Encore At Parkside

Based on record review and interview, it was determined that for one (R106) out of eighteen residents reviewed for quality of care, the facility failed to notify family representative of the resident's 8/1/25 lab work. Findings include:Facility Consent for Treatment form stated, We will keep you informed about the routine nursing and emergency care we provide to you, and we will answer your questions about the care and service we provide you. Last reviewed 7/9/20247/24/25 - E6 (MD) ordered in R106's EMR, Labs - CMP (complete metabolic panel), CBC (complete blood count) in one week from date of admission. 7/25/25 - R106 was admitted to the facility with diagnoses including but not limited to pancreatic cancer.7/31/25 - R106's admission MDS (Minimum Data Set) revealed R106's BIMS (Basic Inventory of Mental Status) as 13, which was reflective of normal cognition.8/1/25 8:12 AM - R106 had labs (CMP, CBC) drawn at the facility.8/1/25 10:00 AM - F7 (R106's wife) signed R106's discharge paperwork and R106 was discharged from the facility.8/1/25 11:29 AM - R106's lab results were reported…

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 (R6) out of one resident reviewed for discharge, the facility failed to ensure that R6 had home health services arranged per the discharge plan from the facility to home on [DATE] (Friday). Findings include: Review of R6's clinical record revealed:9/26/25 - R6 was care planned for discharge with the goal to be discharged to home. Approaches included:-home health services per physician order;-physician to review discharge and admission orders, care plan and prior level of function;-therapy services per physician order.12/5/25 - An insurance appeal determination letter documented, A review of the medical records received shows that the patient [R6] was admitted to a SNF [skilled nursing facility]. Self-care tasks such as bathing, dressing, and toileting require moderate to maximum assistance. Bed mobility tasks require supervision assistance. Transfer tasks require moderate assistance. The patient can walk up to 50 feet with a wheeled walker and…

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 (R46) out of one resident reviewed for PASARR (Preadmission Screening and Resident Review), the facility failed to complete MDS assessments to accurately reflect changes in R46's behavior and medication status. Findings include:Review of R46's clinical record revealed:11/15/2024 - R46 was admitted to the facility with diagnoses including hypertension and osteoarthritis.4/29/2025 - A Behavior Note entered in R46's clinical record documented, [R46] noted agitated sitting around nurse's station.asking roommate to get off his property.[R46] yelling at everyone to vacate his property.5/26/2025 9:30 PM - A Behavior Note entered in R46's clinical record documented, [R46] continues to yell at the nursing station.5/29/25 - A quarterly MDS assessment completed for R46 indicated no behaviors of delusions or yelling at others.8/22/25 9:04 AM - A Behavior Note entered in R46's clinical record documented, Staff reported that [R46] was aggressive verbally and physically hitting his CNA in the face.aggression started when [R46]…

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 one (R94) out of two residents reviewed for catheters and one (R91) out of three residents reviewed for ADLs (Activities of Daily Living), the facility failed to ensure that a person-centered care plan was developed to address each residents' identified needs. Findings include:1. Review of R94's clinical record revealed: 12/13/25 – R94 was admitted to the facility with a diagnosis of a stroke. 12/15/25 – A physician's order stated to bladder scan q6 [every 6 hours]. Straight cath if PVR [post void residual] is greater than 400 ml [milli-liters]. Document output every 6 hours. Review of the R94's care plan lacked evidence of the development to address R94's urinary retention and the approaches on how the facility would meet R94's needs. 1/9/26 3:08 PM – During a combined interview with E2 (DON) and E3 (ADON), finding was reviewed and confirmed. 2. Review of R91's clinical record revealed: 12/16/25 – R91 was admitted to the facility with diagnoses including severe dementia with agitation. 12/17/25 – R91 had…

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 (R80) out of four residents reviewed for respiratory care, the facility failed to review and revise the resident's care plan. Findings include: 8/28/23 - R80 was admitted to the facility.9/25/25 - R80 was re-admitted to the facility after hospitalization for COVID pneumonia with acute respiratory failure and hypoxia (low oxygen saturation).9/25/25- E6 (MD) ordered in R80's EMR, Change mask/cannula and tubing and clean oxygen concentrator filter every night shift every Thursday.10/1/25 - R80's admission MDS (Minimum Data Set) assessment documented that R80 was using supplemental oxygen.1/8/26 12:30 PM - A review of R80's care plan lacked evidence of the addition of R80's supplemental oxygen intervention, goals and tasks.1/8/26 1:11 PM - During an interview, E7 (RNAC) stated, I don't see any mention of oxygen therapy in [R80]'s care plan. I will add it.The facility failed to revise R80's care plan to include his supplemental oxygen requirement after the 10/1/25 MDS assessment.1/12/25 3:30 PM - 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 record review, observation and interview, it was determined that for one (R80) out of four residents reviewed for respiratory care, the facility failed to provide care consistent with professional standards as the supplemental oxygen tubing was out-of-date. Findings include:8/28/23 - R80 was admitted to the facility.9/25/25 - R80 was re-admitted to the facility after hospitalization for COVID pneumonia with acute respiratory failure and hypoxia (low oxygen saturation).9/25/25- E6 (MD) ordered in R80's EMR, Change mask/cannula and tubing and clean oxygen concentrator filter every night shift every Thursday.9/25/25 10:51 PM - R80's alert charting note documented, Resident arrived at facility via stretcher on oxygen 2L (liters) via nasal cannula.1/5/26 (Monday) 2:15 PM - An observation of R80's supplemental oxygen tubing revealed that it was marked as having been changed on 12/26/25 (11 days prior).1/8/26 (Thursday) 1:11 PM - An observation of R80's supplemental oxygen tubing revealed that it was marked as having been changed on 12/26/25 (14 days prior).1/9/26 1:37 PM - 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 record review and interview, it was determined that for one (R22) out of four residents reviewed for accidents, the facility failed to ensure that R22 received medically-related social services, when it was determined that the resident lacked capacity for medical decision making in F6's (MD) progress note dated 11/10/25. Findings include: The facility's job description of Social Worker, updated July 2015, included, but were not limited to the following job duties:- . 2. Assists with the coordination of Health Center admissions. 9. Maintains regular and on-going relationship with family to discuss needs or concerns, mediates issues that may arise between resident/family/staff. Cross refer to F553 example #1 and F561 example #1 Review of R22's record revealed: 9/21/25 - A typewritten letter from F5 (R22's POA/friend) to R22 stated, September 21, 2025. [R22's name] As you have informed me, in a few days you'll be returning to your home. You've asked me for keys and I am enclosing the set you gave me some time ago . I am reminding you I will no longer be available 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 interview and record review, it was determined that for one (R3) out of two residents reviewed for dental services, the facility failed to provide or obtain from an outside resource, R3's routine dental services. Findings include:Cross refer F553 and F656Review of R3's clinical record revealed:12/15/25 - R3's quarterly MDS assessment revealed that R3 had a BIMS score of 15 and an intact cognition.1/5/26 1:35 PM - In an interview, R3 stated that it has been a long time since she was last seen by the dentist. R3 stated, I did not know that I can be seen by a dentist here in the facility.1/9/26 11:10 AM - Further review of R3's clinical records lacked evidence of dental consults and appointments for 2025.1/9/26 11:30 AM - In a telephone interview, F3 (Family Member and POA) stated that she and R3 prefer to set up the appointments and transportation services for R3's outside facility consultations and that included an unsuccessful dental clinic visit. When asked if R3 was seen by the dentist lately, F3 stated that R3 was all set up for the dental visit one time but the dentist…

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 facility record review, it was determined that the facility failed to ensure that it had a written transfer agreement in effect with one or more hospitals approved for participation in Medicare/Medicaid programs. Findings include:Review of facility documents revealed:12/15/25 - A [NAME] of Sale between O1(former facility owner) and O2 (new facility owner) was made and entered into. 1/12/26 9:00 AM - A request for the facility's written transfer agreement was made to E1 (Interim NHA). 1/12/26 2:46 PM - E1 confirmed that the facility did not have a written transfer agreement. 1/12/26 3:30 PM - Findings were reviewed with E1 and E2 (DON) during the Exit Conference.

Based on interview and facility record review, it was determined that the facility failed to ensure that it has complied with the disclosure of ownership requirements. Findings include:Review of facility documents revealed:12/15/25 - A [NAME] of Sale between O1(former facility owner) and O2 (new facility owner) was made and entered into. 1/12/26 9:00 AM - A request for the facility's written notice to the State Agency responsible for licensing with disclosure requirements at the time of change was made to E1 (Interim NHA). 1/12/26 2:46 PM - E1 confirmed that the facility did not have the document with the facility disclosure of ownership requirements. 1/12/26 3:30 PM - Findings were reviewed with E1 and E2 (DON) during the Exit Conference.

Based on observation, record review and interview, it was determined that for one (R94) out of four residents reviewed for accidents, the facility failed to ensure R94's bilateral bed rails were being included in a routine maintenance safety check. Findings include: Review 94's clinical record revealed: 1/5/26 2:11 PM - Observation of bilateral bed rails positioned up on R94's bed. 1/9/26 9:49 AM - Observation of R94 in bed revealed bilateral bed rails positioned up and no gap. R94 confirmed that he used them during therapy sessions. 1/9/26 10:13 AM - During an interview, E30 (Maintenance Director) was asked if there are routine maintenance/safety inspections of bed rails being performed in the facility. He stated no, but he would start doing this. E30 stated that maintenance staff would apply resident bed rails when the request was submitted through the maintenance work order system. He also stated that therapy would remove bed rails if they were no longer necessary. 1/12/26 3:30 PM - Finding was reviewed during the exit conference with E1 (Interim NHA) and E2 (DON).

Based on interview and review of facility documentation, it was determined that for seven (E14, E15, E16, E17, E18, E19, and E21) out of seven facility staff reviewed, the facility failed to ensure that the required Communications training was completed. Findings include:1/12/26 1:30 PM - Review of the facility training records revealed a lack of evidence of Communications training for the following facility staff:2/4/25 - E14's first day in the facility as RN (Registered Nurse).4/1/25 - E15's first day in the facility as RN.3/18/25 - E16's first day in the facility as CNA (Certified Nurse Aide).9/16/25 - E17's first day in the facility as CNA.6/10/25 - E18's first day in the facility as CNA.10/8/24 - E19's first day in the facility as LPN (Licensed Practical Nurse).11/18/25 - E21's first day in the facility as Restorative Aide/CNA.1/12/26 2:00 PM - Findings were discussed with E1 (Interim NHA).1/12/26 3:30 PM - Findings were reviewed with E1 and E2 (DON) during the Exit Conference.

Based on record review and interview, it was determined that for four (R1, R2, R3, R4) out of four residents reviewed for admission, the facility failed to provide services that meet the professional standard of quality as defined by the Delaware State Code regarding RN (registered nurse), LPN (licensed practical nurse) and NA (nurse aide)/ UA (unlicensed assistant) Duties for admission assessments. Findings include: Delaware State Board of Nursing - RN, LPN and NA/UAP Duties 2024 .admission Assessments *. RN (registered nurse) . *Once a care plan is established, the LPN may do assessments. Updated 10/11/24Facility admission Assessment and Follow Up: Role of the Nurse policy included a document that listed all the evaluations in the facility EMR that were considered admission Evaluations. The list included: N Adv- Clinical Admission, N Adv- Skin Check, N Adv- Braden scale- for Predicting Pressure Ulcer Risk Evaluation, N Adv- Lift/Transfer Evaluation, N Adv -Fall Risk Evaluation, N Adv -Dehydration Risk Evaluation, N Adv- Elopement Evaluation, Hot Liquids Safety Data Collection,…

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 Pharmacy services, the facility failed to provide pharmaceutical services that included acquiring and receiving a medication (lorazepam) to meet R1's needs during her 8/5/25 admission. Findings include:Facility Pharmacy Information document stated, Pharmacy Order Timeline - New Orders, admission Orders or Refills ordered by 11 AM have a delivery window of 9 PM to 11 PM. Controlled Substances Orders - Controlled substances can only be sent upon valid script from a prescriber or a verbal order from a prescriber or an agent of the prescriber. (Note Agents of the prescriber may NOT order CII, only CII, CIV and CV.) Issued Jan-2024The U.S Drug Enforcement Agency (DEA) listed lorazepam as a Schedule VI medication. Drugs, substances, and certain chemicals used to make drugs are classified into five (5) distinct categories or schedules depending upon the drug's acceptable medical use and the drug's abuse or dependency potential. 15-Oct-2025Review of R1's clinical record…

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 observations, interviews, and policy review, the facility failed to ensure food was served under sanitary conditions and failed to ensure the kitchen was kept in a clean and sanitary manner to prevent contamination from foreign substances and the potential for development of foodborne illnesses. This deficient practice has the potential to affect 89 of 91 residents who received meals and beverages prepared in and served from the facility's kitchen. Findings include: During the initial kitchen tour on 11/24/24 at 8:54 AM, upon entrance to the kitchen through the dishwasher area, observation of the floor, the floor underneath the dishwasher, freezer, cooler, and shelf revealed trash, food debris, dust/dirt, and a greasy blackish-brown substance. The substance was found throughout the kitchen on the floors, legs/feet of equipment, and underneath freestanding coolers and freezers, as well as the range, ovens, prep tables, and shelving. The greasy substance stained the baseboards and walls. Observation of the commercial juice machine revealed the water lines were stained with a…

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 policy review, the facility failed to ensure one of 25 sampled residents (Resident(R) 18) was afforded the opportunity to be included in all aspects of person-centered care planning. Findings include: Review of the facility's policy titled, Care Plan, Comprehensive, Person-Centered Care, revised March 2022, read in pertinent part, 1. The Interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . The resident is informed of his or her right to participate in his or her treatment and provided advance notice of care plan conferences. Review of R18's Face Sheet, located in electronic medical record (EMR) under the Profile tab, revealed an admission date of 06/02/22 with diagnoses of major depressive disorder, sarcoidosis, and erythema intertrigo. Review of the Care Plan Conference Summary Form, provided by the facility, revealed no documented evidence that the resident attended the care plan meeting held on 06/05/24.…

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 review of facility policy, the facility failed to maintain the personal privacy of one resident (R3) during medication administration from a sample of 25 residents. This failure had the potential to cause embarrassment to the resident. Findings include: Review of R3's admission Record, located in the resident's electronic medical records (EMR) section titled Profile, revealed the resident was admitted to the facility on [DATE] with diagnoses that included sarcopenia (muscle loss) and osteoarthritis. Review of R3's Physicians Orders for November, located in the resident's EMR section titled Orders, revealed that the resident was to receive a Lidocaine 4% pain patch every morning. Observation during medication administration on 11/26/24 at 9:05 am revealed Licensed Practical Nurse (LPN) 1 administering a Lidocaine pain patch to R3's left shoulder. R3 was seated in her wheelchair at the nurses' station. LPN1 pulled the resident's shirt over the resident'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 interview, record review, and policy review, the facility failed to provide written notification of the bed hold policy to the resident and responsible party (RP) for one of five residents (Resident (R) 287) reviewed for hospitalization out of a total sample of 25. The failure had the potential to affect the residents planning on returning to the facility. Findings include: Review of R287's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R287 was admitted to the facility on [DATE] with acute respiratory failure and dysphagia (difficulty swallowing). On 10/30/23 R287 was diagnosed with COVID-19 and discharged to a hospital on [DATE]. Review of R287's Health Status Note, dated 11/10/23 at 9:34 AM and located in the EMR under the Progress Note tab, revealed, . Resident sent out to the ER [emergency room] for further evaluation. Spouse notified and she also requested bed hold until issue is resolved . Review of the Misc (miscellaneous), Prog (progress) Notes,…

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 review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one resident (Resident (R) 22 out of 25 sampled residents had an accurate Minimum Data Set (MDS) assessment. This had the potential to cause the resident to have unmet care needs. Findings include: Review of the RAI Manual, dated 10/01/19, indicated, . It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. Review of R22's admission Record, located in the resident's electronic medical record (EMR) section titled Profile, revealed the resident was admitted to the facility with diagnoses that included congestive heart failure and shortness of breath. Review of R22's Physician Orders, dated 09/23/24 and located in the resident'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 observation, interview, record review, and review of facility policy, the facility failed to revise care plans for three of 25 sampled residents (R22, R65, and R70). The care plan for R22 was not revised to reflect his oxygen therapy. The care plan for R65 was not revised to reflect an incident of wandering into a female resident's room. R70's care plan was not revised to reflect the resident's urinary catheter. This failure had the potential to affect care provided to the residents. Findings include: 1. Review of R22's admission Record, located in the resident's electronic medical record (EMR) section titled Profile, revealed the resident was admitted to the facility on [DATE] with diagnoses that included congestive heart failure and shortness of breath. Review of R22's Physician Orders, dated 09/23/24 and located in the resident's EMR section titled Orders, revealed the resident was to receive continuous oxygen therapy at two liters via nasal cannula. A review of R22's Care Plan, located in 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 increase the frequency of assessments when a resident was diagnosed with COVID-19 for one of three residents (Resident (R) 287) reviewed for COVID-19 infection out of a total sample of 25. The lack of assessment could result in the facility not noticing symptoms which warranted further treatment and intervention. Findings include: Review of R287's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R287 was admitted to the facility on [DATE] with acute respiratory failure and dysphagia (difficulty swallowing). Review of R287's Order Summary Report, located in the EMR under the Orders tab, revealed an order dated 07/26/23 which read, Monitor the following at least daily. Vital Signs - Temp, Pulse, Respirations, Pulse OX [oxygen saturation level], B/P [blood pressure], for COVID-19 symptoms of Fever, Chills, Cough, Shortness of Breath . if symptoms occur, place resident in transmission-based…

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, record review, and review of facility policy, the facility failed to provide supervision for one of five residents (Resident (R) 65) reviewed for supervision out of a total sample of 25. The failure had the potential to cause harm to R65 due to his behavior of wandering. Findings include: Review of R65's admission Record, located in the resident's electronic medical record (EMR) section titled Profile, revealed the resident was admitted to the facility on [DATE] with diagnoses that included cognitive communication, dementia, anxiety disorders, and altered mental status. Review of R65's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/21/24 and located in the resident's EMR section titled MDS, revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of 00 which indicated the resident was severely impaired in cognitive skills for daily decision making. It was recorded that the resident did not exhibit any wandering…

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 provide appropriate treatment and services for urinary catheters for one of three residents (Resident (R) 70) reviewed for urinary catheters out of a total sample of 25. The facility failed to have physician orders for the use of a urinary catheter and failed to ensure the drainage bag and tubing were not placed directly on the floor, inhibiting the proper flow of urine. The failure had the potential for the resident to develop reoccurring urinary tract infections (UTIs). Findings include: Review of R70's admission Record, located in the resident's electronic medical record (EMR) section titled Profile, revealed the resident was admitted to the facility on [DATE] with diagnoses that included urinary tract infection (UTI), hydronephrosis, urinary retention, and chronic kidney disease. Review of the R70's admission Minimum Data Set (MDS), with an Assessment Reference Date of ARD of 10/13/24 and located under the MDS tab of the EMR, revealed…

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 administer oxygen at the physician prescribed dose for two of five residents (Residents (R) 9 and 22) reviewed for respiratory care out of a total sample of 25. This had the potential to cause the residents respiratory distress. Findings include: 1. Review of R9's admission Record, located in the Profile tab of the electronic medical record, (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses that included pneumonia, chronic obstructive pulmonary disease (COPD), and chronic respiratory failure. Review of R9's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/26/24 and located under the MDS tab of the EMR, revealed R9 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident was moderately cognitively impaired. Review of R9's Physician Orders, located in the EMR under the Physician Orders tab, revealed an order dated 10/16/24 for oxygen 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 interview, record review, and policy review, the facility failed to document an end date for an as needed (PRN) psychotropic medication for one of six residents (Resident (R) 294) reviewed for unnecessary medications out of a total sample of 25. The failure had the potential for residents to receive psychotropic medications without ongoing assessment by a physician or practitioner for continued appropriateness. Findings include: Review of R294's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed R294 was admitted to the facility on [DATE]. R294 had diagnoses which included anxiety, depression, and bipolar disorder. Review of R294's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/28/24 and located in the MDS tab of the EMR, revealed R294 scored 14 out of 15 on her Brief Interview for Mental Status (BIMS), which indicated she was cognitively intact. Review of R294's Encounter, dated 09/20/24 at 1:00 AM and located in the EMR under…

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 reviews, interviews, and a review of facility policy, the facility failed to secure one of three (Second floor medication cart) medication carts on one of two nursing units. The facility failed to dispose of expired supplies in one of two (Second floor medication storage room) medication storage rooms. These failures had the potential to result in residents being subject to unsafe or ineffective treatment or adverse effects leading to more serious illnesses and could permit unauthorized access to residents' medications. Findings include: 1. Observation on [DATE] at 6:34 PM revealed the second-floor medication cart was unlocked and was located between rooms [ROOM NUMBERS], approximately six steps away from the nurses' station. The cart remained unlocked for nine minutes and fifty-eight seconds. The top drawer contained insulin pens and over-the-counter medications. The second drawer contains residents' medications and a locked narcotic box. No staff were present, and the cart was not…

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 (R1, R2 and R3) out of three residents reviewed for elopements the facility failed to recognize the elopements as allegation's of neglect. This resulted in the failure to report them to the State Agency. Findings include: The facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating last updated, September 2022 indicated,If resident abuse neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected the suspicion must be reported immediately to the administrator and to other official according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the state agency . 1. 7/11/24 - R3 eloped from the facility. 2. 8/16/24 and 8/18/24 - R1 eloped from the facility. 3. 8/17/24 - R2 eloped from the facility. 8/22/24 - Review of the State Agency's Incident Referral Center revealed the facility's last reported elopement was on 11/30/22. During an interview on 8/23/24 at 12:50 PM,…

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 facility documentation, it was determined that for seven (E8, E12, E15, E16, E21, E27 and E28) out of ten staff reviewed, the facility failed to ensure that the required Behavioral Health training was completed. Findings include: 8/27/24 - Review of the employee training records revealed a lack of evidence of Behavioral Health training of the following staff: 11/18/21- E8 (receptionist) and E12 (RN) were hired by the facility. 1/20/22 - E28 (CNA) was hired by the facility. 3/7/23 - E15 (LPN) was hired by the facility. 7/25/23 - E16 (CNA) was hired by the facility. 8/8/23 - E21 (H) was hired by the facility. 10/3/23 - E27 (CNA) was hired by the facility. During an interview on 8/28/24 at 11:15 AM, E1 (ED) confirmed the above staff did not receive their required training. Findings were reviewed during the exit conference on 8/28/24 at 1:06 PM with E1 (ED), E2 (DON) and E3 (ADON).

Based on record review and interview it was determined that for one (R3) out of three residents reviewed for elopement the facility failed to thoroughly investigate an allegation of neglect. Findings include: The facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating last updated, September 2022 indicated, All investigations will be thoroughly investigated. 7/11/24 2:40 PM - A progress note in R3's clinical record documented the resident eloped from the facility. 8/23/24 9:15 AM - The Surveyor requested the investigative documents for R3's elopement. 8/23/24 2:12 PM - E2 (DON) confirmed there were no investigative documents for R3's 7/11/24 elopement. Findings were reviewed during the exit conference on 8/28/24 at 1:06 PM with E1 (ED), E2 (DON) and E3 (ADON).

Based on observation, interview, and review of facility documents, it was determined that the facility failed to store foods in a sanitary manner. Findings include: The following were found during the initial kitchen tour on 10/16/23 from approximately 8:45AM through 9:45AM: - The walk-in refrigerator in the main kitchen had moldy strawberries and peppers; - The shelves in the walk-in were moldy. Findings were reviewed and confirmed by Dietary Manager (DM) on 10/16/23 at approxmately 10:00AM:

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility investigation, the facility failed to notify the physician of an elevated anticoagulant lab value in a timely manner for one resident (Resident (R) 14) reviewed for a significant medication error out of a total sample of 26 residents. Findings include: Review of R14's admission Record located in the electronic medical record (EMR) indicated she was admitted to the facility on [DATE] with a primary diagnosis of heart failure and atrial fibrillation (irregular heartbeat). Review of R14's Care Plan, located in the EMR under the Care Plan tab and revised on 06/02/21, included usage of anti-coagulant therapy to manage the medical condition of atrial fibrillation and history of cerebral vascular accident (stroke). Review of R14's Order Summary Report, located in the EMR and dated 02/24/22, included Coumadin 4mg tablet by mouth at bedtime due to permanent atrial fibrillation. Review of R14's Order Summary Report, located in the EMR and dated 07/07/22,…

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 review of the facility policy, the facility failed to ensure one of one residents (Resident (R) 50) reviewed for prevention of skin breakdown out of a total sample of 26 residents received padding to the skin as ordered by the physician. Findings include: Observation on 10/16/23 at 10:42 AM revealed the padding on R50's hip was dated 10/06/23. During interview on 10/16/23 at 1:35 PM, R50's family member (F)1 stated that she also noted the date of the padding was 10/06/23. Review of R50's admission Record, provided by the facility, revealed the resident was admitted to the facility on [DATE] with a diagnosis of dementia and protein calorie malnutrition. Review of the quarterly Minimum Data Set (MD) with an Assessment Reference Date (ARD) of 09/07/23 revealed R50 was at risk for developing pressure ulcers but had no pressure ulcers or skin breakdown. Observation on 10/16/23 at 2:17 PM revealed the left hip patch was dated 10/06/23. Further observation on 10/16/23…

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 observations, interviews, and record reviews, the facility failed to provide nursing services as ordered for one of three residents (Resident (R) 36) reviewed for application of splints out of a total sample of 26 residents. This failure had the potential to decrease physical functioning, quality of life, and independence. Findings include: Review of the facility policy titled, Resident Mobility and Range of Motion, revised 07/2017, stated in part . 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM [range of motion]. 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable . Review of R36's admission Record, located in the electronic medical record (EMR) indicated he was admitted to the facility on [DATE] with a primary diagnosis of acute respiratory failure with hypoxia. Comorbidities included muscle wasting…

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 clean respiratory equipment for one of one resident (Residents (R) 65) reviewed for oxygen therapy out of a total sample of 26 residents. Findings include: Review of R65's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed R65 was admitted to the facility on [DATE] with diagnoses which included pneumonia, acute respiratory failure hypoxia, depression, and anxiety disorder. Review of R65's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/12/23, located under the RAI tab, indicated R65 was extensive assist of one staff member for bed mobility, dressing, and toileting; transfers only happened once or twice. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R65 was cognitively intact. Review of R65's EMR under the Orders tab revealed the following physician's orders: Continuous oxygen 2 Liter/minute via NC (nasal cannula).…

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 personnel record review, the facility failed to ensure that a Certified Nursing Aid (CNA) was registered with the state of Delaware for one of five personnel records reviewed. Findings include: Review of the personnel record of CNA1, indicated CNA1 was employed at the facility as a CNA on 03/29/22. Further review of CNA1's personnel file indicated CNA1 had obtained a Certificate of Completion as a Temporary Nurse Aide on 06/12/21. CNA1's CNA Registry for the State of Delaware could not be located in the personnel file. During an interview on 10/19/23 at 1:14 PM with the Administrator, the Administrator confirmed CNA1 was not a registered CNA in the state of Delaware. The Administrator explained CNA1 had received temporary status during the Coronavirus disease 2019 (COVID - 19) epidemic but had not obtained an actual/active registry since the COVID-19 waiver had been lifted. The Administrator stated CNA1 worked in the building as recently as yesterday but will not be returning as an employee of the facility at this time.

Based on interview and personnel record review, the facility failed to ensure that Certified Nursing Assistant (CNA)1 received a yearly performance evaluation for one of five personnel records reviewed. Findings include: Review of the personnel record for CNA1, indicated CNA1 completed the Temporary Nurse Aide online course on 06/12/21. The personnel record indicated CNA1 had been employed as a CNA at the facility since 03/29/22. During an interview on 10/19/23 at 1:14 PM with the Administrator, the Administrator confirmed CNA1 had not received a yearly performance evaluation (due March of 2023). The Administrator explained CNA1 was an employee of the assisted living side and had moved over to the long-term care side. The Administrator explained it was an oversight of the Human Resource Departments of the Long-Term Care and the Assisted Living areas of the facility that the performance evaluation was not completed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to provide the appropriate dosage of antibiotics upon admission for one of six residents (Resident (R) 176) reviewed for medication administration out of 26 sample residents. Findings include: Review of R176's admission Record, found in the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE], with diagnoses including acute osteomyelitis (infection of the bone) right ankle and foot. The resident was discharged on 08/23/23. Review of R176's admission Minimum Data Set (MDS) assessment located in the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 08/19/23, revealed a Brief Interview for Mental Status (BIMS) assessment with a score of 15 out of 15 which indicated no cognitive impairment. R176 required limited assistance from one staff with bed mobility, transfer, walk in room, dressing, and toileting. R176 also had impairment on one side lower extremity. He had…

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, facility record reviews, and policy reviews, the facility failed to ensure that one resident (Resident (R) 14) out of a total sample of 26 residents was free from significant medication errors. Specifically, R14 was erroneously administered Coumadin (anticoagulant medication) four mg (milligrams). This failure had the potential to increase the risk for bleeding, bruising, and death. Findings include: Review of the facility's policy titled, Medication and Treatment Orders, revised 07/2016, stated in part Orders for medications and treatments will be consistent with principles of safe and effective order writing .Orders for anti-coagulants will be prescribed only with appropriate clinical and laboratory monitoring . Review of the facility's policy titled, Anticoagulation- Clinical Protocol, revised 11/2018, stated in part .the nurse shall assess and document/ report the following: a. current anticoagulation therapy, including drug and current dosage; b. recent labs, including…

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.