Encore At Wilmington

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, it was determined that for seven (R13, R22, R33, R34, R47, R54, R270) out of seventeen residents reviewed for Infection Control, it was determined that the facility failed to establish and maintain an infection prevention and control program that included Enhanced Barrier Precautions (EBP). Additionally, it was determined that for 3 (three) R34, R47, R270 residents reviewed for urinary catheter care the facility failed to ensure a safe and sanitary process regarding urinary collection bags. Findings include: Facility Enhanced Barrier Precautions (EBP) Policy Statement- Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents .Policy Interpretation and Implemenetation 2. EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied before performing the high-contact resident care activity (as opposed to…

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

Based on record review and interview, it was determined that for nine (R4, R13, R18, R19, R33, R45, R51, R60 and R223) out of seventeen residents reviewed for vaccines, the facility failed to document in each resident's medical record the administration of the pneumococcal and/or influenza vaccines. Additionally, it was determined that for one (R22) out of seventeen residents reviewed for immunizations, the facility failed to offer R22 an updated pneumococcal vaccine. Findings include: Vaccinations of Residents Policy Statement- All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated .All new residents shall be assessed for current vaccination status upon admission .If the resident receives a vaccine, at least the following information shall be documented in the resident's medical record: a. site of administration; b. date of administration; c. lot number of the vaccine (located on the vial); d. expiration date (located on the vial); and e. name of person…

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 (R18, R34 and R270) out of the survey sample of seventeen residents reviewed for resident rights, the facility failed to ensure that the residents had the right to a dignified existence. Findings include: 1. Review of R270's clinical record revealed: 6/19/24 - R270 was admitted to the facility with multiple diagnoses, including obstructive uropathy, and R270 had a foley catheter in place at admission. 6/25/24 - A review of R270's electronic medical record (EMR) revealed the presence of an admission care plan with interventions to care for R270's catheter, which included to place the catheter bag away from the entrance room door. The following observations were made on 6/24/24: 10:29 AM - An uncovered urinary catheter bag hanging on the right had side of the bed, visible from the entrance room door. 12:30 PM - An uncovered urinary catheter bag hanging on the right side of the bed, visible from the entrance door. The following observations were made on 6/25/24: 10:30 AM -R270 was sitting in his wheelchair with 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 R4's clinical record revealed: 1/21/24 - R4 was admitted to the facility. 1/23/24 - R4 participated in his Care Plan conference and signed his Care Plan Conference Summary dated 1/23/24. 4/26/24 - R4's quarterly Minimum Data Set (MDS) assessment was completed. The facility was not able to produce any documentation of R4 participating in any other Care Plan conferences. 6/28/24 12:20 PM - During an interview, E4 (Corporate CNS) stated, The facility did not do a care plan meeting in April with [R4]. We are scheduling one ASAP. We did not update the care plan in April because we didn't have a care conference. 3. R13's clinical record revealed: 5/24/24 - R13 was admitted to the facility after being hospitalized . 5/30/24 - R13's admission MDS assessment stated that she had a moderate cognitive impairment. 6/7/24 at 6:47 PM - A physician's order by E5 (NP) discontinued R13's Flomax medication with a diagnosis incorrectly listed as benign prostatic hyperplasia (BPH). There was no evidence in R13's clinical record that F1 (R13's POA) was notified of this medication change.…

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 three (R19, R33 and R45) residents reviewed, the facility failed to ensure that the call bells were within their reach on three observed occasions. Findings include: 1. Review of R19's medical records revealed: 4/2/2016 - R19 was admitted to the facility with diagnoses including shortness of breath, asthma, and congestive heart failure. 517/24 - R19's significant change MDS assessment documented a BIMS score of 14 (fourteen), indicating no cognitive impairment. 6/24/24 10:15 AM - R19 was observed lying in bed. The bell was observed on the floor near the head of the bed. 6/24/24 11:30 AM - R19 was observed lying in bed. The call bell was observed on the floor near the head of the bed. 6/24/24 1:00 PM - R19 was observed lying in bed. The call bell continued to be on the floor near the head of the bed. 6/24/24 1:10 PM - The surveyor asked R19 if she used the call bell to let the staff know if she needed assistance, R19 stated, Yes, where is my call bell?. 2. Review of R33's clinical records revealed: 11/30/23 - R33 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 (R5) out of one resident reviewed for hospitalization, the facility failed to notify the resident and the resident's representative in writing of R5's transfer to the hospital, including the reason for the transfer. Findings include: Review of R5's clinical record revealed: 6/13/23 - R5 was admitted to the facility. 5/15/24 - R5 was transferred to the hospital because of chest pain. R5 was admitted to the hospital and was discharged back to the facility on 5/21/24. 6/27/24 2:20 PM - During an interview, E3 stated that the facility's process for hospital transfer communications is to provide verbal communication to resident representatives when residents are transferred to the hospital, not written communication. R5's representative would not have received written communication related to E5's 5/15/24 transfer. Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist), and State of DE Ombudsmen (via telephone).

Based on record review and interviews, it was determined that for one (R44) out of seventeen reviewed for Resident Assessments, the facility failed to assess R44 no less than once every three months. Findings include: 11/14/23 - R44 was admitted to the facility. 1/3/24 - R44's admission Minimum Data Set (MDS) assessment was completed. 1/29/24 - R44 was hospitalized . 1/30/24 - R44 was re-admitted to the facility. 2/6/24 - R44's admission MDS was completed. As of 6/26/24, there were no other MDS assessments completed for R44. There has been more than 141 days since the last MDS assessment. 6/27/24 1:26 PM - During an interview, E33 (MDS coordinator) confirmed that R44 was past due for a quarterly MDS assessment. E33 stated, I'm not sure why the system did not flag him. Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist) and two State of DE Ombudsmen (via telephone).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that for two (R21, R22) out of seventeen residents reviewed for Resident Assessments, the facility failed to ensure accuracy of the assessments. Findings include: 1. Review of R21's clinical record revealed: 8/10/19 - R21 was admitted to the facility with diagnoses, including but not limited to, Parkinsonism, epilepsy and hypertension. 5/3/24 - R21's quarterly Minimum Data Set (MDS) assessment was completed and failed to document in Section I Parkinson's disease as one of R21's diagnoses. 6/27/24 1:21 PM - During an interview, E33 (MDS Coordinator) confirmed that the diagnosis of Parkinson's was not in R21's MDS dated [DATE] and that it should have been included. 2. Review of R22's clinical record revealed: 4/27/21 - R22 was admitted to the facility with diagnoses, including but not limited to, atrial fibrillation, heart failure and dementia. 5/1/24 R22's annual MDS assessment was completed and documented in Section I pneumonia as one of R22's active…

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 (R62) out of two reviewed for PASARR, the facility failed to secure R62's PASARR upon admission on [DATE]. Findings include: 4/8/24 - R62 was admitted to the facility with diagnoses including Parkinson's, diabetes and bipolar disorder. 4/21/24 - R62's Minimum Data Set (MDS) assessment documented bipolar disorder as one of R62's diagnoses in Section I. 6/27/24 1:30 PM - During an interview, E2 (DON) stated, We haven't been able to locate that PASARR. We are looking. R62 came here from an AL (Assisted Living) community. 6/28/24 8:52 AM - During an interview, E2 stated, We still have not been able to find her (R62's) PASARR. I am going to request it online again and see if they will send me a duplicate. 7/2/24 2:10 PM - E2 confirmed that the facility has not located R62's PASARR document. Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist) and two State of DE Ombudsmen…

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 two (R54 and R172) out of four reviewed for care plans, the facility failed to develop and implement a person-centered care plan. Findings include: 1. Review of R54's clinical record revealed: 5/16/23 - R54 was admitted to the facility with diagnoses, including but not limited to, multiple sclerosis and stroke affecting R54's right side. 5/22/24 - E36 (DO) ordered, Apply resting hand splint to righthand at the end of 3-11 shift and remove at the end of 11-7 shift. Review of R54's care plan revealed no interventions/tasks regarding R54's righthand splint. The facility was not able to produce any documentation of the righthand splint on R54's care plan. 6/28/24 8:55 AM - During an interview, E2 (DON) confirmed that R54's care plan did not include any mention of R54's righthand splint. We can add it into the care plan if that is what we need to do. 2. Review of R172's clinical records revealed: 11/14/21 - R172 was admitted to the facility. 1/24/24 - R172's quarterly MDS assessment documented that the resident 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 (R5) out of one resident reviewed for care planning, the facility interdisciplinary team failed to review and revise R5's care plan after a comprehensive assessment was completed. Findings include: Review of R5's clinical record revealed: 6/13/23 - R5 was admitted to the facility. 5/28/24 - A Minimum Data Set (MDS) comprehensive assessment was documented for R5, which included a newly assessed care area for dehydration. 6/13/24 - A care plan meeting was held with the interdisciplinary team to review R5's care needs. 6/25/24 - A review of R5's electronic medical record (Emr) care plan revealed the lack of a care plan problem for dehydration. 6/28/24 10:40 AM - During an interview, E33 (MDS Coordinator) confirmed that dehydration was a new care area identified for R5, but that R5's care plan lacked a problem for dehydration after the care plan meeting was held on 6/13/24. Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist), and State 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 clinical record review and interview, it was determined that for three (R5, R223 and R270) out of twenty-one residents reviewed for care planning, 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 2024 . 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. 1. Review of R5's clinical record revealed: 6/13/23 - R5 was admitted to the facility. A review of the clinical record revealed the following 6/13/23 facility admission assessments conducted by E38 (LPN): Wander Risk Evaluation, Pain evaluation, Bladder and Bowel Continence evaluation, Trauma Informed Screening, Functional Abilities and Goals-Admission, Baseline Care Plan, Braden (scale for predicting pressure ulcer risk)…

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 1 (R45) resident out of 2 (two) reviewed for ADLs, the facility failed to ensure that R45 received appropriate care to maintain good grooming. Findings include: Review of R45's clinical records revealed: 6/23/23 - R45 was admitted to the facility with diagnoses including heart disease and muscle weakness. 7/28/23 - R45's care plan documented, .Please check my nail length, clean and trim on bath day and as necessary . 6/21/24 - R45's annual MDS assessment documented a BIMS of 00, indicating severe cognitive impairment, and was dependent on staff for bathing, grooming and hygiene. 6/24/24 10:30 AM - R45 was observed in bed, her fingernails on both hands were long and dirty. 6/24/24 12:30 PM - R45 was observed feeding herself with a fork. R45's fingernails continued to be long and dirty. 6/25/24 10:00 AM - R45 was observed with long, dirty fingernails on both hands on both hands. 6/26/24 8:30 AM - R45 was observed feeding herself with a fork, then picked up an item and put it in her mouth. Her fingernails…

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 (R4) out of one reviewed for Communication-Sensory, the facility failed to ensure R4 received proper treatment to assist/ maintain hearing abilities as evidenced by not submitting a referral for a hearing consult despite R4 being severely hard of hearing. Findings include: 1/21/24 - R4 was admitted to the facility. 1/21/24 - E36 (DO) ordered in R4's electronic medical record (EMR), May have dental, podiatry, ophthalmology, audiology consult. 6/24/24 5:20 PM - During an interview, R4 stated, You have to speak in my right ear; that is the good one. I have difficulty hearing. I think it is wax buildup but I would like to have my hearing checked. 6/27/24 10:40 AM - During an interview, E26 (LPN) stated, [R4] has really bad hearing. That is why we keep his door closed because he blasts the volume on his TV and it bothers the other residents. 6/28/24 9:42 AM - During an interview, when asked about R4's hearing E35 (CNA) stated, Oh that is him. He has always been hard of hearing. That is why his TV is on the max (volume)…

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 a review of facility documents and interview, it was determined that the facility failed to complete a performance review every twelve months for one (E16) out of five nurse aides. Findings include: The facility was provided a list of five names of CNAs to provide documentation of the completion of annual performance evaluations. 7/1/24 - A review of E16's performance evaluation documentation revealed the lack of an 2024 annual performance evaluation since E16 was hired on 2/22/23. 7/1/24 12:30 PM - During an interview, E21 (HR) confirmed that E16 has not had an annual performance evaluation since E16 was hired on 2/22/23. Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist), and State of DE Ombudsmen (via telephone).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, it was determined that for one (R54) out of six reviewed for Pharmacy Services, the facility failed to ensure that the pharmacy services provided safe and effective medication use. Findings include: Facility Medication Regimen Review (MRR) Policy Statement- the consultant pharmacist reviews the medication regimen of each resident monthly .5. The MRR involves a thorough review of the resident's medication record to prevent . d. inadequate monitoring for adverse consequences .g. incorrect medications, administration times or dosage forms . May 2019 Combination Use of Clopidogrel and Proton Pump Inhibitors Increase Major Adverse Cardiovascular Events ([NAME]) in patients with Coronary Artery Disease: A meta-Analysis- In conclusion, the result of out meta-analysis supports the notion that the combination use of clopidogrel and PPIs (such as protonix) will increase the risk of [NAME] in patients with coronary artery disease, which is in accordance with pharmacokinetic 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, it was determined that for one (R22) out of four residents reviewed for Advanced Directives, the facility failed maintain accurately documented medical records regarding R22's code status. Findings include: [DATE] - R22 was admitted to the facility with diagnoses, including but not limited to, atrial fibrillation, heart failure and dementia. [DATE] - E36 (DO) completed a Delaware Medical Orders for Scope of Treatment (DMOST) with F2 (R22's son/POA), which stated that R22 was to have CPR/ attempt resuscitation. [DATE] - E36 (DO) ordered, CPR- FULL code status in R22 's EMR. [DATE] - E36 (DO) documented in R22's EMR a progress note that stated, .History-Code Status List: Full scope of treatment .Advanced Care Planning details: Pt and family agreed to discuss advance directive. Patient and family would like to remain DO NOT RESUSCITATE (DNR) with no artificial nutrition or hydration through conduit. Within the same note, there is documentation of both a full code status and a…

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

Based on record review and interviews, it was determined that the facility failed to have a designated infection preventionist with specialized training in infection prevention and control. Findings include: May 2024 - Review of the Facility Assessment, which was dated May 2024, revealed on page 5, the Infection Preventionist was the ADON (E3). 6/27/24 1:28 PM - During an interview, E33 (RN/MDS Coordinator) stated, I am not the Infection Preventionist. It is [E3] (ADON). 6/27/24 1:56 PM - During an interview, E4 (Clinical Specialist) stated, That's not right. [E2] (DON) is the facility Infection Preventionist. [E3] cannot be the Infection preventionist; she is not certified. 7/1/24 10:46 AM - During an interview, E4 (Clinical Specialist) stated, Infection control is a group effort while we try to fill the role. We had someone and then at the last minute, they turned down the role. [E2] (DON), [E3] (ADON) and [E33] (RN/MDS Coordinator) work on it together. 7/1/24 12:26 PM - The facility has not been able to provide a copy of E2's Infection preventionist training certificate as it 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 review of facility documentation and interview, it was determined that the facility failed to provide required in-service training (12 hours per year) for five out of five CNAs reviewed. Additionally, the facility failed to provide evidence of resident abuse prevention training for the five CNAs reviewed. Findings include: The facility was provided a list of five names of CNAs to provide documentation of the required 12 hours per year of CNA in-service training. 7/1/24 - A review of facility documentation submitted for staff training lacked evidence that E16, E17, E18, E19 and E20 met the 12 hours of annual in-service training required, including resident abuse prevention training. 7/2/24 10:00 AM - During an interview E2 (DON) stated that the facility was unable to provide documentation of the total number of required training hours, including resident abuse prevention training, for E16, E17, E18, E19 and E20. The facility failed to provide 12 hours of required annual in-service training's for five out of five staff CNA's. Findings were reviewed during the exit conference…

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 F609 Report Allegation of Abuse- Based on record review and Interviews, it was determined that for one (R28) out of two residents reviewed for Abuse, the facility failed to report R28's allegation of abuse within the two hour time frame. Findings include: 10/15/16 - R28 was admitted to the facility. 12/28/23- R28's quarterly MDS assessment documented a BIMS score of 7, which was reflective of moderate cognitive deficit. 1/23/24 6:30 PM - While providing care to R28, E37 (CNA) noted a left forearm skin tear, which E37 reported to E38 (LPN). 1/24/24 - While investigating R28's left forearm skin tear of unknown origin, R28 stated that the CAN hurt her ( causing the skin tear) and she (R28) doesn't know why the CAN wants to hurt her. 1/24/24 - R28 was care planned for making false accusations. 1/24/24 4:12 PM - The allegation of abuse was reported to the State agency. This allegation of abuse was reported to the State agency twenty-two hours after the incident was [NAME] to the attention of facility staff. 6/28/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that for one (R18) out of twenty-five residents reviewed for Quality of Care, the facility failed to ensure the resident received treatment and care in accordance with professional standards as evidenced by ordering a regular diet when discharge instructions recommend a low potassium diet. Findings include: 5 STAGES OF KIDNEY DISEASE Stage 1 CKD (chronic kidney disease): Mild kidney damage, GFR 90 or higher Stage 2 CKD: Mild loss of kidney function, GFR 60-89 Stage 3a & 3b CKD: Mild to severe loss of kidney function, GFR 30-59 Stage 4 CKD: Severe loss of kidney function, GFR 15-29 Stage 5 CKD: Kidney failure or close to failure, GFR less than 15 Review of R18's clinical record revealed: 7/3/24 11:23 AM - The hospital Interagency Discharge orders stated, .Discharge diagnoses: . CKD stage 4, GFR (glomerular filtration rate) 15-29 ml/min Diet: .Soft and Bite-sized diet, Thin liquids, Low Potassium . 7/3/24 - R18 was admitted to the facility with diagnoses…

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 a review of documents and interviews, the facility failed to ensure that nursing staff demonstrated competence through satisfactory participation in a State approved nurse aide training and competency evaluation program. Findings include: 7/1/24 - A review of facility documentation revealed that E15 (CNA Agency) had worked at the facility on the following dates: 9/23/23 9/24/23 10/28/23 12/19/23. 7/1/24 4:10 PM - During an interview, E3 (ADON) and E41(Consulting DON) stated that they were unable to produce a valid CNA certification from E15's employment agency. 7/2/24 12:07 PM - Validation was received from DHSS/DHCQ that E15's did not hold a Delaware CNA certificate and is not on the State of DE CNA Registry. Findings were reviewed during the exit conference on 7/2/24 at 2:15 PM with E1 (NHA), E2 (DON), E3 (ADON), E4 (Clinical Specialist), and State of DE Ombudsmen (via telephone).

Based on record review and interviews, it was determined that that for three (R1, R4 & R15) out of three residents reviewed for hospitalization, the facility failed to issue bed- hold notice upon their hospitalizations. Findings include: 1-Review of R1's clinical record revealed: 5/29/23 - R1 was admitted to the facility with diagnoses including, but not limited to, diabetes, heart failure and right foot ulcer. 6/12/23 - An admission Minimum Data Set (MDS) assessment documented R1's BIMS score as 12, which was reflective of moderate cognitive deficit. 6/29/23 11:15 AM - E20 (LPN) documented in a Transfer Out to Hospital note, Resident is being sent to hospital per family request for right foot wound. Resident is alert and oriented x (times) 3 at time of transfer. The facility was not able to produce evidence of the written bed-hold policy that was/should have been given to R1 or her family member at the time of transfer to the hospital. 2- Review of R4's clinical record revealed: 10/4/23 - R4 was admitted to the facility with diagnoses including, but not limited to, heart failure,…

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 (R6) out of three residents reviewed for discharge, the facility failed to allow R6, who still required the nursing services provided by the facility, to remain in the facility and to assist R6 with the Medicaid coverage application. Findings include: Review of R6's clinical record revealed: 11/3/23 - R6 was admitted to the facility with diagnoses including but not limited to morbid obesity, right elbow bursitis, weakness and major depressive disorder. 12/1/23 - E7 (MD) entered an order in R6's EMAR that stated, Discharge Home: D/C (discharge) resident from skilled services PT/ OT/ST to home/ ALF (assisted living facility) on 12/2/23 with Home Health services, RN eval, PT, OT HHA (home health aide). 12/2/23 10:59 AM - E8 (RN) electronically signed R6's Transition of Care and Discharge Summary. R6's Discharge Summary stated, .Bowel and Bladder- Bowel continence- occasionally incontinent. Urinary incontinence- occasionally incontinent .Nursing Summary of Stay- .Resident is continent of bowel and bladder with use 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 one (R15) out of three residents reviewed for hospitalization, the facility failed to notify the LTC Ombudsman of R15's transfer and admission to the hospital on [DATE]. Findings include: 6/28/23 - R15 was admitted to the facility with diagnoses including but not limited to stroke and diabetes. 9/29/23 - A quarterly Minimum Data Set (MDS) assessment documented R15's Basic Inventory of Mental Status (BIMS) as 15, which was reflective of normal cognition. 10/23/23 - R15 admitted to [hospital] with osteomyelitis and underwent a right fifth toe amputation. 1/5/24 10:15 AM - During an interview, E4 (ADON) stated that she looked at the month of October Ombudsman notification sheet and R4 was not on the list. 1/8/24 12:30 PM - Findings were reviewed with E1 (NHA), E2 (ADON), E3 (Clinical specialist), E4 (acting ADON) and E14 (DON) at the exit conference.

Based on record review and interview, it was determined that for one (R10) out of four residents reviewed for Hospice care, the facility failed to complete an MDS assessment documenting R10's significant change regarding his hospice admission. Findings include: 6/15/23 - R10 was admitted to the facility with diagnoses including, but were not limited to, stroke, seizures and congestive heart failure (CHF). 12/8/23 - R10 was admitted to hospice services at the facility. 1/5/24 - The Surveyor observed that R10's significant change Minimum Data Set (MDS) assessment was noted as in progress. This was twenty-eight (28) days after his admission to hospice and fourteen (14) days after R10's deadline for completion of the significant change MDS assessment. 1/5/24 1:35 PM - During an interview, E3 (Clinical Specialist) confirmed that R10's significant change MDS assessment's status was still in progress. 1/8/24 9:20 AM - E22 (admission coordinator) delivered a copy of R10's completed significant change MDS (dated 12/14/23) to this Surveyor. 1/8/24 12:30 PM - 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 interviews, it was determined that for one (R6) out of three residents reviewed for Preadmission Screening and Resident Review (PASARR) coordination, the facility failed to be compliant with R6's PASARR mandated specialized services of a one-time psychiatric medication management evaluation by a psychiatrist/psychiatric nurse practitioner within 30 days of admission. Findings include: Review of R6's clinical record revealed: 11/1/23 - R6's PASARR determination at the hospital documented R6's medical history as including two suicide attempts by overdosing on her medications on 9/24/23 and 9/25/23 with hospitalization on 9/26/23, hospitalization 10/10/23- 10/27/23 for kidney stones, and rehospitalization on 10/28/23 after one day at home due to a fall. PASARR determination explanation stated, .You have a Level II PASARR condition of Major Depressive Disorder, recurrent, severe, without psychosis which has recently led to functional impact and need for ongoing treatment support. If you are admitted to a Medicaid certified nursing facility .you will need 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, it was determined that for four (R3, R9, R19 and R21) out of six residents reviewed for respiratory care, the facility failed to provide respiratory care consistent with professional standards. R3 was sent to an outpatient appointment without enough supplemental oxygen to last for the duration of the excursion. R9, R19 and R21 all had oxygen compressors with dusty/dirty filters. R21's oxygen tubing was not changed as ordered. Findings include: 1. Review of R3's clinical record revealed: 4/24/23 - R3 was admitted to the facility with diagnoses including, but were not limited to, COPD, congestive heart failure (CHF) and respiratory failure with hypoxia. 4/24/23 - E7 (DO) placed an order in R3's EMAR stating, Continuous Oxygen @4 liters/min (minute) via nasal cannula to maintain pulse ox above 92% every shift. E7 (DO) also placed another order stating, Change O2 tubing and humidifier bottle every Monday 11-7 (shift). Date, time, and initial tubing (as a 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 interviews, it was determined that for one (R5) out of four residents reviewed for Hospice care, the facility failed to provide pain management consistent with professional standards. R5, who was admitted to the facility on [DATE] on hospice services, did not receive any narcotic pain medication until four days after admission. Findings include: The facility's Pain Assessment and Management policy stated, the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standard of practice .Monitor the resident by performing a basic assessment with enough detail and, as needed, with standardized assessment tools (e.g. approved pain scales, etc) . MED-PASS Revised March 2020 The pain management standards were approved by the American Geriatrics Society in April 2002 which included: appropriate assessment and management of pain; assessment in a way that facilitates regular reassessment and follow-up; same…

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 (R6) out of three residents reviewed for discharges, the facility failed to identify and provide R6 medically-related social services to maintain her highest practicable physical, mental and psychosocial well-being. Findings include: Cross refer F625, example # 1, F644, and F660 Review of R6's clinical record revealed: 11/1/23 - R6's PASARR evaluation was completed prior to her admission to the nursing facility, which documented that R6 required the following specialized services within 30 days of admission: - an evaluation by a psychiatric Provider within 30 days of admission; and - a one-time psychiatric medication management evaluation by a Provider. R6's PASARR also documented that the following services and/or supports would need to be provided: - case management to explore community based living, family involvement or training in R6's care; - ongoing evaluations of the effectiveness of current psychotropic medications on target symptoms and a safety plan; and - if R6 returned to the community, the resident…

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 one (R7) out of three residents reviewed for call lights, the facility failed to ensure a functioning call bell system. Findings include: 10/9/17 - R7 was admitted to the facility with diagnoses including, but not limited to, Down Syndrome, HTN, non-Alzheimer's dementia and depression. Review of R7's annual and quarterly MDS respectively documented independence for toileting. 1/4/24 at 10:23 AM - The call light in R7's bathroom did not light up when the cord was pulled by this surveyor to check call light functioning. After three separate pulls on the cord, the light still did not come on. It was noted that the cord was wrapped multiple times around the bathroom rail. E15 (CNA) was asked how R7 calls to get help if needed in the bathroom. Per E15, she [R7] would pull the cord. E15 was asked to demonstrate and upon pulling on the cord said, It's not coming on. E15 was then heard contacting maintenance. 1/4/24 at 12:30 PM - E2 (ADON) and E16 (maintenance technician) presented the cord saying, It worked but the cord had been…

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 that the kitchen was maintained to ensure proper food safety. Findings include: The following were observed during the kitchen tour on 1/19/23 from 8:45 AM to 10:00 AM: - The hand washing sink paper towel dispenser was dispensing too much paper towel causing the clean paper towel to dispense into the hand sink, thus contaminating paper towels; - The light cover in the dry storage room, handwashing station by the dry storage room, and loading bay were in disrepair; - The loading bay door sweep was in disrepair creating gaps for pests. Findings were reviewed and confirmed with E22 (Food Service Director) on 1/19/23 at approximately 10:00 AM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and review of the clinical record and facility documentation as indicated, the facility failed to have an effective Infection Prevention and Control Program surveillance system that identified, tracked, monitored and/or reported infections from January 1, 2022 through April 30, 2022. In addition, the facility's surveillance system for the subsequent months were incomplete with missing data and lacked evidence of an ongoing analysis of the data and documentation of follow-up activity. Findings include: Cross refer F882 Sept. 2017 last revised - The facility's policy entitled Surveillance for Infections stated, The infection preventionist will conduct ongoing surveillance for healthcare-associated infections and other . significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions . Gathering Surveillance Data 1. The infection preventionist . is responsible for gathering and interpreting…

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 and review of facility documentation, the facility failed to have an ongoing facility-wide antibiotic stewardship program from January 2022 through December 2022. Findings include: Cross refer to F880, F882 12/2016 last revised - The facility's policy entitled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes stated, . As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist (IP), or designee . identify specific situations that are not consistent with the appropriate use of antibiotics . 4. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form . 12/2016 last revised - The facility's policy entitled Antibiotic Stewardship - Staff and Clinician Training and Roles stated, . The IP will monitor over time and report to the IPCC (Infection Prevention and Control Committee): a. measures of antibiotic use . b.…

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 and review of facility and State of Delaware's Department of Public Health (DPH) documentation, it was determined that the facility failed to conduct COVID-19 testing of staff and residents in response to a positive resident on 1/1/23 and a positive staff member on 1/16/23 according to the State of Delaware COVID-19 infection guidance. Findings includes: 1/3/23 at 6:20 AM - Based on the facility reporting a COVID-19 positive resident, an email was sent to E2 (DON) from the State of Delaware's DPH that outlined recommended general guidance that included testing of residents/staff. 1/17/23 at 1:40 PM - Based on the facility's reporting of a COVID-19 positive staff member, an email was sent to E25 (HR Director) from the State of Delaware's DPH that outlined recommended general guidance that included testing of residents/staff. 1/25/23 at 10:45 AM - During a combined interview with E4 (IP), E31 ([NAME] Living ADON) and E2 (DON), E2 (DON) stated that during the first outbreak on 1/1/23, 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 interview and review of facility documentation as indicated, it was determined that the facility failed to have an Infection Preventionist (IP) responsible for the facility's IPCP (Infection Prevention and Control Program) that had completed specialized training in infection prevention and control from 9/1/22 to 1/3/23, approximately 4 months. Findings include: 1/19/23 - In response to documentation requests during the Survey's Entrance Conference, the facility provided evidence of specialized infection prevention and control training of E4, who was hired on 1/4/23 as the facility's IP. 1/25/23 at 1:15 PM - During an interview, E2 (DON) stated that she took over the IP role after E30 (former DON) left the faciity on 8/31/22. E2 confirmed that she did not have specialized training in infection prevention and control. 1/26/23 from 1:20 PM to 2:15 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 and E19 (Regional Clinical Nurse Specialist).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and review of facility documentation, it was determined that the facility failed to inform residents, their representatives, and families after infections of COVID-19 of one resident on 1/1/23 and one staff member on 1/16/23 by 5:00 PM the next calendar day. Findings include: 1/19/23 - In response to the Survey's Entrance Conference request for facility documentation, the facility provided a handwritten response that stated: The facility's mechanism use to inform residents, their representatives and families of confirmed or suspected COVID-19 activity in the facility is via (by) email. Review of the facility's line listing for the past four weeks revealed: -1/1/23, one resident tested positive for COVID-19; and -1/16/23, one staff person tested positive for COVID-19. The facility lacked evidence that residents, their representatives, and families were informed by 5:00 PM the next calendar day by email after each positive COVID-19 individual. 1/25/23 at 10:45 AM - During a combined interview,…

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

Based on observation and interview, it was determined for one (R15) out of 47 residents reviewed for dignity, the facility failed to protect and value R15's private space when staff entered the residents room without requesting permission. Findings include: 1/19/23 9:37 AM - During the initial pool interview R15 was asked about any privacy and dignity concerns and R15 stated, Fifty percent of the time when I'm being changed I have to ask them to close the door. 1/20/23 1:43 PM - R15's door was closed with staff present in the room. R15's call light was on. 1/20/23 1:45 PM - E18 (LPN) was observed entering R15's room without knocking and receiving permission to enter. E18 immediately confirmed the finding. 1/26/23 from 1:20 PM to 2:15 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E19 (Regional Clinical Nurse Specialist).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record reviews, it was determined that for two (R8 and R17) out of three residents sampled for advanced directives, the facility failed to offer the opportunity to these residents to formulate an advanced directive and document the discussions in each residents' clinical record. Findings include: The facility's admission paperwork, under the Advanced Directives section, documented, Residents are permitted and encouraged to have an advance health care directive, and any other related documentation recognized by state law, in their file at the Community. If you have executed any advance directives, you must provide a copy to us upon move-in. If you change your advance directive while a resident of the Community, you must provide us with a copy of the new advanced directive. Information on Advance Health Care Directives is attached here. Attached was a 2 page brochure from the DHSS Long Term Care Ombudsman's Office. 12/2016 (last revised) - The facility's policy entitled Advance Directives…

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 clinical record review and review of facility documentation, it was determined that for one (R298) out of 14 sampled residents, the facility failed to immediately consult the Physician when R298 experienced a change in condition after an unwitnessed fall. Findings include: Review of R298's clinical record revealed: R298 was admitted to the facility on [DATE] with a past medical history including Congestive Heart Failure, Dementia, and a history of falling. 11/7/22 at 12:00 PM- R298 was found lying on the floor face up on her back. The fall was unwitnessed. 11/8/22 at 10:40 AM- A progress note documented, R298 was transferred to the hospital. Resident sustained fall from bed yesterday. Resident noted with bruise to right lower lip chin area and tongue. Oral cavity assessed, no s/s (signs or symptoms) of active bleeding and/or open areas noted. Resident noted with increased confusion and lethargy. Resident opens eyes with verbal and tactile (touch) stimuli for a few seconds. Resident unable to follow…

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 one sampled resident reviewed for PASARR (Preadmission Screening & Resident Review), the facility failed to refer R14 to the appropriate State-designated authority for a Level II PASARR evaluation and determination after R14 was given a new diagnosis and prescribed medication that would require a new PASARR. Findings include: R14's clinical record revealed: R14's PASARR Level I, completed by the hospital on 8/9/19 noted, Indication of mental illness, mental retardation/related conditions but meets physician's exemption criteria. R14 was admitted to the facility with a diagnosis of anxiety disorder. 6/18/20- R14 was care planned for alterations in mood and behaviors as evidenced by hallucinations, talking into remote due to psychosis. 6/30/20- During a Neurology phone consult, R14 was diagnosed with visual hallucinations and delusions and was prescribed Seroquel, an antipsychotic medication, by E15 (Neurology NP). E15's consult note documented that the former Nursing Director was Most worried about her…

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 (R44) out of one death record reviewed the facility failed to ensure that the baseline care plan was developed within 48 hours of admission and failed to have evidence that the resident/responsible party was provided the baseline care plan summary. Findings include: 10/22/22 - R44 was admitted to the facility. 10/25/22- Care plans were created for R44. 1/24/23 at 2:24 PM - Review of R44's clinical record lacked evidence of a baseline care plan and that a care plan summary was provided to the resident/responsible party. 1/24/23 4:46 PM - During an interview with E2 (DON), E2 confirmed the absence of a baseline care plan for R44. 1/26/23 from 1:20 PM to 2:15 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 and E19 (Regional Clinical Nurse Specialist).

Based on observation, record review and interview, it was determined that the facility failed to revise the advanced directive care plan for one (R15) out of 14 sampled residents to reflect the current code status order. Findings include: 1. Review of R15's clinical record revealed: 11/7/22- R15's advanced directives care plan listed the following interventions: The resident has an advanced directive(s) and has documentation in their medical record r/t Code status: Full code. The residents wishes will be honored and maintained through the next review date, honor the resident choice for code status, monitor for decline with the resident's health status, and Report findings to the MD. 4/28/22- R15's code status changed from a full code to a Do Not Resuscitate (DNR) and was signed by the Power of Attorney (POA) and the Facility Representative, E21 (SW). 5/5/22- A Physician's DNR code status order was written. 1/24/23 at 2:14 PM- An interview with E21 confirmed findings. E21 stated the facility's Interdisciplinary Team (IDT) was responsible for updating the residents care plan. E21…

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 resident interview and observation, the facility failed to ensure that one (R15) out of three sampled residents reviewed for Activities of Daily Living (ADLs) received the necessary services to maintain appropriate care for toileting. R15 waited from 9:30 AM to 10:23 AM for incontinence care. Findings include: Review of R15's clinical record revealed: 4/27/21- R15 was admitted to the facility with a past medical history including Chronic Kidney Disease and the need for assistance with incontinence care. 11/7/22- R15's ADL care plan revealed, The resident requires extensive assist of 1-2 staff for toileting. 1/19/23 at 9:37 AM- During an interview with R15, he stated, I lay in poo (stool) over an hour many times and the staff says to me . 'We have other people to take care of.' I felt disgusting [it] dries up and cakes up, I have to go through two pants a day because the urine goes through the diaper. 1/24/23 at 10:02 AM- R15 approached the Surveyor in his wheelchair and stated that he had been waiting since 9:30 AM to get changed and he was upset because activities start at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of R298's clinical record revealed: R298 was admitted to the facility on [DATE] with a past medical history including Congestive Heart Failure, Dementia, and a history of falling. 11/7/22 at 12:00 PM- R298 was found lying on the floor face up on her back. The fall was unwitnessed. 11/7/22- Review of the facility's Neurological Evaluation Flow Sheet from 12:00 PM - 11:38 PM, after R298's unwitnessed fall, revealed that the facility failed to complete Neurocheck assessments in their entirety post fall. The Glasgow Coma Scale (GCS) total was blank for the entire first day post fall. The GCS total is used to assess for signs of brain injury. Additionally, the Neurological Evaluation Flow Sheet, also showed that the Respiratory Pattern was inconsistently completed. The Neurological Evaluation Flow Sheet was completed for 11/8/2022. 1/25/23 at 3:05 PM- E1 (NHA) and E2 (DON) were informed of the findings. Based on policy and record review, observations and interviews, it was determined that for three (R3, R7…

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 reviews and review of facility documentation, it was determined that for two (R15 and R25) out of five residents reviewed for unnecessary medications, the facility failed to ensure that the Attending Physician reviewed the Medication Regimen Review (MRR) timely. Findings include: Review of R15's clinical record revealed: 1. 3/5/22- A pharmacy consultation report for R15 read, Comment: [R15] was recently initiated on fexofenadine 180 GIVE 1 TABLET BY MOUTH ONE TIME A DAY FOR RASH FOR 7 DAYS and had an estimated CrCl (Creatinine Clearance) of 50 ml/min (milliliters per minute) on 3/5/22, which may increase the risk of potential adverse events (e.g. [for example], sedation, falls). Recommendation: Please consider reducing the dose of 60 mg (milligrams) once daily. Reducing the dose of fexofenadine/pseudoephedrine 12 hour to one tablet once daily. The MRR lacked evidence that the Attending Physician reviewed or signed the MRR as of 1/25/23. 8/22/22- A pharmacy consultation report for R15 read, Comment: [R15] has received a combination topical…

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 reviews, interviews, and review of facility documentation, it was determined that for one (R15) out of five residents sampled for medication review, the facility failed to monitor uric acid levels for a resident on gout medication. Findings include: Review of R15's clinical record revealed: 11/7/22- A Medication Regimen Review for R15 includes, REPEATED RECOMMENDATION from 8/22/22: Please respond promptly to assure facility compliance with Federal regulations. Please monitor a serum uric acid concentration on the next convenient lab day and every six months. Medications used in management of gout are recommended at doses which maintain a serum uric acid concentration below 6mg/dL. 11/9/22- R15's Physician accepted the recommendation(s) to be implemented as written. The facility was unable to provide evidence that a Physician's order was submitted and was unable to provide evidence that the labs were completed. The facility failed to monitor the gout medication for R15 as recommended by the Pharmacist and approved by the Physician. 1/25/23 at 11:40 AM- Findings were…

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, observation and interview, it was determined that for one (R17) of 28 medication (med) administration opportunities during the med pass, the facility failed to have a current label in accordance with the Physician's order for a med with blood pressure (BP) parameters of when to hold the medication. Findings include: 1/17/23- A physician's order was written for Midodrine HCL (used for low BP by raising the BP) 5 mg give two tablets three times a day and hold for a systolic (top number) BP (SBP) greater than 140. 1/24/23 8:20 AM- E27 (RN Supervisor) obtained R17's BP. 1/24/23 at approximately 8:35 AM- The Surveyor observed the blister pack of Midodrine for R17. The parameter on the label stated to hold for a BP greater than 130/90. When questioned, R27 stated the Physician order in the electronic Medication Administration Record (eMAR) was to hold for the med for a SBP greater than 140. 1/24/23 at approximately 8:40 AM- E27 administered the Midodrine. 1/24/23 9:45 AM- After verifying the eMAR Midodrine order, findings were discussed and confirmed with…

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

Based on record review and interview, it was determined that the facility failed to have an Infection Preventionist participate on the QAPI (Quality Assurance and Performance Improvement) committee. Additionally, the facility failed to have quarterly QAPI meetings in 2022. Findings include: 1/26/23 - Review of the facility QAPI Team Members list does not include an Infection Preventionist. 1/26/23 - Review of the 2022 quarterly QAPI meeting attendance sheets revealed a missing attendance sheet for quarter two (April, May and June). 1/26/23 - During an interview, E2 (DON) confirmed that the facility did not have a QAPI meeting in quarter two of 2022. 1/26/23 from 1:20 PM to 2:15 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 and E19 (Regional Clinical Nurse Specialist).

Based on interview and review of facility documentation, it was determined that the facility failed to ensure that required training for abuse, neglect, and exploitation training was completed for one (E26) out of 10 randomly sampled staff members. Findings include: Review of E26's personnel records revealed: 3/14/19- E26 worked her first assignment in the facility. 4/23/20- E26's Abuse, Neglect, and Exploitation Training was completed. 1/20/23- E25 (HR Director) completed the Staff Training and Vaccination packet, however, annual Abuse, Neglect, and Exploitation Training documentation was outstanding for E26. It was last completed on 4/23/20. 1/25/23 at 3:05 PM- E2 (DON) and E1 (NHA) confirmed findings. 1/26/23 at 8:22 AM- Documents that were left for the Surveyor revealed updated Abuse, Neglect, and Exploitation Training for E26. The training was signed and dated 1/23/23 by E26, after E25 completed the initial Staff Training and Vaccination packet and was provided the random selection of employees. E26 was due for her annual abuse training since 4/23/21 and was not provided 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.