted a resident review for R84. 1/29/24 2:37 PM - Findings were reviewed E1 (NHA) and E2 (DON).

Based on observation, interview and record review for one (R106) out of three residents reviewed for careplans, it was determined that the facility failed to accurately develop and implement a comprehensive person-centered care plan for R106's use of bed rails. Findings include: 11/7/22 - R106 was admitted to the facility with diagnoses including muscles weakness, and seizure disorder. 1/24/23 11:29 AM - R106's medical records documented, .R106's sister requested that side rails be placed on the bed .care plan updated, nurse practitioner made aware. 1/16/24 9:30 AM - R106 was observed laying on a concave mattress in bed with two long bed rails in the raised position. 1/16/24 11:30 AM - R106 was observed laying on a concave mattress in bed with two long bed rails in the raised position. 1/17/24 10:15 AM - R106 was observed laying in a concave mattress in bed with two long bed rails in the raised position. 1/24/24 9:15 AM - A review of R106's care plans lacked evidence for the use of the bed rails. During an interview E52 (UM) stated, I have been working here for about one and a half…

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 facility documentation, it was determined that for one (R524) out of two residents reviewed for discharge, the facility failed ensure that R524's discharge needs regarding his wound care were identified. Findings include: Review of R524's clinical record revealed: 8/20/23 - R524 was admitted to the facility for a five (5) day respite stay. 8/23/23 - The following orders and notes were written: - A progress note was written by E50 (RN) that the resident had a skin tear under his right 3rd toe while he was self-ambulating with non-skid socks on. - 9:25 AM - A physician order was written by E51 (Wound MD) for wound care that was to cleanse the right 3rd toe, pat dry, apply bacitracin (an antibiotic ointment) and leave open to air, every day shift. 8/25/23 7:53 AM - A discharge summary note was written by E7 (SW) that documented under the nursing section that no nursing education was provided, that a skin tear wound was currently present, and with the current wound care as described above. 1/18/24 3:00 PM - During an interview, E10 (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined that for one (R476) out of three residents reviewed for accidents the facility failed to ensure R476 received adequate supervision during a transfer. Findings include: Review of R476's clinical record revealed: R476' care plan for falls last reviewed 3/17/22 included the intervention to transfer the resident with assistance of two staff members. 4/4/22 - A physical therapy discharge summary documented, Staff reports consistent one person transfers, on average moderate assist fluctuates depending on patients level of motivation for the task. There was no documented change in R476's clinical record to change to one person assistance transfers. 8/29/22 - A quarterly MDS assessment documented R476 as being cognitively impaired and requiring total assistance of two staff members for transfers with impairment to one side. 11/21/22 - A quarterly MDS assessment documented R476 as being cognitively impaired and requiring extensive assistance of two staff members 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined that for one (R31) out of three residents reviewed for bowel and bladder, the facility failed to ensure that R31 was appropriately assessed on admission to ensure that treatment and services were provided to promote continence of bladder and bowel to the extent possible. 10/31/23 - R31 was admitted to the facility with diagnoses including muscle weakness gait abnormality and diabetes. 10/31/23 - R31's admission bowel and bladder assessment lacked documentation of whether she was continent or incontinent of bowel. R31's bladder assessment documented, no altered bladder elimination. 10/31/23 - R31's [NAME] (electronic record for care givers for resident's care) documented, Assist of one (1) with mobility, provide incontinence care as needed. 11/3/23 - R31's admission MDS documented a BIMS score of 13 indicating cognitively intact. 11/7/23 - R31's urinary care plan documented, [R31] is incontinent of bowel and bladder, with interventions…

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 ( R475) out of four residents reviewed for nutrition the facility failed to implement interventions related to risk for weight loss when the weekly weights were missed and percentage of supplement consumed was not documented. Findings include: The facility policy on Resident weights, last updated 12/12/23 indicated, Weights will be obtained routinely in order to monitor national health over time. Each residents weight will be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission and monthly or more often if risk is identified, or as ordered. Nursing is responsible for obtaining weights. Review of R475's clinical record revealed: 2/6/23 - 2/16/23 - Hospital records documented, Weight 122.75 pounds [55.8 KG] history and physical reports poor appetite and decreased intake .nutrition problem related to increased nutrient needs. readmission risk moderate. 2/16/23 - R475 was admitted to the facility with multiple diagnosis including dementia and dysphagia.…

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, record review and review of other facility documentation, it was determined that for two (R525 and 274) out of five residents reviewed for pain, the facility failed to ensure that that adequate pain management was provided for R525 and R274 pain assessments were not conducted with a consistent scale for pre and post pain assessments. Findings include: The pain management standards were approved by the American Geriatrics Society in April 2002 which included: appropriate assessment and management of pain; assessment in a way that facilitates regular reassessment and follow-up; same quantitative pain assessment scales should be used for initial and follow up assessment; set standards for monitoring and intervention; and collect data to monitor the effectiveness and appropriateness of pain management. According to The National Library of Medicine (2008) pain should be reassessed after each intervention to evaluate the effect and determine whether modification is needed. Review of R525's clinical record revealed: 8/4/22 - R525 was admitted to the facility with…

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, and record review, the facility failed to accurately assess R106's medical condition for the necessary use of two (2) bed rails. Additionally, the facility failed to ensure the bed rail padding was provided on the bed rails as documented in R106's medical records. Findings include: A facility policy titled, Bed rail policy, dated 3/10, and revised 4/24/23 documented, The use of bed rails will be limited to circumstances where they are used to treat a medical condition and enhance the residents' functional abilities. 11/7/22 - R106 was admitted to the facility with diagnoses including muscles weakness, and seizure disorder. 11/7/22 - R106's admission side rail assessment documented, No medical needs, and resident does not benefit from the use of bed rails. 4/27/23 - R106's quarterly nursing side rail assessment documented, No medical needs for bed rails, and resident does not benefit from bed rails. 6/29/23 - R106's [NAME], and care plan documented, Bed rail padding. 12/27/23 -…

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 interview, it was determined for one (R274) out of five sampled residents for pain the facility failed to provide routine pharmaceutical services for acquiring and receiving medication. Findings include: Review of R274's clinical record revealed: [DATE] - R274 was admitted to the facility with a diagnoses of cervical disc degeneration, wedge compression fracture of thoracic vertebra, and chronic low back pain. [DATE] - An updated physician order was written for hydromorphone (narcotic pain medication) 2 mg give one tablet every eight hours as needed for severe pain. [DATE] 6:33 PM - A shipment detail form confirmed delivery of hydromorphone (15 tablets) by pharmacy to the facility. [DATE] 10:20 PM - A controlled substance log revealed that R274 received a dose of hydromorphone and the count resulted of zero of quantity. [DATE] 9:45 AM - A progress note revealed that R274 was out of hydromorphone 2 mg. E9 (LPN) notified pharmacy that medication was not available and requested to remove…

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 two (R54, R98) out of five residents (R2, R43, R54, R98, R106) reviewed for unnecessary medications, the facility failed to ensure that R54's PRN for Lorazepam Gel 1 mg for anxiety was limited to 14 days, and R98's PRN order for Alprazolam 1 mg for anxiety was limited to 14 days. Findings include: 1. 11/20/23 - R54 was admitted to the facility with diagnosis including muscle weakness, dementia, and major mood disorder. 12/22/23 - R54's physician's orders included, lorazepam gel, apply to skin topically every twelve (12) hours as needed for agitation. 1/18/24 - A review of R54's physician's orders revealed that the PRN order for lorazepam gel was still active for a total of twenty-seven (27) days. 1/22/24 8:30 AM - During an interview E2 (DON), confirmed that R54's clinical record lacked the fourteen (14) days stop date for the use of the PRN antianxiety medication. 2. 12/22/23 - R98 was admitted to the facility with diagnoses including anxiety disorder and depression. 12/26/23 - R98's physician's orders 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.