Excelcare At Newark LLC

Based on interview and record review, it was determined that for one (R4) out of one resident reviewed for death, the facility failed to ensure R4 had a completed and signed resident agreement upon admission to the facility. Findings include: Review of R4's clinical record revealed: 11/7/25 - R4 was admitted to the facility on Friday evening shift with a diagnosis that included, but was not limited to prostate cancer with metastases to the bone and brain. R4's facesheet revealed that he was listed as the Responsible Party. 12/2/25 9:40 PM - A nursing note documented that R4 passed away in the facility. Review of R4's 11/7/25 DE (Delaware) admission Packet revealed that it was unsigned and incomplete. A written statement by E14 (admission Director) revealed, On November 10th patient [R4] was asleep when trying to do the admission agreement; went back in the afternoon and was still sleeping. On November 11th patient refused due to being tired. Facesheet from the hospital had 2 people listed as siblings that we did not find out they were NOT family members until the brother came 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.

Based on observation, interviews, and facility policy review, the facility failed to ensure containers with rice and pasta were labeled, dated and cleaned; the inside and outside of the oven and microwave were not clean and grease/debris on the handles; the floor under the three-tiered rack had grease and debris; and during meal service the chicken and mixed vegetables were not served at the appropriate temperature on the steam table. This deficient practice had the potential to affect 95 of 95 residents who received meals prepared in the facility. This failure had the potential to affect the spread of food borne illness. Findings include: Review of the undated facility policy titled, Equipment Cleaning Policy provided by the facility indicated, The director of Dining Services or designee will ensure that all equipment is maintained, kept clean and in a sanitary condition before and after each use .Conventional/Convection Ovens: Clean after each use, inside and out, using soap and water .Microwave: Clean after each use, inside and out, using soap and water. Review of the undated…

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, document review and policy review, the facility failed to act promptly to the concerns and /grievance of the resident council to noise level at shift changes, staff use of phones, earbuds when providing care, and choices offered for breakfast meals for nine of nine (R)60, R4, R21, R37, R14, R39, R5, R73, and R76 sampled residents. This failure could place the residents at risk for decreased quality of life and feelings of hopelessness. Findings include: Review of the facility policy titled Grievance Program dated 05/01/2024, documented grievances could be reported verbally or in writing, and the right to receive prompt efforts by the facility to resolve resident grievances. The actions that should be taken in response to grievances or concerns included, but not limited to, investigation and most practicable resolution, routing the grievance to the appropriate departments for ongoing improvement, identifying trends in care, service delivery, and system organization, and developing long term solutions, implementing changes to improve care/service systems. 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 record review, interviews, and review Resident Assessment Instrument (RAI) Manual, the facility failed to ensure that three residents (Resident (R) 23, R71, and R153) in the sample of 28 were accurately assessed for falls and one resident (R54) was accurately assessed for insulin. 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 [Interdisciplinary Team] completing the assessment. 1. Review of R23's admission Record located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included history of falls, dementia, and chronic obstructive pulmonary disease. Review of the facility's accident and incident log dated 2024…

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, document review and staff interview, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNOC) notification was provided timely for one of three residents (Residents (R) 303) reviewed for beneficiary notification. This had the potential to affect all residents being discharged from services. Findings include: 1. Review of R303's admission Record located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy. Review of R303's SNF Beneficiary Notification Review form revealed Medicare Part A skilled services start date was 10/09/24 and the last day covered was 11/04/24. Further review revealed no ABN notification was provided prior to the last date of services. During an interview on 02/19/25 at 2:14 PM the Social Service Worker (SSW) stated that she was under the impression that R303 would discharge home on [DATE] since that was the resident's initial projected discharge…

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, interview, and policy review, the facility failed to ensure an incident of resident-to-resident abuse was thoroughly investigated for two of five residents (Resident (R)7 and R12) reviewed for abuse out of 23 sample residents. This had the potential to affect residents in the facility who were at risk for abuse. Findings include: 1. Review of R7's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia, major depressive disorder, anxiety disorder and bipolar disorder. Review of R7's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/24 and located in the EMR under 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. 2. Review of R12's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted to the facility…

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 policy, the facility failed to ensure that staff appropriately assessed residents with a change in condition for one Resident (R )153 from a sampled 28 residents. Additionaly staff failed to hold laxatives when the resident was having loose stools. Findings include: Review of facility's policy titled, Medication Administration dated 05/01/24 documents Medications are administered under written orders of the attending physician. lf a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse call the provider pharmacy for clarification before the administration of the medication. lf necessary, the provider pharmacy contacts the physician for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate . Review of R153's admission Record located in the resident's electronic medical records (EMR) section…

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 review of facility policy, the facility failed to ensure that expired medications and syringes were removed from one of one medication storage room. The failure has the potential for staff to inadvertently use the expired items. Findings include: Review of the facility's policy titled Storage of Medications dated 05/01/24 indicated, .Drug containers that have missing, incomplete, improper, or incorrect, labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biological are returned to the dispensing pharmacy or destroyed . Observation of the facility's main medication storage room next to the nurses' station on 02/17/25 at 1:17 PM revealed the following concerns: Six of six Magellan three-centimeter (cc) syringes with hypodermic need safety needle 23 gauge one inch with an expiration date of 07/31/21 The facility's Intravenous (IV) tray contained the following expired items: one bottle of Imipenem Hydrochloride…

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

Based on observation and interview during the initial kitchen tour, it was determined that the facility failed to ensure that proper sanitation practices were in place and that food was stored in accordance with professional standards. Additionally, it was determined that the facility failed to ensure dishes were chemically sanitized when dish washing machine temperatures failed to rise to the degree required for heat sanitization. Findings include: 1. 2/29/24 from 9:00 AM to 9:20 AM, observation of the kitchen with E42 (Dietary Services Director) revealed the following: E43 (Dietary Aide) did not have a hair net or beard covering in place. The hand washing sink had no paper towels available. The walk-in freezer had two containers of what appeared to be soup and one container of what appeared to be gravy, all without content description labels, dates of preparation and expiration. The above findings were immediately confirmed with E42. 2. The Wareforce dish washing machine [brand used by the facility] manual indicated 140°F temperature and chlorine/bleach required for sanitization…

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 (R37, R63, R96, R446, R447) out of twenty-three residents reviewed for care plans, the facility failed to meet professional standards of the Delaware Board of Nursing Scope of Practice by having LPNs complete the admission assessment and admission progress note. Findings include: Delaware State Board of Nursing - RN, LPN and NA/UAP Duties 2023 . admission Assessments * - RN . *= Once a care plan is established, the LPN may do assessments . The Braden Scale is a validated tool designed to assess a patient's risk of developing pressure ulcers. National Library of Medicine, Nov. 21, 2022. Cross refer F660, F695, F677 1. Review of R37's clinical record revealed: 2/17/24 - R37 was admitted to the facility. 2/17/24 - E68 (LPN) completed the dehydration risk and the Braden scale for prediction of pressure ulcer risk evaluations in R37's electronic medical record (EMR). 2/17/24 4:00 AM - E68 (LPN) wrote R37's clinical admission note in R37's EMR. 2/24/24 - E31 (LPN) completed the elopement form in R37's EMR. An LPN, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of facility documentation it was been determined that for three (R102, R346, R446) out of twently-three residents reviewed for choices, the facility failed to ensure care preferences were being honored. Findings include: 1. Review of R346's clinical record revealed: 12/5/22 - R346 was admitted to the facility with diagnoses including stroke and aphasia (affects ability to communicate). 12/6/22 - Review of R346's care plan for communication problem related to aphasia revised 1/19/24 included interventions to allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, use simple brief words and cues. Other interventions included: resident is able to answer yes/no by nodding, points to things and is able to make needs know to staff at all times. 2/25/23 - Review of the facility's form for verification of investigation documented . 1. Following investigation and interview of witness the assigned CNA…

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 (R96) of three residents reviewed for beneficiary notification, the facility failed to provide evidence that R96 or her responsible party was notified of Medicare non-coverage prior to her discharge on [DATE]. Findings Include: Review of R96's clinical record revealed: 11/18/23 - R96 was admitted to the facility with diagnoses, including but not limited to, ataxia (poor muscle control that causes clumsy movements) and weakness. 11/25/23 - R96's admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 11, which is reflective of moderate cognitive impairment. 12/20/23 - R96 was discharged from the facility. 3/11/24 2:19 PM -During an interview, E1 (NHA) confirmed that the facility did not have a Notice of Medicare Non-Coverage (NOMNC) form for R96. 3/13/24 3:45 PM - Findings were reviewed with E1, E2 (DON), E3 (Corporate Clinical Operations), E4 (Regional Clinical Specialist) and representatives…

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 (R100) out of four residents reviewed for abuse, the facility failed to have evidence that R100's allegation of abuse was thoroughly investigated. Findings include: R100's clinical record revealed: 7/12/24 - R100's admission MDS assessment documented her BIMS as 13 (cognitively intact). 7/20/23 at 12:14 PM - R100 was sent to the hospital for an unrelated medical reason. 7/21/23 at 11:17 AM - The facility's incident report documented by E2 (DON) revealed the following: - . an allegation of abuse; - Resident is in the hospital where incident of abuse was first reported. - Resident is oriented to self . time . place; - Resident was sent to the hospital . During conversation with the case worker, she reported an allegation of physical abuse by someone posing as an aide. She refused to reveal the name of the aide for fear of being killed. - Yes, police were notified. The facility provided the following additional investigative documents in response to R100's allegation of abuse: - 7/21/23 typed statement of the…

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

Based on record review and interviews, it was determined for three (R55, R103, R247) out of twenty three residents in the investigative sample, the facility failed to accurately completed the resident assessments . Findings include: 1. Review of R55's clinical record revealed: 2/8/23 - A physicians order was written for R55 to receive two liters of oxygen to be worn continuously. 1/30/24- A quarterly MDS assessment documented in the special treatments section that oxygen not in use by R55. January 2024 - Review of R55's MAR revealed R55 received oxygen daily. During an interview on 3/6/24 at 10:31 AM E33 (RNAC) confirmed the MDS assessment error. 2. Review of R247's clinical records revealed the following: 12/20/23 - R247 was admitted to the facility. 12/20/23- R247 had a physician's orders for the following medications for Parkinson's Disease: - amantadine 100 mg 1 tablet daily; - carbidopa/levodopa 24/100 mg 3 tablets 3x a day; - entacapone 200 mg 1 tablet 3x a day. 12/21/23 - R247 was care planned for Parkinson's disease. Interventions included but not limited to give medications…

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, it was determined that for one (R95) out of twenty-three residents reviewed for care plans, the facility failed to develop and implement a person-centered care plan that accurately reflected R95's medical needs. Findings include: Reviw of R95's record revealed: 12/18/23 - E46 (hospital Infectious Disease MD) documented in R95's Progress Note Infectious Disease, Sepsis - repeat [blood] culture - negative . Endocarditis-Vegetation is small .continue ceftriaxone for total of 6 weeks. Stop date will be January 19, 2024. 12/21/23 - R95 was admitted to the facility with diagnoses including, but not limited to, heart disease and anxiety. 12/22/23 - R95's care plan included a focus stating, the resident is on IV medications r/t (related to) sepsis with interventions that address the IV access. The interventions do not document the location (LUE) or type of access (PICC). The care plan also included a focus stating, the resident is on antibiotic therapy related to sepsis with interventions that fail to name the specific antibiotic and address the duration of the…

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

2. Review of R296's clinical record revealed: 6/30/23 - R296 was admitted to the facility with multiple diagnoses, including kidney cancer and chronic kidney disease. R296 was admitted to the facility directly from a hospital stay during which he had a nephrostomy tube (tube placed to drain urine) placed in his left kidney. R296's left kidney was unable to drain urine related to his kidney cancer. R296 was admitted to the hospital from the facility on the following dates because his nephrostomy tube became dislodged: 8/18/23, 10/14/23, 11/18/23, 12/19/23 and 1/24/24. 3/1/24 - A review of R296's 1/2/24 quarterly Resident Assessment Instrument and the comprehensive care plan, updated 2/28/24, revealed the lack of care plan revisions to reflect monitoring for nephrostomy tube dislodgement and the hospitalizations that R296's had for nephrostomy tube dislodgement on the above dates. 3/7/24 10:20 AM- E47 (LPN) confirmed that R296's care plan had not been revised to reflect his many hospitalizations since he was admitted to the facility. 3/13/24 3:45PM - Findings were reviewed with E1…

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 (R96) out of three residents reviewed for discharge, the facility failed to assess R96's functional abilities and consider R96's caregiver's availability and capability to perform required care, to re-evaluate and update R96's changing needs, to show evidence of the Interdisciplinary team (IDT) involvement in the process and to document R96's community referrals and contact information. Findings include: Cross refer F582 Review of R96's clinical record revealed: 11/18/23 - R96 was admitted to the facility with diagnoses, including but not limited to, ataxia (poor muscle control that causes clumsy movements) and weakness. 11/25/23 - R96's admission Minimum Data Set (MDS) assessment documented that R96 had a Brief Interview for Mental Status (BIMS) score of 11, which is reflective of moderate cognitive impairment. 11/25/23 - R96's admission MDS documented in Section H Bowel and Bladder that R96 was frequently incontinent for both urinary and bowel continence. R96's admission MDS documented in Section GG Functional…

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 (R247) out of 3 residents reviewed for discharge, the facility's discharge summary failed to accurately capture and document R247's post-discharge plan of care. Findings include: Review of R247's clinical records revealed the following: 12/20/23 - R247 was admitted to the facility from the hospital. 1/18/24 4:36 PM - A nurse progress notes documented that R247 had an unwitnessed fall that resulted to a skin tear to his left arm and lacerations to the left eye and left cheek. 1/18/24 - R247 had the following physician's orders: - monitor steri strips (used for cuts or wounds that are not too severe); - cleanse skin tear to left cheek with soap and water, apply bacitracin and leave open to air; - cleanse skin tear to left elbow with soap and water, apply bacitracin and cover with dry dressing daily. 1/19/24 - R247 was discharged home via ambulance. 3/11/24 10:59 AM - Review of the form titled BVC - Discharge Instructions and Post Discharge Plan of Care - Version 3 revealed a lack of discharge instructions for wound…

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 (R31) out of one resident reviewed for rehab and restorative the facility failed to ensure R31 received restorative services consistently when R31 was not walked daily. Findings include: Review of R31's clinical record revealed: 1/17/24 - The CNA Task list for the care of R31 was revised to include the resident is to participate in the restorative walking program and ambulate with walker 30 foot daily or as tolerated. 2/1/24- A Quarterly MDS assessment documented in the special services section that R31 received restorative services of walking training and range of motion (ROM). During an interview on 2/29/24 at 12:04 PM R(31) stated, I was told I had graduated to walking therapy but getting that has been hit or miss. February 2024 - Point of care (POC) CNA responses for assisting R31 to walk lacked evidence that the resident was assisted with walking on the following dates: 2/1, 2/2, 2/3, 2/4, 2/6, 2/10, 2/17, 2/18, 2/19, 2/20, 2/22, 2/24 and 2/25. During an interview on 3/5/24 at 1:00 PM E58 (RN) unit manager…

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 interviews, it was determined that for one (R63) out of one resident reviewed for respiratory, the facility failed to provide care consistent with the professional standards with regards to R63's albuterol nebulizer (neb) treatment. Findings include: Albuterol (Inhalation Route) Proper Usage- . The albuterol inhalation solution should be used with a jet nebulizer that is connected to an air compressor with good air flow .To use the inhalation solution in the nebulizer: -Use one container of solution or mix the exact amount of solution using the dropper provided for each dose. -Place the inhalation solution in the medicine reservoir or nebulizer cup on the machine -Connect the nebulizer to the face mask or mouthpiece. -Use the face mask or mouthpiece to breathe in the medicine. -Use the nebulizer for about 15 minutes, or until the medicine in the nebulizer cup is gone. Mayo Clinic, February 1, 2024 The facility's Nebulizer Therapy policy (dated 4/1/2020) stated, Policy: It is the policy of this facility for nebulizer treatments, once ordered, to be…

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 (R446) out of one resident reviewed for dialysis, the facility failed to ensure that R446's transportation needs related to dialysis were met as evidenced by the failure to schedule/confirm transportation to dialysis on 3/6/24. Findings include: Review of R446's clinical record revealed: 2/21/24 - R446 was admitted to the facility with diagnoses, including but not limited to, end-stage renal disease (ESRD) requiring hemodialysis. 2/21/24 - R446's care plan documented, The resident needs dialysis: hemo (hemodialysis) r/t (related to) renal failure with Interventions stating Dialysis (Mon/Wed/Fri) at [hemodialysis facility]. Chair time 7:20 AM. Pick up 6:00 - 6:30 AM. 3/6/24 7:15 AM - The Surveyor observed R446 sitting in a wheelchair in the facility lobby. E1 (NHA) confirmed that R446's ride to hemodialysis did not pick her and the facility was arranging another ride to get her to her dialysis treatment. This hemodialysis treatment was exactly 14 days (2 weeks) from R446's admission date. 3/6/24 9:35 AM…

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 clinical record review and interview, it was determined that for one (R2) out of five residents reviewed for unnecessary medications, the facility failed to complete an AIMS assessment for R2 a resident taking anti-psychoactive medications. For one (R198) out of one residents reviewed for behavioral-emotional distress the facility failed to effectively monitor R198 for side effects related to use of an antipsychotic medication when AIMS testing was not completed November 2022 - May 2023 during which the resident continued to receive antipsychotic medications. Additionally the facility failed to administer R198's antipsychotic medication [olanzapine] for seven doses due to lapse in pharmacy delivery. Findings include: Review of the facility's policy and procedure titled Behavior and Psychoactive Management Program last updated 4/1/20, documented . 1. Monitoring for any adverse side effects of medications, which includes completion of Abnormal Involuntary Movement Scale (AIMS) as per recognized standards of practice. 1. Review of R2's clinical record revealed: 3/10/23 - R2…

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

Based on observation and interview, it was determined that for two (R27 and R28) randomly observed residents, the facility failed to ensure that the residents received the selected food and drinks from the menu. Findings include: 2/29/24 12:15 PM - During a random dining observation of R28's lunch tray, the meal ticket did not match when R28 did not receive cranberry juice or sauteed spinach. E45 (CNA) confirmed the finding. 3/5/24 8:10 AM - During a random dining observation of R27's breakfast tray, the meal ticket did match when R27 was not served oatmeal. E40 (LPN) confirmed the finding. 3/8/24 12:58 PM - During a random dining observation of R28's lunch tray, the meal ticket did not match when R28 did not receive cranberry juice. E48 (LPN) confirmed the finding. 3/13/24 3:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (Corporate Clinical Operations) , E4 (Regional Clinical Specialist) and representatives from the Ombudsman Office.

Based on observation and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment. Findings include: Review of the 4/1/22 facility policy for Glucometers revealed the following: -Purpose: Disinfection of Blood Glucose Monitoring -Procedure: .3. Use EPA approved disinfectant to disinfect glucometer per glucometer manufacturer's guidelines. The manufacturers guidelines for cleaning and disinfecting state that the glucometer should be cleaned and disinfected after use on each patient. 3/6/24 7:45AM - During a medication observation, E26 (LPN) obtained a blood glucose level on R27 using a glucometer, E26 did not clean or disinfect the glucometer after using it. At 7:56 AM, E26 obtained a blood glucose reading on R15 using the same glucometer that had not been cleaned or sanitized after it had been used on R27. E26 confirmed the findings at 8:05 AM. 3/13/24 3:45PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (Corporate Clinical Operations), E4 (Regional Clinical Specialist) 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 interview and review of facility documentation, it was determined that the facility failed to develop, implement, and maintain an effective training program for staff, consistent with their expected roles. Findings include: Review of the facility Nursing Orientation Check List revealed that nephrostomy (tube placed to drain urine) care was not on the checklist. Review of R296's clinical record revealed: 6/30/23 - R296 was admitted to the facility with multiple diagnoses, including kidney cancer and chronic kidney disease. R296 had a nephrostomy tube placed in his left kidney during a recent hospitalization. R296's left kidney was unable to drain urine because of his kidney cancer. 7/15/23 - A physician's order was written to flush R296's nephrostomy tube with 10 ml saline flush daily, every day shift. R296 was hospitalized seven times from 7/16/23 through 2/28/24, and the facility physician's order for the nephrostomy flush resumed with R296's facility readmissions. 3/7/24 1:30 PM - During an observation E40 (LPN) flushed R296's nephrostomy tube. During an interview, E40…

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.