Coral Springs Rehab & Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that for one (R125) out of six residents reviewed for transfer/discharge, the facility failed to implement a policy allowing R125 to return to the facility after his 10/31/23 hospitalization. The facility refused to allow R125 to return to the facility due to lack of a payor source and he remained unnecessarily hospitalized for an additional 91 days. The facility also failed to allow R125 to return to the facility while appealing this discharge. Findings include: Facility's Transfer and Discharge- Policy Explanation and Compliance Guidelines: . 2. Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions: . e. The resident has failed, after reasonable and appropriate notice, to pay or have paid under Medicare or Medicaid for his or her stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after…

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.

4. Cross refer F700, example 6 Review of R76's clinical record revealed: 2/22/23 - R76 was admitted to the facility. 10/28/24 11:30 AM - During an observation a left sided quarter bed rail was in place in place on R76's bed. 11/7/24 - A review of R76's care plan revealed the lack of a care plan focus for the bed rail on R76's bed. 11/12/24 1:32 PM - During an interview, E3 (LPN) confirmed the lack of a care plan focus area for R76's bed rail. 11/13/24 at 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), E47 (RCC), E58 (RDO) and a representative from the Ombudsman's office. Based on observation, record review and interview, it was determined that for one (R41) out of five residents reviewed for medications and three (R14, R67 and R76) out of seven residents reviewed for side rails, the facility failed to develop and implement individualized care plans with respect to a seizure disorder and bed rail usage that included measurable objectives and timeframes. Findings include: 1. R41's clinical record revealed: 11/22/20 - R41 had a active physician's order for Levetiracem 500 mg…

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.

4. Review of R18's clinical record revealed: 11/18/09 - R18 was admitted to the facility. 9/27/24 - R18's quarterly MDS documented that R18 had multiple current diagnoses including dysphagia (difficulty swallowing), right sided paralysis following a stroke and that R18 had a feeding tube. 11/7/24 - A review of R18's care plan lacked the infection control focus for EBP. 5. Review of R55's clinical record revealed: 12/13/17 - R55 was admitted to the facility. R55 had multiple current diagnoses including dysphagia (difficulty swallowing) and left sided paralysis following a stroke. and that R55 had a feeding tube in place. 9/30/24 - R55's quarterly MDS documented that R55 had multiple current diagnoses, including dysphagia (difficulty swallowing) and left sided paralysis following a stroke. R55 had a feeding tube in place. 11/7/24 - A review of R55's care plan revealed the lack the infection control precaution focus for EBP. 6. Review of R76's clinical record revealed: 2/22/23 - R76 was admitted to the facility. 9/27/24 - R76's quarterly Minimum Data documented that R76 had multiple…

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 R15's clinical record revealed: 9/20/23 - R15 was admitted to the facility. 9/22/24 to 9/26/24 - R15 admitted to the hospital. 9/27/24 - R15 re-admitted to the facility after hospital stay. 9/27/24 - E55 (LPN) completed the following facility required admission Assessments: A. Resident Basics/Vitals/Medical History, B. Sensory/Facility Orientation/Elopement Risk, C. Pain, D/E. Musculoskeletal/Fall/Lift/Side Rail or Grab/ Skin Integrity/Braden Scale, F. Oral/Nutrition, G. Respiratory/Smoking, H. Bowel & Bladder, and I. IV/Other. An LPN, not an RN as required by the State of Delaware regulation for the Board of Nursing Scope of Practice, completed the initial assessments. 3. Review of R102's clinical record revealed: 8/20/23 - R102 was admitted to the facility. 9/20/24 to 9/22/24 - R102 admitted to the hospital. 9/22/24 - R102 re-admitted to the facility after hospital stay. 9/22/24 - E60 (LPN) completed the following facility required admission Assessments: A. Resident Basics/Vitals/Medical History, B. Sensory/Facility Orientation/Elopement Risk, C. Pain, D/E.…

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

5. Review of R60's clinical record revealed: 3/31/17 - R60 was admitted to the facility. 8/1/24 - R60's MDS documented that R60 had a BIMS of 10, indicating moderate cognitive impairment, and had diagnoses of high blood pressure and arthritis. 10/28/24 9:05 AM - An observation revealed a quarter length (22 inches) side rail on the right side of R60's bed. Review of R60's clinical record lacked evidence of the following: -the date that the bed rail was installed; -the attempt to use appropriate alternatives prior to installing the bed rail; -an assessment of R60 for the risk of entrapment from the bed rail prior to installation; -the presence of the informed consent for the use of a bed rail -review that the bed dimensions are appropriate for the resident's size and weight. 10/18/24 1:02 PM - The facility's form Side Rail/Grab Bar Evaluation by E21 (RN, UM) documented that R60 was educated on the risks associated with side rail/grab bar use, despite having moderate cognitive impairment. 11/7/24 1:30 PM - During an interview, E66 (Rehab Director) stated that rehabilitation evaluates…

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. 10/31/24 - An observation on the B unit from 9:07 AM through 9:55 AM revealed the following residents' meal trays which did not include coffee or tea beverages contrary to what was indicated in their breakfast meal tickets: R14 - no coffee or hot tea; R106 - no coffee or hot tea; R105 - no coffee or hot tea; R52 - no unsweetened coffee or hot tea; R103 - no coffee or hot tea; R78 - no unsweetened coffee or hot tea; R99 - no coffee or hot tea; R11 - no coffee or hot tea; and R69 - no coffee or hot tea. 10/31/24 9:13 AM - During an interview, E65 (CNA) confirmed that R14, R106 and R105 did not have coffee nor tea on their meal trays. 10/31/24 9:23 AM - In an interview, E64 (CNA) confirmed that R52, R103, R78, R99, R11 and R69 did not have coffee nor tea on their meal trays. 10/31/24 9:40 AM - In a follow up interview, E64 also stated, It happens all the time that the residents on this (B) unit are not getting their coffee or tea. If the resident requests for it, then we go to the kitchen and ask. 11/1/24 10:21 AM - In an interview, E8 (Dietary Supervisor) stated that she 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 observation and interview, it was determined that the facility failed to ensure food/items were stored and/or prepared under sanitary conditions. Findings include: 1. During the initial tour of the kitchen on 10/28/24 beginning at 9:00 AM, the following observations were made: - The walk-in freezer contained bread, ice cream, and debris on the floor; - The standard refrigerator near the entrance had a pink and orange substance spilled inside at the base; - The dry food storage room revealed three bags of onions, a bag of potatoes, and a container of icing stored on the floor; - A pan with meat that was to be seasoned was located on a table uncovered and unattended; - A prepared salad located inside the refrigerator without a date; - In the ware washing room, the table in the dish area where the clean dishes come out of the ware washing machine was covered in food debris; - In the ware washing room, clean plastic mugs were stored inside the room placing them at risk of exposure to splash and in a wet location. The plastic mugs had visible white spots on them; and - Paper…

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 eleven (R16, R18, R33, R38, R43, R55, R94, R113, R310, R456 and R457) out of forty-two residents reviewed for resident records, the facility failed to maintain complete, accurate and readily accessible resident medical records. Findings include: 1. Review of R38's clinical record revealed: 4/19/24 - R38 was admitted to the facility. 10/22/24 1:39 PM - R38's urine culture specimen that was ordered by E3 (MD) was received at the laboratory. 10/24/24 4:05 PM - R38's urine culture results were received at the facility stating 1 Organism growth. 10/24/24 11:21 PM -E52 (NP) documented in R38's EMR that the urine culture was reviewed. 11/12/24 12:53 PM - During an interview, E4 (LPN/IP) confirmed that [contracted laboratory] does not upload final culture results to the residents' EMR. The facility gets the final results and then sends the results in an email group to all the providers but it is not in the resident's records. 11/13/24 10:30 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that for seven (R14, R25, R92, R102, R120, R314 and R456) out of thirteen residents reviewed for infection control, the facility failed to maintain an infection control program that included enhanced barrier precautions for residents who met the criteria. In addition for R25, high-contact suprapubic care was provided on 10/31/24 without the staff wearing the appropriate PPE. Direct care was provided to R14 on 11/7/24 without the staff wearing appropriate PPE. An environmental tour confirmed several observations of infection control issues. Findings include: Facility's Infection Prevention and Control Program Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines. (revised 1/2024) Facility's Enhanced Barrier…

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 (R147, R307 and F606) out of twenty-one residents reviewed for antibiotic stewardship, the facility failed to ensure that antibiotics were prescribed in accordance with recognized standards. For R606 the facility also failed to ensure the antibiotic was placed on the line list. Findings include: Facility's Infection Prevention and Control Program Policy: . 3. Surveillance: a. A system of surveillance for prevention, identifying, reporting, investigating and controlling infections and communicable diseases for all residents . based on national standards . 6. Antibiotic Stewardship: b. Antibiotic use protocols and a system to monitor antibiotics use will be implemented as part of the antibiotic stewardship program. (revised 1/2024) McGeer's Criteria for Infection Surveillance: Syndrome - UTI with indwelling catheter Criteria- Must fulfill both 1 and 2. 1. At least one of the following sign or symptom: - fever, rigors, or new onset hypotension, with no alternate site of infection - either acute change in mental…

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 four (R15, R33, R102 and R138) out of eight residents reviewed for vaccines, the facility failed to have evidence in each resident's medical record the administration of the influenza and/or pneumococcal vaccines. Findings include: Facility's Infection Prevention and Control Program- . 7. Influenza and Pneumococcal Immunization: . b. Residents will be offered the pneumococcal vaccines recommended by the CDC (Center for Disease Control) upon admission, unless contraindicated or received the vaccines elsewhere . e. Documentation will reflect the education provided and details regarding whether or not the resident received the immunizations. (revised 1/2024) 1. Review of R15's clinical record revealed: 9/20/23 - R15,aged [AGE] years, was admitted to the facility. 9/20/23 - E3 (MD) documented an order to give pneumococcal vaccine IM (intramuscularly). 10/30/24 10:35 AM - Review of R15's electronic medical record (EMR) revealed that no pneumococcal…

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 has been determined that for five (R26, R29, R62, R81 and R82) randomly observed during the survey, the facility failed to ensure each resident were treated with respect and dignity. Findings include: 1. R82's clinical record revealed: 6/5/22 - R82 was admitted to the facility. 9/24/24 - A review of R82's MDS assessment revealed, [R82] was dependent for toileting, showering/bathing and personal hygiene. 10/2/24 (last revised) - R82's care plan interventions documented, Resident has a suprapubic catheter position catheter bag and tubing below the level of the bladder and away from entrance doorway. 10/31/24 10:18 AM - Observed R82's suprapubic catheter bag and tubing was visible from the doorway. 10/31/23 10:33 AM - R82's catheter bag remained visible from the hallway. During an interview, E25 (CNA) stated, I'm [R82's] care provider this is my first time working with him, I guess I overlooked where the bag was. E25 left R82's room and was observed entering another resident's room. R82's catheter bag and tubing remained visible…

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, record review and review of other facility documentation, it was determined that for three (R20, R78 and R80) out of four sampled residents reviewed for activities, the facility failed to allow cognitively intact residents the choice to go outside on their own or alone. Findings include: 1. Cross refer F679, example 1 8/21/20 - An activity care plan was developed for R20 to participate in current preferred leisure group of his choice including . community outings, outdoors during appropriate weather months. R20's interventions included providing a program of activities that was of interest and empowers R20 by encouraging/allowing choice, self expression and responsibility . R20's preferred activities are: . community outings, outdoors during appropriate weather months. 10/28/24 1:46 PM - During an interview, R20 stated, With the new management, we are not allowed to go outside to get some fresh air. Before, we were allowed to go out - there's a courtyard that is enclosed but we can't go there whenever we want to go, unless (sic) staff would take us…

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 (R159) out of four residents reviewed for beneficiary notification, the facility failed to provide R159's responsible party with the required notification of the expiration of her Medicare of benefit. Findings included: R159's clinical records revealed: 9/20/23 - R159 was admitted to the facility with diagnoses including Parkinson's Disease, muscle weakness and dementia. 9/26/23 - R159's admission MDS documented a BIMS score of 3, indicating severe cognitive impairment. 10/4/23 3:34 PM - R159's Social Services notes documented, Resident/Rp [Responsible Party] invited to participate in care plans scheduled this week. Copy of care plan, medications, and orders offered. 1/4/24 12:45 PM - R159's clinical records documented, Resident [R159] to discharge to home to be picked up by daughter and HHA (Home Health Association) referral sent out and accepted by resident. 11/6/24 10:00 AM - During a telephone interview, F1 (R159's Responsible Party) stated, My brother and I visit every evening and we speak to the nurses. No…

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 (R14) out of seven residents reviewed for hospitalization, the facility failed to report the injury of unknown origin, which resulted in an emergent transfer to the hospital for treatment, to the State Agency. Findings include: Cross refer F610 R14's clinical record revealed: 9/4/24 6:30 AM - The facility's incident report documented that R14 was found in bed with a bleeding laceration to her left lower leg. R14 was transferred to the hospital. 9/5/24 10:00 PM - Approximately 39 hours later, the facility reported R14's incident from 9/4/24 at 6:30 AM to the State Agency. 11/12/24 8:28 AM - During a combined interview, findings were reviewed and discussed with E1 (NHA), E2 (DON) and E4 (LPN/QA/IC). 11/13/24 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E47 (RCC), E58 (RDO) and a representative from the Ombudsman's office.

Based on observation, record review, interview and review of other documentation as indicated, it was determined that for one (R14) out of seven residents reviewed for hospitalizations, the facility failed to have evidence that R14's injuries of unknown origin were thoroughly investigated. Findings include: R14's clinical record revealed: 9/2/24 - A weekly skin evaluation was performed on day shift and there was no documented evidence of a bruise under R14's left side chin. 9/4/24 6:30 AM - The facility's incident report documented that a CNA went to resident room to perform rounds and noted blood on sheet and on resident leg. Informed nurse. Resident unable to give description . Immediate Action Taken . Pain assessment and first aid. Resident sent to ED [emergency department] . Laceration . left lower leg . Resident has extremely fragile skin, non-compliance with DermaSavers, legs dangling on side of bed . 9/4/24 7:53 AM - The hospital record documented, . 8 in [inch] linear laceration on medial L [Left] calf with clean borders exposing underlying adipose [fat] tissue, multiple…

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 (R102) out of six residents reviewed for transfer/discharges, the facility failed to notify the Ombudsman of R102's 4/27/24 transfer to the hospital. Findings include: Review of R102's clinical record revealed: 8/20/23 - R102 was admitted to the facility. 4/27/24 - R102 was transferred to [hospital]. 11/7/24 11:30 AM - Review of R102's electronic medical record (EMR) and April 2024 [facility] Ombudsman Transfer log lacked evidence that the Office of the State Long-Term Care Ombudsman was notified. 11/8/24 9:50 AM- During an interview, E1 (NHA) confirmed that R102 was sent to the hospital from the facility on 4/27/24. E1 also confirmed that R102's name did not appear on the April 2024 [facility] Ombudsman Transfer log nor did the facility have any documentation to prove that the Ombudsman's Office was notified of this transfer. 11/13/24 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E27 (ADON), E47 (RCC), E58 (RDO) and a representative from the Ombudsman office.

Based on record review and interview, it was determined that for one (R158) out of the residents reviewed in the investigative sample, the facility failed to ensure the Minimum Data Set (MDS) was accurate. Findings include: 6/27/24 - R158 admitted to the facility. 6/27/24 - E3 (MD) ordered R158's nightly bipap with settings in the EMR. 11/10/24 2:17 PM - Review of R158's admission MDS revealed that in Section O - Special Treatments, Procedures and Programs, the facility failed to document R158's bipap usage. 11/12/24 10:59 AM - During an interview, E57 (RNAC) stated, yeah, we did not code for [R158]'s bipap. 11/13/24 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E27 (ADON), E47 (RCC), E58 (RDO) and a representative from the Ombudsman office.

Based on record review and interview, it was determined that for two (R141 and R125) out of two sampled residents reviewed for PASARR, the facility failed to notify the appropriate state-designated authority when the residents' new diagnosis of mental disorder were identified. Findings include: 1. Review of R141's clinical record revealed the following: 7/11/24 - A PASARR Level I Screen Outcome revealed No Level II Required. 7/12/24 - R141 was admitted to the facility. 10/24/24 1:00 PM - An encounter note by E52 (NP) documented, Chief Complaint: Depression . Patient verbalized that he is feeling okay now and goes in and out of feeling depressed secondary to being here in the facility. 10/28/24 - R141 had a physician's order for citalopram (Lexapro) 20 mg (milligram) 1 tablet by mouth daily for depression. 10/28/24 - A nurse progress note by E54 (RN/UM) documented, . resident [R141] was started on new medication Lexapro 20 mg daily . 11/6/24 - A facility Psychiatric Evaluation revealed that R141 was diagnosed with adjustment disorder with depressed mood. 11/7/24 12:29 PM - There was…

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 (R157) out of 42 residents reviewed in the investigative sample, it was determined that the facility failed to ensure that the baseline care plan was provided to the resident/resident representative. Findings include: Cross refer F697 Review of R157's clinical record revealed: 7/27/24 - R157 was admitted to the facility with multiple diagnoses, including dementia. 7/28/24 - A baseline care plan was generated and was signed by E27 (Previous DON, now ADON) on 8/2/24. 7/31/24 - R157's MDS documented that R157 had a BIMS score of 6, which indicated that R157 had severe cognitive impairment, and that it was very important to R157 to have her family involved in discussions about her care. 11/6/24 - A review of R157's baseline care plan revealed that a Resident/ Resident Representative signature was not present on the baseline care plan. 11/7/24 9:00 AM - During an interview E14 (SW) confirmed that baseline signature page was not signed by R157's resident representative. E14 could not confirm that the baseline care plan…

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, record review and review of other facility documentation, it was determined that for two (R20 and R80) out of four sampled residents reviewed for activities, the facility failed to provide outdoor activities during appropriate weather based on their comprehensive assessments and care plans. Findings include: 1. Cross refer F561, example 1 Review of R20's clinical records revealed: 8/12/20 - R20 was admitted to the facility with diagnoses which included acquired absence (amputation) of the left leg above the knee. 8/21/20 - An activity care plan was developed for R20 to participate in current preferred leisure group of his choice including . community outings, outdoors during appropriate weather months. R20's interventions included providing a program of activities that is of interest and empowers R20 by encouraging/allowing choice, self expression and responsibility .R20's preferred activities are: . community outings, outdoors during appropriate weather months. 5/1/24 - R20's annual MDS revealed that R20 was cognitively intact, indicated going…

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 (R92) out of three residents reviewed for bladder continence, the facility failed to ensure that R92 received services and assistance to maintain bladder continence to the extent possible. Findings included: 4/20/24 - A facility document titled, Incontinence, Policy Explanation and Compliance Guidelines, documented, The facility must ensure that residents who are continent of bladder and bowel upon admission receive appropriate treatment, services, and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain . Residents who are incontinent of bladder or bowel will receive appropriate treatment . and to restore continence to the extent possible. R92's clinical records revealed: 7/24/24 - R92 was admitted to the facility with diagnoses including muscle weakness and urinary tract infection. 7/24/24 - R92's nursing admission assessment documented, Continent of…

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

Based on interview and review of the facility clinical record and dialysis record, it was determined that for one (R102) out of two residents reviewed for dialysis, the facility failed to have ongoing collaboration with R102's dialysis center with respect to her dialysis labs (monthly and weekly) from June 2024 through November 2024. Findings include: The facility's policy and procedure entitled Care Planning Special Needs - Dialysis, last revised 1/24, stated, . 2. The care plan will reflect the coordination between the facility and the dialysis provider and will identify nursing home and dialysis responsibilities . 5. If no written report is received upon return from dialysis, nursing staff will call the dialysis provider to receive a report . R102's clinical record revealed: 8/30/23 - R102 was admitted to the facility and care planned for dialysis. One of the interventions in the dialysis care plan was to monitor labs and report to doctor as needed. The positions that were responsible for this intervention was the RN and LPN. Review of the R102's EHR and the Dialysis…

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 (R141) out of 13 residents reviewed for food, the facility failed to ensure that R141's food was prepared and appropriate to meet R141's needs and according to his care plan. Findings include: Review of R141's clinical record revealed the following: 7/12/24 - R141 was admitted to the facility. 7/15/24 - R141 had a care plan developed for nutrition/hydration risk related to poor food intake by mouth and for potential for weight changes. R141's interventions included but not limited to monitor and to report to the physician . refusing to eat, appears concerned during meals and to provide and serve diet as ordered . 9/23/24 - R141 had a physician's order for regular diet regular texture, regular (thin) consistency diet for comfort feeding. 10/28/24 1:30 PM - An observation of R141's lunch tray revealed a plate with ground fried chicken with country gravy, buttered mashed potatoes, seasoned spinach, buttered dinner roll and diced pears. R141's meal ticket documented mechanical soft (texture). 10/28/24 1:31…

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. 11/1/24 11:00 AM - R78 reported that the facility breakfast meal is always determined by the kitchen, and that there are no alternative meal choices for breakfast. Additionally, there are no breakfast items on the always available menu. 11/12/24 8:30 AM - During an interview, E28 (Food Service Director) confirmed that the facility does not have an alternative breakfast menu and that there are no breakfast items on the always available menu food list. 11/13/24 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), E47 (RCC), E58 (RDO) and a representative from the Ombudsman's office. Based on observation, interview and record review, it was determined that for two (R141 and R78) out of 13 residents reviewed for food, the facility failed to accommodate a food preference. Findings include: 1. 10/28/24 1:15 PM - During an interview, R141 stated that a facility staff (not identified) came to see him that morning and showed him the day's lunch menu. R141 also stated that he told the staff that he did not want the primary menu which was fried chicken with gravy, mashed potatoes,…

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. Cross refer F561 and F802, example 2 11/1/24 11:00 AM - During an interview, R78 stated that the facility does not always provide evening snacks. R78 stated that because the timing of each meal is unpredictable, and that bedtime snacks are sometimes not provided, she was aware that many of the residents in the facility stored food in their rooms. R78 stated that they cannot depend on the facility to provide their food or bedtime snacks timely. 11/13/24 3:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), E47 (RCC), E58 (RDO) and a representative from the Ombudsman's office. Based on review of the facility's scheduled meal times and interview, it was determined that for two (R23 and R78) out of 13 residents reviewed for food, the facility failed to ensure that R23 and R78 received their evening snacks. Findings include: 1. Review of R23's clinical record revealed: 8/3/21 - R23 was admitted to the facility. 10/28/24 12:38 PM - In an interview, R23 told surveyor that she was not getting her bedtime or evening snacks. She further stated, You have to call the girls (nursing…

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 two (R25 and R33) out of eight residents reviewed for vaccines, the facility failed to record R25 and R33's COVID vaccines in their medical records. Findings include: Facility's Infection Prevention and Control program- . COVID-19 Immunization: . f. Documentation will reflect the education provided and details regarding whether or not the resident or staff received the vaccine. (revised 1/2024) 1. Review of R25's clinical record revealed: 7/9/24 - R25,aged [AGE] years, was admitted to the facility. 10/30/24 10:35 AM - Review of R25's electronic medical record (EMR) revealed no COVID-19 vaccines were documented as administered to R25. 10/30/24 11:00 AM - Review of the DELVAX website, the State of Delaware public immunization portal, revealed R25 as having received the COVID-19 vaccine on the following dates: 2/17/21, 3/17/21, 12/15/21 and 8/15/22. The facility was unable to provide evidence of R25's education and declination of the COVID vaccine. 2.…

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 facility's policy, the facility failed to ensure residents' expired and discontinued medications were removed from medication carts for six of six medication carts. Resident (R) 12, R18, R23, R47, R116, R138, R299, R448, R87, R22, R32, R62, R109, R121, R34, R56, R65, R118, R128, R122, R124, R125, R301, R302, R13, R103, R129, R140, R457, and R458 had expired or discontinued medications on the medication carts. This created the potential for medications to be diverted or for residents to receive medications with no current physician order. Additionally, it was determined that the facility failed to permit only authorized personnel to have access to the keys to locked compartments containing medications. Registered Nurse (RN)10 , unauthorized personnel due to being off shift, entered the facility and was given access to locked medications. The medications RN 10 gained access to were not witnessed as wasted. Findings include: Review of the facility'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 observations and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings include: The following were found during the initial kitchen tour on 10/24/23 from 8:15 AM through 9:00 AM: - The cantaloupes in the walk-in were not stored 6 inches above floor; - There were 2 packages of ham improperly thawing in the prep sink; - The food disposal was not cleaned properly. Findings were reviewed and confirmed by Food Service Director (FSD) on 10/24/23 at 9:15AM.

Based on observations, interviews, and policy review, the facility failed to ensure a clean and homelike environment for 13 resident rooms out of 89 sampled resident rooms. This failure had the potential for decreasing the independence and safety of the residents. Findings include: Review of the undated facility policy titled, Cleaning Privacy Curtains stated, . Curtains should be changed with every detailed cleaning or as needed .Whenever a curtain is taken down, it should be replaced immediately with a clean one . Review of the facility's undated policy titled, Cycle Cleaning, revealed, It is the policy of this facility to identify the functional areas in the facility that require cleaning and to use cycle cleaning schedules to outline the frequencies and maintain regularly scheduled environmental service tasks . Review of the October 2023 Housekeeping Deep Clean Schedule provided by the Housekeeping Supervisor indicated deep cleaning began on 10/12/23. Review of the facility's undated policy titled, Maintenance Inspection stated, It is the policy of this facility to utilize 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility policy review, the facility failed to properly maintain clean filters on oxygen concentrators for six of eight residents sampled for respiratory care (Resident (R) 403, R402, R93, R103, R38, and R43). The facility also failed to properly administer nebulizer treatments for two residents (R43, and R121) two residents sampled. The facility failed to maintain supplemental oxygen for one of one dependent residents (R30). Findings include: Review of the facility's policy titled, Oxygen Administration dated 2/2023 revealed, Policy: Oxygen is administered to residents who need it consistent with professional standards of practice, comprehensive person-centered care plans, and the resident's goals and preferences . 7. Cleaning and care of equipment shall be in accordance with facility policies for such equipment. 1. Review of R402's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed R402 was admitted to the…

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

Based on record review and interview it was determined that for one (resident (R) 251) out of one resident reviewed for insulin use, the facility failed to prevent significant medication errors when R251 received insulin greater than one hour after the ordered time repeatedly from December 2022 through May 2023. Findings include: The facility policy on medication administration, undated, indicated Administer medication as ordered in accordance with manufacturer specifications. Insulin Detemir, sold under the brand name Levemir, among others, is a long-acting insulin used to treat diabetes. It is used by injection under the skin. It is effective for up to 24 hours. https://www.drugs.com/levemir.html. Review of R251's clinical record revealed: 12/15/22 - R251 was admitted to the facility. 12/15/22 - A physician's order was written for R251 to receive insulin Detemir, inject 40 units two times a day for diabetes. 12/27/22 - A care plan was implemented for diabetes with the intervention to administer medications, as ordered. December 2022 MAR [Medication Administration Record] - Review…

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 reviews and facility policy review, the facility failed to have an effective infection control program to mitigate the spread of infections. The facility failed to ensure proper cleaning and disinfecting of multi-use glucometers; failed to ensure proper use of Personal Protective Equipment for residents on enhanced precautions; failed to ensure PPE was properly used for standard precautions; and failed to ensure proper hand hygiene was performed in between glove changes. Findings include: Review of the Licensed Nurse New Hire Competency Checklist under Infection Control read in part, . Sanitizes hands between patients, washes hands when gloves are removed . The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings which includes, .Healthcare personnel…

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 R249's clinical record revealed: 8/28/21 - A significant change MDS documented R249 as cognitively intact and having a very important preference to choose between bath, shower, bed bath, and sponge bath. R249's care plan for ADL deficit last updated 3/8/22 included the intervention to assist in showering and/or bathing needs with extensive to total assist of one person and needs extensive assist with personal hygiene with one person. 2/18/22 - A quarterly MDS assessment documented R249 as cognitively intact and in need of extensive assistance of one staff person for hygiene and needing physical help of one staff person for bathing. January 2022 - March 2022 - Review of documentation of showers completed for R249 revealed the resident was to be offered a shower on each Sunday and Wednesday during the day shift. R249 received showers the following dates: January no showers received, February two showers received, and March one shower received. There were no documented refusals of showers in R249's clinical record. During an interview on 10/27/23 at 11:09 AM, Certified…

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 facility policy review, the facility failed to ensure six of 32 sampled residents (Resident (R) 38, R50, R398, R119, R123 and R118) or their surrogate decision maker were provided written information informing them of their right to formulate an advanced directive. Findings include: Review of the facility's undated policy titled, Topic: Residents' Rights Regarding Treatment and Advance Directives, revealed, Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Guideline: l. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. 2. The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment 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, it was determined that for one (R307) out of five residents reviewed for nutrition, the facility failed to consult the physician of the significant change in R307's weight. During the first nine months of R307's admission, R307 lost a documented 67.9 pounds. Findings include: 2/2/22 - R307 underwent bilateral above the knee (AKA) amputations. 2/17/22 - R307 was admitted to the facility with diagnoses including, but were not limited to stroke, diabetes and bilateral above the knee amputations. 2/17/22 10:59 PM - RN2 documented R307 as weighing 273.5 pounds. 3/18/22 2:21 PM - R307's weight was documented as 222 pounds. This reflected a 51 pound weight loss since R307's admission weight one month prior. Review of R307's clinical record revealed no evidence that the providers (MD/NP) were consulted about this significant weight loss. 4/13/22 2:23 PM - R307's weight was documented as 219 pounds. Review of R307's clinical record revealed no evidence that the providers were consulted about this significant weight loss. 8/11/22 2:55 PM - RD (Dietician) note…

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 two (R123, R200) out of twenty-nine residents reviewed for assessments, the facility failed to accurately reflect the residents' status in their admission MDS assessments. Findings include: 1. R123's clinical record revealed: 8/22/23 - R123's hospital admission History & Physical stated, Problem list/Past Medical History Ongoing: .tobacco use . 9/1/23 - R123 was admitted to the facility. 9/10/23 5:22 PM - E2's (DO) admission History & Physical documented, .Past Medical History .tobacco use .Social History : + tobacco/marijuana use . 9/14/23 10:42 PM - R123's admission Minimum Data Set (MDS) documented no current tobacco usage. 10/25/23 1:39 PM - During an interview, R123 stated that he was an active smoker. He does not have cigarettes here at this building as it was a non-smoking facility. But when he leaves the building almost daily, he smokes. He keeps his smoking material (cigarette and lighter) at his Mom's house. 2. R200's clinical record revealed: 9/6/23 - R200 was admitted to the facility. 9/6/23 5:01 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 record review and interview, it was determined that for one (R50) out of two residents reviewed for PASARR (Preadmission Screening and Assessment Resident Review), the facility failed to refer R50 for a PASARR Level II after R50 was diagnosed with delusional disorder. Findings include: Review of R50's clinical record revealed: 6/3/22 - The PASARR, which was completed while R50 was hospitalized , documented, PASARR Level 1 Determination: No Level II Required . 6/4/22 - R50 was admitted to the facility with diagnoses including, but were not limited to, diabetes and stroke with left sided weakness. 11/29/22 - R50's quarterly Minimum Data Set (MDS) assessment documented that R50 did not have a diagnosis of psychosis. 12/8/22 - R50's medical diagnoses in the electronic medical record (EMR) added delusional disorder with the classification diagnosed during stay. 12/15/22 - E2 (MD) ordered R50 Risperidone 0.5 mg by mouth two times a day for major depression recurrent, severe psychotic symptoms. 12/19/22 - R50's significant change MDS assessment documented R50 as having a diagnosis…

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 2. Review of R308's clinical record revealed: 6/8/22 - R308 was admitted to the facility. 6/8/22 8:01 pm - An admission progress note documented R308 had an active left AV fistula (an abnormal connection between an artery and a vein for dialysis) and a non-active AV fistula in the right upper arm. 10/30/23 12:35 PM - The DON confirmed that the care plan for R308 had not been developed to identify that R308 had an AV fistula in both arms. The facility failed to develop a care plan that identified R308 had AV fistulas in both arms. Based on observations, interviews, record reviews, and facility policy review, the facility failed to develop a comprehensive care plan for three of 38 sampled residents (Resident (R) 140, R308 and R309). This failure had the potential to leave the resident with unmet care needs. In, additon the facility failed to create a person-centered care plan for R308 a resident that had a dialysis access in both arms. Findings include: Review of the facility's policy titled, Comprehensive Care…

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 three (R73, R95 and R123) out of six residents reviewed for care plans, the facility failed to ensure that the residents or the resident's representative was invited to participate in their care plan meetings. Findings include: 1. Review of R73's clinical record revealed: 4/25/19 - R73 completed a Power of Attorney (POA) for Healthcare in which R73 named FM1 as Healthcare Representative with the power to make decisions with regard to my health care if and when I am unable to make my own health care decisions. 6/28/21 - R73 was admitted to the facility with diagnoses including, but were not limited to, Parkinson's disease, dementia and depression with psychotic symptoms. 7/6/21 3:31 PM - R73's admission Minimum Data Set (MDS) assessment documented R73's Basic Inventory of Mental Status (BIMS) as 9, which reflected moderate cognitive impairment. FM1 was listed in R73's electronic medical record (EMR) as R73's representative, responsible person, POA financial, POA health care, care conference person and emergency…

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 (R307) out of seven residents reviewed for hospitalization, the facility failed ensure follow-up appointments and diagnostic tests were scheduled timely after a hospital stay. Findings include: Cross refer F580 and F842 1. Review of R307's clinical record revealed: 2/17/22 - R307 was admitted to the facility with diagnoses including, but were not limited to, stroke, diabetes and bilateral above the knee amputations. 12/7/22 - R307 was admitted to the hospital with abdominal pain. 12/12/22 - The Hospital Discharge Summary stated, Discharge Diagnoses: cecum mass, large bowel obstruction, hepatic (liver) lesion . Follow Up Providers: Follow up with Radiology within 2-7 days for a CT chest scan, Follow up with Hematology/Oncology Service within 2-7 days for further management, Follow up with Colorectal Surgery Service within 2-7 days for colonoscopy and Follow up with VIR (Vascular Interventional Radiology) within 2-7 days for liver biopsy . 12/12/22 - R307 was readmitted to the facility. 12/13/22 - E2 (Doctor of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that for two (R200, R248) out of two reviewed for bladder continence, the facility failed to ensure that the residents received appropriate treatment and services to maintain highest practicable urinary function. Findings include: 1. Cross refer F641, example 2. Review of R200's clinical record revealed: The facility's Incontinence Policy and Procedure, undated, stated, Purpose- A resident who is continent of bladder will receive appropriate care and services to maintain as much bladder function as possible as determined by the IDT (Interdisciplinary team). Each incontinent resident will be assessed in an effort to improve or maintain bladder function as indicated. Bladder and bowel continence is defined as voluntary control of urinary bladder and bowel function. Incontinence is defined as involuntary loss of these functions. Habit Training/Scheduled Toileting- Habit training or timed voidings (sic), is scheduled toileting on a planned basis. The goal is 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, interviews, record reviews, and facility policy review, the facility failed to ensure appropriate care of a gastrostomy (g-tube) during medication administration for three residents (Resident (R) 30, R43 and R95) of three residents during medication administration with gastric tubes. Specifically, Licensed Practical Nurse (LPN) 14 and LPN17 failed to check for proper g-tube placement, did not flush the g-tube before and after medication administration, and administered medication via push method rather than by gravity administration for R43. LPN23 failed to check for proper g-tube placement, administered water flush via push method, and administered medications via push method rather than by gravity method for R95. This failure increases the risk for nausea, vomiting, or aspiration. Findings include: Review of facility's policy titled Verifying Placement of Feeding Tube revised 07/2023 stated, It is the practice of this facility to ensure proper placement of feeding tubes prior to…

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

Based on record review and interviews, it was determined that for one (R50) out of three residents reviewed for Physician services, the facility failed to ensure that R50's total program of care, including R50's advanced directives, was reviewed by the providers at the time of his admission. Findings include: Cross refer F578, example 6 Review of R50's clinical record revealed: Advance Care Planning is a process of communication between individuals and their healthcare agents to understand, reflect on, discuss and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions. An Advance Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. 2/16/16 - R50 completed Durable Personal Power of Attorney designating his son (FM3) as financial agent. This power of attorney does not authorize your Agent to make health…

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 (CNA6) out of five certified nursing assistants (CNA) reviewed for Registry verification, the facility failed to ensure that CNA6, who successfully completed an out of state CNA competency evaluation program, went on to register with the State of Delaware. Findings include: 10/19/10 - CNA6 obtained her certified nursing assistant license from the State of Maryland. 6/28/22 - CNA6 was hired as an employee at the facility during the COVID-19 Public Health Emergency (PHE) when CMS waived the nurse aide training requirement. 5/11/23 - CMS ended all waivers for the Public Health Emergency. 8/21/23 - CNA6 renewed her Maryland Nursing Assistant certification. 10/23/23 3:58 PM -Delaware Division of Health Care Quality (DHCQ) verified that there are no current CNA waivers in place in Delaware. 11/7/23 - During an interview, E1 (NHA) stated that CNA6 was covered by the waiver and did not require a Delaware license. The facility failed to ensure that CNA6 was certified to work in Delaware.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of R307's clinical record revealed: 2/2/22 - R307 underwent bilateral above the knee (AKA) amputations. 2/17/22 - R307 was admitted to the facility with diagnoses including, but were not limited to, stroke, diabetes and bilateral above the knee amputations. 2/18/22 - NP's progress note documented, . Physical exam: . Skin: Bilateral AKA's with staples, clean, dry and intact. Left AKA with light purple ecchymosis . 2/23/22 - E17's (Wound Specialist NP) progress note documented, . Pt seen this am on wound round and noted with: L (left) abdomen- trauma. Review of Daily Skilled Notes revealed: 2/25/22 - E18 (Unit manager) documented, . No surgical wound noted. No wound noted . 3/2/22 10:45 PM - LPN15 documented, . No surgical wound noted. No wound noted . 3/13/22 9:00 PM - LPN2 documented, . No surgical wound noted. No wound noted . 3/14/22 7:52 PM - LPN2 documented, . No surgical wound noted. No wound noted . 3/15/22 9:46 PM - LPN2 documented, . No surgical wound noted. No wound noted . 3/16/22 8:37 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 observations and interview, it was determined that the facility failed to ensure all mechanical, electrical and patient care equipment is maintained in safe operating condition. Findings include: The following were found during the initial kitchen tour on 10/24/23 from 8:15AM through 9:00AM: The reach in refrigerator by the hand washing sink had broken gaskets on the door. Findings were reviewed and confirmed by Food Service Director (FSD) on 10/24/23 at 9:15AM.