Pike Creek Nursing & Rehabilitation Center

Based on interview and review of facility documentation, it was determined that for two (E57 and E58) out of five nursing staff reviewed, the facility failed to ensure that the required QAPI (Qualify Assurance And Performance Improvement) training was completed. Findings include: 8/26/24 1:00 PM - Review of the agency staff training records revealed a lack of evidence of QAPI training of the following agency staff: 3/25/24 - E57's first day in the facility assigned as Agency RN. 7/16/24 - E58' s first day in the facility assigned as Agency LPN. 8/26/24 1:30 PM - During an interview, E48 (Staff Educator) confirmed that E57 and E58 did not have records of the QAPI trainings on their files. 8/26/24 2:33 PM - Findings were discussed with E1 (NHA). 8/27/24 2:52 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E10 (VPO).

Based on interview and review of facility documentation, it was determined that for two (E57 and E58) out of five nursing staff reviewed, the facility failed to ensure that the required training on Compliance and Ethics Program was completed. Findings include: 8/26/24 1:00 PM - Review of the employee training records revealed a lack of evidence of Compliance and Ethics Program training of the following staff: 3/25/24 - E57's first day in the facility assigned as Agency RN. 7/16/24 - E58' s first day in the facility assigned as Agency LPN. 8/26/24 1:31 PM - During an interview, E48 (Staff Educator) confirmed that E57 and E58 did not have records of the Compliance and Ethics Program trainings on their files. 8/26/24 2:33 PM - Findings were discussed with E1 (NHA). 8/27/24 2:52 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E10 (VPO).

Based on interview and review of facility documentation, it was determined that for five (E43, E55, E56, E57 and E58) out of five nursing staff reviewed, the facility failed to ensure that the required Behavioral Health training was completed. Findings include: 8/26/24 1:00 PM - Review of the employee training records revealed a lack of evidence of Behavioral Health training of the following staff: 6/4/24 - E43's first day in the facility hired for the Registered Nurse (RN) position. 6/24/24 - E55's first day in the facility hired for the Licensed Practical Nurse (LPN) position. 7/8/24 - E56's first day in the facility hired for the LPN position. 3/25/24 - E57's first day in the facility assigned as Agency RN. 7/16/24 - E58' s first day in the facility assigned as Agency LPN. 8/26/24 1:30 PM - During an interview, E48 (Staff Educator) confirmed that E43, E55, E56, E57 and E58 did not have records of the Behavioral Health trainings on their files. 8/26/24 2:33 PM - Findings were discussed with E1 (NHA). 8/27/24 2:52 AM - Findings were reviewed with E1 (NHA), E2 (DON) and E10 (VPO).

Based on observation, interview, and record review, it was determined that for one (R422) out of two residents reviewed for dignity, the facility failed to ensure that the urinary collection container was placed in a privacy bag. Findings include: Review of R422's clinical records revealed: 1/14/24 - R422 was admitted to the facility with diagnoses including obstructive uropathy and bladder dysfunction. 1/30/24 - R422 clinical records included, Catheter care every shift, and as needed. 6/26/24 - R422's quarterly MDS assessment documented a BIMS score of 00, indicating severe cognitive impairment. R422 required total assistance from staff with all activities of daily living. 7/16/24 - R422's care plan included, Maintain catheter privacy bag. 7/30/24 9:10 AM - R422 was observed lying in his bed, an uncovered/undated urinary collection bag was visably observed from the door on the floor on the right side of the bed. 7/30/24 10:15 AM - R422 was observed lying in his bed, an uncovered/undated urinary collection bag was visibly observed from the door on the floor on the right side of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and review of clinical records and other documentation as indicated, it was determined that for two (R176 and R344) out of seventeen (17) residents reviewed for abuse, the facility failed to report alleged violations involving abuse no later than 2 hours after each allegation was made. Findings include: 1. 8/30/24 at 6:08 PM - Review of State Agency's incident intake revealed that the facility reported an allegation of abuse involving R175. 8/30/24 from 4:30 PM to 6:00 PM - The facility's investigation of R175's allegation documented that E46 (SW) interviewed other residents, which included R176. 9/3/24 at 5:30 PM - Review of the State Agency's incident intake revealed that the facility reported an allegation of abuse involving R176. 9/10/24 at 8:32 AM - During an interview, E46 (SW) confirmed that R176 hand wrote a statement. E46 collected the statement along with other residents' signed statements and handed all the statements to E59 (DON 2) on 8/30/24. 9/10/24 at 8:36 AM - During an…

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

Based on interview and record review, it was determined that for one (R320) out of four residents reviewed for accidents and one (R31) out of one resident reviewed for care planning, the faciliy failed to review and revise the residents' care plans. Findings include: 1. R320's clinical record revealed: 5/30/24 - R320 was admitted to the facility with a primary diagnosis of a urinary tract infection. 5/30/24 - R320 was care planned for incontinent of bladder and bowel with the following two approaches: - record bowel movements; and - refer to occupational therapy as indicated. 7/22/24 - In response to an incident that occurred on 7/2/24 at 7:30 AM, E3 (ADON) interviewed R320, who stated stated that he was reaching for his urinal and getting ready to use it at the same time and was probably too close to the edge of the bed and slid down. The facility failed to ensure R320's incontinence care plan was person centered and included the use of a urinal. 8/8/24 at approx. 3:45 PM - Finding was reviewed with E1 (NHA), E2 (DON) and (E3) ADON. No further information was provided. 2. Review 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 observation, interview and record review it was determined that for one (R105) out of seven residents reviewed for activities of daily living (ADLs), the facility failed to ensure that R105 received the treatment/services to prevent further avoidable reduction of ROM and mobility. The facility lacked evidence that the palm device was applied to prevent further worsening of contractures to R105's left hand as recommended. Findings include: Review of R105's clinical record revealed: 10/26/23 - R105 was admitted to the facility with diagnoses including but not limited to multiple scelrosis (nervous system disease that affects the brain and spinal cord), chronic pain and muscle weakness. 10/26/23 - Review of R105's care plan for chronic pain to hands related to MS (Multiple Sclerosis) and neuropathic pain revised 2/19/24 interventions included .1. Left hand palm guard worn at all times remove for skin assessment at shift change and for hygiene. 2/7/24 2:44 PM - A order writen for R105 included left hand…

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 three (R324, R170 and R270) out of 14 residents reviewed for accidents, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents. For R324, the facility failed to transfer R324 with a hoyer lift per the plan of care. For R170, the facility failed to provide supervision while care was being provided by a staff member. For R270, the facility failed to put the wheelchair foot rests on prior to transportation. Findings include: 1. Cross refer to F580, example 1 R324's clinical record revealed: 6/12/24 - R324 was admitted to the facility for rehabilitation with diagnoses that included, but were not limited to, glioblastoma (brain tumor) status post craniotomy (brain surgery) in February 2024, seizure disorder, lack of coordination, and long term use of blood thinning medication. 6/12/24 at 12:48 PM - R324's admission nursing collection tool documented that R324 was oriented at all times; had no history of falls; was bedbound; adequate vision; and was not able 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 observation, interview, and record review, it was determined that for one (R111) out of two residents reviewed for nephrostomy catheter, the facility failed to provide safe and sanitary urinary catheter care to prevent urinary infections to the extent possible. Findings include: Review of R111's clinical records revealed: 7/1/24 - R111 was admitted to the facility with diagnoses including urinary tract infection, acute pyelonephritis (kidney infection), and right nephrostomy tube (a tube inserted into the kidney to drain urine because of kidney stones.) R111's hospital discharge records included, Follow up in one week for urology consult for removal of kidney stones. 7/11/24 - R111's admission MDS assessment documented a BIMS of 12, indicating a moderate cognitive impairment. 7/3/24 - R111's MAR documented, Empty nephrostomy drainage bag every shift. 7/30/24 8:30 AM - R111 was observed lying on the bed. An undated urinary collection bag with yellow urine was observed on the left-hand side of the bed.…

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 (R90) out of one resident reviewed for respiratory care, the facility failed to ensure that R90 received oxygen per physician's order. Findings include: Review of R90's clinical record revealed: 6/15/24 - R90 was admitted to the facility with diagnoses including heart disease and high blood pressure. 6/15/24 - R90's respiratory care plans documented, At risk for respiratory complications due to asthma and hypoxemia (not enough oxygen reaching body tissues), administer oxygen as ordered. 6/17/24 - R90's clinical records included oxygen at 2 liters per minute via nasal cannula (a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels). 6/26/24 - R90's MDS documented, Continuous oxygen therapy. 7/29/24 9:30 AM - R90 was observed lying on the bed. The oxygen tubing was observed on the floor on the left-hand side of the bed. 7/29/24 10:30 AM - R90 was observed lying on the bed. The oxygen tubing was observed on the floor on the left-hand side of the bed. 7/29/24…

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.

Based on record review and interview, it was determined that for one (R173) out of one resident reviewed for pain management, the facility failed to provide pain management according to professional standards of practice. R173 was not provided pain medication since before admission to the facility at 11:00 AM until pain medication administration at 7:08 PM, an estimated eight hours. The facility's failure to administer pain medication caused R173 to experience unnecessary pain related to a recent amputation. Findings include: The facility policy on pain management last updated 1/29/24 indicated, If pain is not relieved, notify the provider. The facility policy on admitting a new patient, last updated 1/29/24 indicated, Obtain provider's orders or verify transfer orders with attending physician for the patient's immediate care. Review of R173's clinical record revealed: 7/27/24 - Hospital interagency discharge orders documented R173 was admitted to the hospital with a foot infection and underwent an above the knee amputation of the right leg, and amputation of the left fifth toe.…

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

Based on interview and review of facility documentation, it was determined that the facility failed to ensure that a performance review was completed at least every twelve months for two out of five (E25 and E26) sampled employees. Findings include: 8/7/24 11:00 AM - Review of the staff performance evaluations revealed the following: 1. E25 (CNA) had a hire date of 3/20/07. A record review revealed lack of evidence of a performance evaluation for the past year and was confirmed by E34 (HR). 2. E26 (CNA) had a hire date of 3/4/08. A record review lacked evidence of a performance evaluation for the past year and was confirmed by E34. 8/12/24 1:34 PM - Findings were confirmed with E2 (DON). and E3 (ADON). 8/12/24 2:15 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E10 (VPO) and a State of DE Ombudsman (via telephone).

Based on record review and interview, it was determined that for one (R107) out of five residents reviewed for unnecessary medications, the facility failed to act on a pharmacy medication review recommendation for R107. Findings include: The facility Medication Regimen Review (MRR) policy number 1303, effective 1/29/24 documents the following: Policy - The drug regimen of each patient will be reviewed at least once per month by a licensed pharmacist. Procedure . 2. The physician is to review and sign the patient's individual MRR and document that he/she has reviewed the pharmacist's identified irregularities within 30 days of receipt . A review of R107's chart revealed: 7/21/23 - R107 was admitted to the facility. 3/19/24 - R 107 was assessed as being a high fall risk. 3/25/24 - A pharmacy medication review was done that documented that attention was needed by the provider to address a fall assessment review related to the side effects of medications that R107 was taking. The pharmacy review further documented that the medications could cause dizziness, and drowsiness. The…

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

Based on observation, interview, and record review, it was determined that for one (R109) out of two residents reviewed for dental care, the facility failed to provide routine dental services to meet R109's needs. Findings include: 9/29/23 - R109 was admitted to the facility with diagnoses including cerebral palsy and bipolar disorder. 7/8/24 - R109's quarterly MDS assessment documented a BIMS score of 14, indicating a cognitively intact status. 7/8/24 - R109's quarterly MDS assessment documented, Mouth or facial pain, discomfort or difficulty with chewing? Yes. 7/29/24 10:28 AM - R109 was observed with chipped and broken front teeth. During an interview, R109 stated, I don't have pain right now, but I am worried my teeth are getting worse because they are already broken. The surveyor asked R109 if the facility offered him to see a dentist. R109 stated, I don't remember if I was offered to see the dentist. 8/2/24 12:40 PM - A review of R109's clinical records lacked evidence of a dental consult for his complaint of pain on 7/8/24. During an interview, E3 (ADON) stated, [R109] will…

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 (R126) out of four sampled residents reviewed for food, the facility failed to provide food that accommodated R126's allergies. Findings include: Review of R126's clinical record revealed: 3/6/23 - R126 was admitted to the facility. 2/13/24 - R126's allergy list was updated to include aspartame, an artificial sweetener for food and drinks. 8/1/24 9:15 AM - A random dining observation of R126's 's breakfast tray revealed the presence of two aspartame sweetener packets on the tray. R126's meal ticket on the breakfast tray documented an aspartame allergy. 8/1/24 9:20 AM - During an interview, E4 (CNA) confirmed the presence of two aspartame sweetener packets on R126's breakfast tray. 8/12/24 2:15 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E10 (VPO) and a State of DE Ombudsman (via telephone).

Based on interview, review of the facility assessment and an identified deficient practice scoped as an Immediate Jeopardy during the survey, it was determined that the facility failed to conduct a quality assurance and performance improvement activity in response to R322's significant medication error and adverse event on 7/6/24. The facility failed to analyze the cause(s), implement preventive actions and mechanisms that included feedback and learning throughout the facility. Findings include: The facility's assessment, last updated 7/2024, revealed: . 3.5 Staff Training/ education and competencies All staff members have a competency checklist upon hire that is completed during orientation to provide adequate care for our residents . Topics . Date Presented . Medication and Treatment administration . Orientation & Annually, and as needed . Cross refer to F760, example 1 7/6/24 - Review of R322's clinical record and the facility's incident report documented that R322 was administered another resident's medications by E43 (RN) which resulted in R322 being emergently transferred 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 one (R21) out of five residents reviewed for immunizations, the facility failed to provide evidence that the Pneumococcal vaccine was offered or declined. Additionally, for one (R26) out of the same five residents reviewed for immunizations, the facility failed to provide evidence that the influenza vaccine was offered or declined. Findings include: 1. The facility policy on pneumococcal vaccination last updated, 8/4/23 indicated, Vaccination against pneumonia will be offered to center patients as indicated. If vaccine is not provided document reasoning in the medical record. Review of R21's clinical record revealed: 2/11/23 - R21 was admitted to the facility. 8/5/24 11:44 AM - Review of resident immunization lacked evidence of administration or declination of the pneumococcal vaccine to R21. An email request was sent to E3 (ADON) for evidence of administration or declination of the Pneumococcal vaccine. 2. The facility policy on influenza immunization last updated, 5/1/23 indicated, Influenza should be offered…

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 one (R26) out of five residents sampled for COVID-19 Immunization the facility failed to provide evidence that R26 had consented or declined to be given the COVID-19 vaccine. Findings include: The facility's policy on COVID-19 vaccines last updated 3/11/24 indicated, The CDC recommends that everyone stay up to date with the use of COVID-19 vaccines to prevent the spread of COVID-19 .Provide education using vaccine information statement. Document attempts and refusals. Review of R26's clinical record revealed: 6/29/23 - R26 was admitted to the facility. 11/28/23 - R26 received education on the COVID-19 vaccine. 8/5/24 11:44 AM - Review of R26's immunization record lacked evidence of any COVID-19 vaccination. An email request for evidence of administration or declination of the COVID-19 vaccine was requested from E3 (ADON) (ICP). During an interveiw on 8/6/24 at 12:45 PM, E3 (ADON) and (ICP) confirmed the facility lacked evidence that R26 received or declined the COVID-19 vaccine. 8/12/24 2:15 PM - Findings were reviewed 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 interview and review of facility documentation it was determined that for three (E14, E27 and E28) out of nine employees sampled the facility failed to provide abuse, neglect, exploitation, and dementia training at least annually. In addition, E21 did not have dementia training. Findings include: The facility was provided a list of nine names selected randomly and instructed to provide documentation of in-service training for abuse, neglect, exploitation, and dementia training for new and existing staff. 8/7/24 11:00 AM - During an interview and record review with E34 (HR) it was confirmed: 1. E14 had a hire date of 9/1/22. E14's record review lacked evidence of abuse and dementia training. 2. E27 had a hire date of 7/22/08. E27's record review lacked evidence of abuse and dementia training. 3. E28 had a hire date of 10/3/23. E28's record review lacked evidence of abuse and dementia training. 4. E21 had a hire date 3/5/24. E21's record review lacked evidence of dementia training. 8/12/24 1:34 PM - Findings were confirmed with E2 (DON) and E3 (ADON). 8/12/24 2:15 PM -…

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

Based on interview and review of the facility's policy and procedure, it was determined that the facility failed to ensure mandatory effective communication training was completed for all direct care staff. Findings include: 3/8/21 - The facility's policy and procedure entitled LEP/Auxiliary Aid Services documented, In order to ensure effective communication with patients and their companions, the Center will provide appropriate auxilliary aids and services, where necessary, including, but not limited to, qualified sign language interpreters for patients and their companions who are deaf or have hearing loss, as well as aids and services to those who are vision impaired or have limited English proficiencies . 11. The Center will provide mandatory ADA (Americans with Disabilities Act) training for all employees and contract employees who are affiliated with the Center who might interact with patients and/or companions who have communication impairments. Training will also be included in new hire orientation and will be incorporated in the training library for all employees annually.…

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

Based on interview, record review and review of facility documentation as indicated, it was determined that for one (R324) out of four residents reviewed for falls, the facility failed to inform R324's representative/POA (Power of Attorney) of a fall. Findings include: Cross refer to F689, example 1 R324's clinical record revealed: 6/22/24 at 6:00 AM - The facility's incident report lacked evidence that F7 (R324's representative/POA) was notified of the fall. 7/6/24 - The facility's investigation of the 6/22/24 incident revealed a documented telephone statement from E43 (RN) that included, . Her [F7, representative/POA] was super involved every day. 7/31/24 at 7:30 PM - During an interview, F7 (R324's representative/POA) stated that R324 called him around 8:00 AM on 6/22/24 and told him that she fell during a transfer. F7 stated that the facility never informed him about the fall. 8/6/24 at 12:25 PM - During an interview, E52 (RN/House Supervisor) stated that E43 (RN), the assigned nurse, was to notify the doctor and the family of the incident. E52 stated that she did not know if…

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

Based on interview, record review and review of facility documentation as indicated, it was determined that for one (R340) out of two residents reviewed for death, the facility failed to consult with R340's physician of her repeated refusals of two medications. Findings include: R340's clinical record revealed: 7/24/24 - R340 was admitted to the facility with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease (COPD/inflammatory lung disease), asthma and acute and chronic respiratory failure with hypoxia (insufficient oxygen in the blood). 7/24/24 - A physician ordered Breo Ellipta inhaler daily for shortness of breath and Spiriva inhaler daily for COPD. Review of the July 2024 eMAR revealed that five out of seven days, R340 refused both her Breo and Spiriva medications. Review of the August 2024 eMAR revealed that four out of six days, R340 refused both her Breo and Spiriva medications. There was no evidence that the physician nor R340's resident representative were notified that R340 was repeatedly refusing these medications per the plan 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 record review and interview, it was determined that for two (R323 and R423) out of two residents reviewed for grievances, the facility failed to ensure that concerns for missing dentures and a fall were resolved in a timely manner. Findings include: A facility policy and procedure, dated 1/23/20, and titled, Service Concerns documented, .Staff are trained appropriately in resolving . patient/family concerns .as promptly as possible . 3. The department manager receiving the company Service Concern Report actively and promptly initiates appropriate action (no later than 48 hours of receiving the concern). The department manager will follow up with the patient/family to determine satisfaction and will complete in full, the Step II Department Manager Response section on the yellow copy of the form and forward it immediately to the Administrator. 4. The Administrator will follow up as needed with the patient/family regarding satisfactory resolution and will verify the final outcome on the form. He/she will complete the Step III Disposition by Administrator section of the company…

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 (R109) out of three residents reviewed for abuse, the facility failed to ensure that R109 was protected from verbal and emotional abuse when a staff member accused him of stealing chips that were left over from a staff party. Findings include: Review of R109's clinical records revealed: 9/26/23 - R109 was admitted to the facility with diagnoses including cerebral palsy and bipolar disorder. 4/25/24 8:30 AM - A facility incident report submitted to the State Agency documented, [R109] reported that a facility employee [E11] called him a thief because he took some chips that were left over from a staff party earlier in the day. In response to R109's 4/25/24 incident, the facility implemented the following corrections: - From 4/25/24 to 5/16/24, the facility's training attendance sheet, titled, Abuse and Neglect, documented that nursing, dietary, administrative and housekeeping staff recieved training in response to this incident. 7/8/24 - R109's quarterly MDS assessment documented a BIMS score of 14, indicating 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 observation, interview, record review and review of facility documentation as indicated, it was determined that for two (R94 and R31) out of seven residents reviewed for activities of daily living (ADLs), the facility failed to ensure each dependent resident received the necessary services to maintain grooming and personal hygiene. Findings include: 1. R94's clinical record revealed: 12/22/23 - R94 was care planned for incontinence of bladder and/or bowels: inability to control bowel and bladder. Approaches included: - 1 person assist with toileting; - check and change briefs frequently as needed; and - refer to occupational therapy (OT) as indicated. 7/2/24 - Review of the July 2024 CNA Documentation Survey Report revealed the absence of documentation of R94's care from 7 AM through 3 PM. In addition, R94's meal intakes (breakfast and lunch) were not documented too. 7/2/24 at 9:11 PM - The facility reported the following incident to the State Agency: On 7/2/24 at approx. 4:40 PM, [R94] (BIMS 13 [cognitively intact] - dependent on staff for care) reported to the nurse that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined that for one (R129) out of two residents reviewed for pressure ulcers the facility failed to promote of healing of pressure ulcers when pressure ulcer prevention interventions were observed not in place. Findings include: The facility policy on wounds/skin impairments last updated 7/17/24 indicated, All mattress or devices will be pressure relieving. Provide treatments as ordered. Review of R129's clinical record revealed: 10/2/23 - R129 was admitted to the facility with multiple diagnoses including history of a traumatic brain injury, with severe bleeding to the brain, convulsions, and muscle weakness. 10/2/23 - A care plan was created for risk for pressure ulcers and skin breakdown that included interventions to assess the skin for breakdown, keep the skin clean and dry, pressure relieving mattress, pressure relieving chair cushions and skin assessments as indicated. 10/9/23 - A Braden scale skin assessment documented that R129 was very high risk for…

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

Based on observation and interview, it was determined that the facility failed to ensure that medications were stored and labeled properly in one out of three medication carts reviewed. Finding's include: The facility policy on storage of medications, last updated August 2020 indicated, .When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 12/4/24 - 2:35 PM - During a medication storage review of the second floor the following observed inside the Heritage II medication cart: - Four opened bottles of oral liquid medications with no open date labeled. - One opened bottle of powdered oral medication with no open date labeled. 12/4/24 - E3 (LPN) immediately confirmed the findings. 12/5/24 12:30 PM - Findings were reviewed with E1 (NHA), and E2 (DON) during the exit conference.

Based on record review and interview, it was determined that for one (R119) out of fifty-four residents sampled in the survey, the facility did not maintain accurate medical records. Findings include: A review of R119's medical record revealed: 12/29/22 - R119 was admitted to the facility with multiple diagnoses, including left sided paralysis, left sided weakness resulting from a stroke, and anxiety. 12/30/22 - A medication order for clonazepam 2 milligrams for anxiety was ordered for R119 by E6 (Nurse Practitioner). A review of the clonazepam package insert revealed that the medication can cause drowsiness and dizziness. A review of the electronic medical record (Emr) revealed a 12/30/22 admission care plan that indicated that R119 was a fall risk due to a history of falls, impaired balance/poor coordination, gait (walking) unsteadiness and left sided weakness. 3/25/24 3:07 PM - An Emr progress note documented that R119 had a fall without injury at 2:34 PM. 3/25/24 6:42 PM-An Emr progress note documented that R119 had a fall without injury at 6:30 PM. 3/26/24 12:46 AM - An Emr…

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

Based on interview and review of facility documentation, it was determined that for three (E14, E26 and E27) out of five sampled CNA's (Certified Nursing Assistants) reviewed the facility failed to ensure that these employees had the mandatory twelve hours of annual in-service training. Findings include: 8/7/24 11:00 AM - Review of the staff training hours documentation revealed the following: 1. E14 (CNA) with a hire date of 9/1/22 had zero hours of annual in-service training and was confirmed by E34 (HR). 2. E26 (CNA) with a hire date of 3/4/08 had 11.25 hours of training and was confirmed by E34. 3. E27 (CNA) with a hire date of 7/22/08 had zero hours of annual in-service training and was confirmed by E34. 8/12/24 1:34 PM - Findings were confirmed with E2 (DON), E3 (ADON). The facility lacked evidence that these employees completed the mandatory twelve hours of annual in-service training. 8/12/24 2:15 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E10 (VPO) and a State of DE Ombudsman (via telephone).

Based on observation and interview it was determined that the facility failed to implement a grievance policy and postings that included a process for residents and families to file anonymous grievances and to identify the grievance official. Findings include: The facility policy on grievances last updated 1/23/20 indicated, The patient has the right to file grievances/complaints (orally, in writing or anonymously) . The Administrator serves as the grievance official of the Center and is responsible for overseeing the grievance process. 9/5/23 10:17 AM -10:24 AM - The facility nurses stations on both the first and second floor, the second floor resident lounge and activity room were observed for signs that informed residents/families of grievance official and process for filing grievances anonymously, none were found. 9/5/23 10:29 AM - 10:34 AM - E1(NHA) accompanied the surveyor on a tour of the aforementioned locations and confirmed the absence of signs informing residents and families of the grievance process and grievance official as well as directions on how to file an anonymous…

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.

7. R125's clinical record revealed: 6/13/23 - R125 was admitted to the facility with diagnoses including deep vein thrombosis (blood clot in the right lower extremity). 6/13/23 - R125's physicians' orders included lovenox 40 mg/0.4 ml (Enoxaparin Sodium) injection daily for deep vein thrombosis. 8/21/23 - There was no evidence in R125's medical records that a pharmacist's review was conducted for the admission medications orders and for July 2023. 8/22/23 10:30 AM - The absence of the pharmacist's reviews were confirmed with E2 (Regional Clinical Director). 8. A policy and procedure titled, Medication Regimen Review Policy # 11.1 dated 8/2020 documented .D. The prescriber is notified as needed. Further review of the policy had not indicated a detailed time frame for when the facility will respond to the Consultant Pharmacist recommendation. 8/28/23 1:53 PM - A brief interview with E2 (RCD) revealed I provided a policy and procedure for the MRR (Medication Record Review). E2 confirmed I don't know what the time frame is for the physician to follow up on recommendations 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 observation and interview, it was determined that the facility failed to provide and store food in accordance with professional standards for food service safety. Findings include: During the initial kitchen tour on 8/17/23 at approximately 8:30 AM, the hand sink by the dish washing area was found to have excessive dirt and grease in the wash basin. Furthermore, the ceiling at the beverage area was observed to be caving down exposing the contents above the ceiling tiles. Finding was reviewed and confirmed by E29 (food service director) on 8/17/23 at approximately 11:30 AM.

Based on observations, interviews and survey investigative findings, it was determined that the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently during a COVID-19 outbreak where the facility failed to implement their infection control program, despite having a COVID-19 policy and procedure and access to the current guidance from the Centers of Disease Control and Prevention (CDC). Findings include: Cross refer to F880, example 1 On 6/5/23, the facility management signed a Health Care Staffing Agreement for a interim RN Director of Nursing (E3) with a start date of 7/11/23 through 8/11/23 (finish date). The signed agreement stated that .Finish dates may be extended by agreement between (name of staffing company) and Client (facility) . Also specified under Additional Terms: . *It is understood that the consultant will function in a management level role and will not be assigned routine, direct patient care or staff nurse duties, such as delivering medications or performing treatments. On 8/16/23 at 11:00 AM, the Survey…

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, the facility failed to ensure that the QAA committee measured the success of actions, track performance and regularly review, analyze, and act on data collected. Findings include: 9/8/23 11:10 AM - An observation of the facility's Quality Assurance Performance Improvement (QAPI) binder revealed the lack of a recent performance improvement project that the facility conducted which measured the success of actions, track performance and regularly review, analyze, and act on data collected. 9/8/23 11:15 AM - During an interview, E1 stated that the facility did not have a current or recent QAPI project to illustrate the facility's attempts at performance improvement. E1 stated that the facility was in the process of developing QAPI projects in the areas of staff recruitment and staff retention. 9/8/23 at 11:30 AM - Findings were reviewed with E1 (NHA), E2 (RCD) and E3 (DON).

Based on record review it was determined that for five (E40, E66, E87, E88 and E89) out of five employees sampled the facility failed to provide abuse, neglect, exploitation, and dementia training at least annually for E87 and E88. Findings include: The facility was provided a list of five names selected randomly and instructed to provide documentation of in-service training for abuse, neglect, exploitation, and dementia training for new and existing staff. 9/20/23 1:29 PM - An email communicated to E1 (NHA) requested training records for E40 (RN), E66 (LPN), E87 (LPN), E88 (CNA) and E89 (SS). 9/25/23 10:36 AM - A second email communicated to E1 (NHA) requested training records for E40, E66, E87, E88 and E89. 9/25/23 11:39 AM - An email communication from E1 stated, we do the training verbally. 9/25/23 11:43 AM - An email sent to E1 requested, an outline of trainings that had been done verbally. 9/25/23 11:45 AM - E1 communicated and confirmed in another email I do not have them. 9/25/23 12:45 PM - Review of a training schedule titled 'Relias Learning Module Assignmentsdated 2023…

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 it was determined that for five (E40, E66, E87, E88 and E89) out of five employees sampled the facility failed to provide QAPI (Quality Assurance Process Improvement) training at least annually. Findings include: The facility was provided a list of [NAME] names selected randomly and instructed to provide documentation of in-service training for QAPI for new and existing staff. 9/20/23 1:29 PM - An email communicated to E1 (NHA) requested training records for E40 (RN), E66 (LPN), E87 (LPN), E88 (CNA) and E89 (SS). 9/25/23 10:36 AM - A second email communicated to E1 (NHA) requested training records for E40, E66, E87, E88 and E89. 9/25/23 11:39 AM - An email communication from E1 stated, we do the training verbally. 9/25/23 11:43 AM - An email sent to E1 requested, an outline of QAPI training that had been done verbally. 9/25/23 11:45 AM - E1 communicated and confirmed in another email I do not have them. 9/25/23 12:45 PM - Review of a training schedule titled 'Relias Learning Module…

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 R26's clinical record revealed: 6/29/23 - R26 was admitted to the facility with a diagnosis of right fifth toe amputation and a right foot infection, vascular dementia, and bipolar disorder. 8/22/23 11:00 AM - Review of R26's clinical record lacked information for an advanced directive. 8/22/23 11:44 AM - During an interview R26 said, they didn't talk to me about anything, and no one talked to me about what my wishes were. 8/22/23 12:15 PM - Review of R26's Discharge Planning admission Assessment, dated 7/12/23, documented that R26 does not have an advanced directive. Additionally, the reviewed documentation lacked evidence that an advanced directive had been offered and or that R26 did not want an advanced directive. 8/22/23 12:59 PM - In an interview E25 (SS) stated that, if a resident had an advanced directive, it would be scanned into the resident's electronic medical record under miscellaneous. In addition, E25 stated, if the resident doesn't want an advanced directive, I just let it go.…

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.

8. The following was reviewed in R173's clinical record: 4/11/22 - R173 was admitted to the facility with dementia. 4/11/22 - R173 was care planned for alteration in musculoskeletal status with interventions including but not limited to: monitoring for risk of falls, educating the resident, family/caregivers on safety measures to reduce risk of falls (9/18/22), bed in low position (4/12/22); educate resident on calling for help prior to reaching for nightstand (2/6/23); have commonly used articles within easy reach (4/12/22), educate resident on use of reacher and calling for help (2/2/23); and encourage to transfer and change positions slowly (4/12/22). 4/24/22 - Per the facility's investigation report at approximately 4:57 AM, the resident was found lying on the floor and the socks were off on the floor near R173's feet. 5/3/22 - An incident report documented that at approximately 7:50 PM, R173 was in a wheelchair with a call bell within reach wrapped around the arm rest of the wheelchair. At about 8:30 PM, the resident was heard yelling, was noted sliding down in the wheelchair…

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.

6. Review of R 113's clinical record revealed: 7/8/23 - R113 was admitted to the facility with multiple diagnoses including a stroke, that resulted in loss of movement to one sided of his body. 7/14/23 - R113's admission Minimum Data Set (MDS) revealed that R113 was cognitively intact. For Activities of Daily Living, the MDS revealed that R113 needed one person assistance for toilet use and that R113's always lacked control of bowel and bladder (incontinence). 9/1/23 - A review of a 9/1/23 8:00 AM facility incident report for R113 revealed that R113 stated to facility staff that he had not had toileting care throughout the previous night (8/31/23) until 9/1/23 at 6:00 AM. 9/1/23 11:45 AM - During an interview with R113, it was confirmed that care was not provided until 6:00 AM and R113 sat in his urine. 9/1/23 - A review of R113's bowel and bladder log from 8/1/23 thru 9/6/23 revealed that on 8/31/23, R113's last episode of care for toileting from facility staff was at 4:02 PM. R113's next episode of care for toileting was documented as being on 9/1/23 at 12:37 PM. 7. Review 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 interviews and reviews of clinical records, it was determined that for nine (R92, R108, R110, R113, R147, R411, R606, R167 and R508) out of 15 residents reviewed for ADLs (including toileting/showers), the facility failed to have sufficient staff to provide basic nursing care services in accordance with the residents' care plan and to meet each resident's needs. Findings include: Cross refer to F677, examples 2, 3, 4, 5, 6, 7, 8 and F697, examples 1 and 2 The facility failed to have sufficient staff to provide basic nursing care services to meet the following seven residents' needs: -R92 was cognitively intact and required assistance of two staff members as she was dependent for bathing/showers. R92 stated that she was not provided showers or had her hair washed. Clinical record revealed that R92 had no showers on 8/5/23, 8/12/23 and 8/19/23. -From 8/1/23 through 8/19/23, R108 was not provided toileting or incontinence care three times on day shift, six times on evening shift and six times on night shift. -R110 was cognitively intact and required extensive assistance of one…

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, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing services for two (R143 and R172) out of seventy-six (76) residents in the investigative sample to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Findings include: 1. Review of R143's clinical record revealed: 7/31/23 - R143 was admitted to the facility with multiple diagnoses including lung cancer and pneumonia. 8/1/23 - R143's care plan includes a nursing problem that the resident is at risk for constipation. The care plan intervention was to administer the constipation relieving medications when indicated. 8/28/23 - Review of the facility Documentation Survey Report…

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 of facility documentation, it was determined that the facility failed to ensure that a performance review was completed at least every 12 months for five (E78, E79, E80, E81 and E82) out of six sampled employees. Findings include: Review of the latest performance appraisals for 6 randomly selected CNAs revealed the following performance review dates and performance review due dates: E78: 5/20/21 performance review for a 3/13/21 performance due date. E79: 1/20/21 performance review for a 11/26/20 performance due date. E80: 9/7/22 performance review for a 2/11/22 performance due date. E81: 1/7/22 performance review for a 11/18/2021 performance due date. E82: 9/24/22 performance review for a 4/24/22 performance due date. 9/8/23 at 11:30 AM - Findings were reviewed with E1 (NHA), E2 (RCD) and E3 (DON).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation of and two out of two test tray results, it was determined that the facility failed to provide food at a palatable taste. Findings include: 1. A test tray was conducted at both hallways of the facility on 8/21/23 on 12:50 PM at [NAME] Wing and Medbridge Unit 1:30PM. - [NAME]: 140F - Vegetable mix: 143F Test trays tasted by three surveyors between 12:50 PM through 1:30 PM. Consensus was unanimous that the food was bland, watery, and not very good. 9/8/23 at 11:30 AM - Findings were reviewed with E1 (NHA), E2 (RCD) and E3 (DON).

Based on interview and review of related documentation, it was determined that the facility failed to provide evidence of a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs. Findings include: The facility policy on transportation and appointments last updated 11/1/19, indicated, A licensed nurse will ensure transportation to medically related appointments and will be responsible for coordinating those accommodations for transport as appropriate. The facility assessment last updated 9/2023 , lacked evidence of a transfer agreement with any hospital in the contracts and agreements section. During an interview on 9/25/23 at 1:40 PM, E1 (NHA) confirmed the facility was unable to provide a written transfer agreement between the facility and a hospital. E1 stated she thought transfer to hospital was indicated in the facility Assessmnet. 9/20/23 1:11 PM - A copy of the facility's written transfer agreement was requested from E1. No agreement was provided. 9/25/23 at 3:15 PM - Findings were reviewed with E1 (NHA) 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 clinical record review and interview, it was determined that for four (R177, R178, R143 and 121) out of four residents reviewed for hospice, the facility failed to ensure a communication process was in place that hospice records were complete and readily accessible. In addition, the facility failed to ensure coordination and collaboration with hospice when R178 had an unplanned transfer and admission to the hospital on [DATE]. In addition for R121 there was not an agreement in place for that provider. Findings include: 1. Review of R177's clinical records revealed: 7/20/21 - R177 was admitted to the facility. 5/19/23 3:58 PM - A social service progress note documented, Referral made to (hospice #1), hospice rep (representative) to reach out to daughter. 5/31/23 - R177 had an unplanned transfer to the hospital. 6/2/23 - A hospital discharge summary note documented, .She (R177) was accepted by hospice to return to nursing home for services following hospital discharge .Continue outpatient care 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 a review of facility documentation, it was determined that the facility failed to conduct quarterly Quality Assurance Performance Improvement (QAPI) meetings and to maintain a QAPI committee of the required members. Findings include: 8/30/23 - A review of the facility QAPI meeting minutes for the last seven quarters revealed: Two meetings have taken place in the last seven quarters. There were no QAPI Meetings held in 2022. - Q4 2021 QAPI Meeting - The Medical Director was not present. - Q1 2023 QAPI Meeting - The Director of Nursing, the Medical Director and the Infection Preventionist were not present. 9/8/23 at 11:30 AM - Findings were reviewed with E1 (NHA), E2 (RCD) and E3 (DON).

Based on interview and record review it was determined that for one (R162) out of 15 residents reviewed for abuse, the facility failed to ensure R162 was free from verbal abuse and physical abuse when a nurse called R162 a dumbass and pulled a gown over his head. Findings include: Policies and Procedures Abuse/Neglect/Misappropriation/Crime Prevention/Screening/Training (effective date 1/23/20): The Administrator promotes the prevention of abuse (including verbal, sexual, mental, physical, corporal punishment, involuntary seclusion, or abuse facilitate or enable through the use of technology) and . 6/13/23 - Most recent admission to the facility. 7/23/23 5:30 AM - A progress note documented that R162 was found on the floor. 7/23/23 5:42 PM - An allegation of physical and verbal abuse reported to the State Agency documented at approximately 6:00 AM, R162 was verbal and physically abused. R162 stated The nurse that took care of me last night physically abused me. This was reported over 11 hours later. 7/24/23 - A facility provided investigation with statements from E32 and E34 (Former…

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 (R162) out of 15 reviewed for abuse the facility failed to report an allegation of abuse within the required time frames. Findings include: Policies and Procedures Abuse/Neglect/Misappropriation/Crime Prevention/Screening/Training (effective date 1/23/20): .All employees receive training in orientation and are routinely in-serviced regarding the definitions of abuse, neglect, and misappropriation of property and . their responsibility to immediately report any cases of suspected or witnessed abuse or neglect. 6/13/23 - Most recent admission to the facility. 7/23/23 6:12 AM - A progress note documented that R162 was alert and responsive no acute distress noted. R162 was found on the floor no visible injuries noted upon assessment. [R162] refused vitals and not compliant with assessment. [R162] state (sic) that I rolled over on the floor because no one came to change me, so I want to go to the hospital. 7/23/23 5:42 PM - An allegation of abuse and neglect was reported to the State Agency documented at approximately…

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

Based on interview, record review and review of other facility documentation as indicated, it was determined that for one (R170) out of fifteen residents reviewed for abuse, the facility failed to investigate, prevent, and/or correct alleged abuse violations. For R170, the facility failed to maintain documentation that appropriate corrective action was taken as a result of R170's alleged violation of abuse. Findings include: 1. Review of R170's clinical record revealed: 4/14/23 - R170 was admitted to the facility. 7/12/23 - The facility reported an allegation of abuse made by R170 to the State Agency and began their investigation. E15 (CNA) suspended. During the facility's investigation, a statement was taken from R170. R170 stated, Around 2 AM this morning I asked to be changed. She [E15], came in to change me. She flipped me on one side and flipped me to the other. When she flipped me to the left side it hurt because she flipped me hard. 7/13/23 - The facility's incident follow-up determined, [R170] was noted to have a new open area on the sacrum and incontinent associated 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 for one (R178) out of six residents reviewed for transfer/hospitalization, the facility failed to provide written notice to R178's resident representative regarding the resident's hospital transfer. Findings include: Review of R178's clinical record revealed: 10/5/22 - R178 was admitted to the facility for rehabilitation. 11/25/23 - R178 had an unplanned hospital transfer. 9/6/23 10:00 AM - Review of R178's clinical record revealed a lacked of evidence that R178 and their representative were provided with a written discharge notice. 9/6/23 10:12 AM - An interview with E2 (RDC) confirmed there was no documentation in the clinical record that showed R178's resident representative was notified in writing and was provided the transfer/discharge notification information. Findings were reviewed with E1 (NHA), E2 (RCD) and E3 (DON) on 9/8/23 beginning at 11:30 AM.

2. Review of R92's clinical record revealed: 3/31/23 - R92 was admitted to the facility with a broken right leg. 7/5/23 - R92's quarterly MDS assessment documented that R92 had a hip fracture (and not a broken leg) and did not have any surgical wounds. 8/22/23 8:06 AM - A skin and wound note documented: The patient has a surgical wound. Presence of other specified functional implants (external fixator). 8/22/23 9:41 AM - During an interview, E64 (MDS Coordinator) confirmed R92's 7/5/23 quarterly MDS assessment did not reflect that R92 had a broken leg and surgical wounds. Based on record review and interview, it was determined that for four (R92, R103, R160, and R256) out of 76 sampled residents the facility failed to ensure the MDS assessment accurately reflected the residents status. Findings include: 1. Cross refer F760. Review of R160's clinical record revealed: 5/21/23 - R160 was diagnosed with a deep vein thrombosis (DVT/Blood Clot) in her right arm prior to her admission to the facility. 6/16/23 10:54 PM - R160 was admitted to the facility with diagnoses that included stroke,…

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 (R75) out of four residents reviewed for PASARR, the facility failed ensure that a referral for a PASARR (Preadmission Screening and Resident Review) screening was completed following a significant change. Findings include: Cross Refer, F758, Example # 2. a. Review of R75's clinical record revealed: 7/6/23 - R75 was admitted to the facility with diagnoses including dementia. An admission Level One PASARR dated 7/6/23 completed for R75 documented no mental health medications. 8/28/23 - A review of R75's physician orders revealed the following active mental health medications ordered: - 7/6/23 Seroquel 25 mg (milligrams) tablet one time a day for bipolar - 8/4/23 Seroquel 50 mg tablet at bedtime for bipolar - 8/10/23 Trazodone 50 mg tablet every 6 hours as needed for agitation 8/28/23 9:43 AM - In an email correspondence, S1 (PASARR State Authority) revealed that, .The facility should have submitted a status change or another resident review PASARR at that time of or timely discovery that the Level 1 (Notice Date…

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

Based on interview and record review, it was determined that for two (R125 and R139) out of four residents sampled for PASARR review, the facility failed to provide evidence that a Delaware State PASARR was obtained prior to admission. Findings include: PASSR (Preadmission Screening and Resident Review) - screening of a patient for signs of serious mental illness and/or intellectual disabilities, developmental disabilities, or related conditions so if residing in a nursing home, the resident receives all necessary services for their condition. 1. 6/13/23 - R125 was admitted to the facility with multiple diagnoses including major depressive disorder. 6/13/23 - R125's physician's orders included the antidepressant mirtazapine 7.5 mg daily for depression. A Pennsylvania State PASARR signed and dated 6/13/23 was uploaded into R125's medical records. There was no evidence that a Delaware State PASARR was obtained prior to admission. 8/21/23 9:30 AM - During an interview E25 (Social Worker) confirmed that R125 did not have a Delaware PASARR prior to admission. 2. 7/1/23 - R139 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 interview and record review, it was determined that for two (R160 and R182) out of thirteen residents sampled for quality of care, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care. For R182, the facility failed to develop and implement a care plan to address her skin integrity issues upon admission. For R160 the baseline care plan did not include epilepsy including seizure prevention interventions. Findings include: 1. R182's clinical record revealed: 7/3/23 - R182 was admitted to the facility. 7/4/23 at 6:06 AM - A skin and wound note documented that R182 was admitted with an unstageable pressure ulcer on the sacrum (bone at the base of the spine) and open lesions on the left medial malleoulus (ankle bone), right shin and left forearm. R182's clinical record lacked evidence of a baseline care plan to address and treat her skin integrity issues. 8/31/23 at 12:10 PM - During a combined interview with E3 (Interim DON) and E4 (RN/UM), R182's skin integrity issues…

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 (R163 and R172) out of seventy-six residents reviewed for investigations, the facility failed to develop and implement comprehensive resident centered care plans for identified care areas. Findings include: 1. Review of R163's clinical record revealed: 6/24/22 - R163 was admitted to the facility with multiple diagnosis including urinary retention. 3/5/23 - A physician's order was written for R163 to have a bladder scan every shift and to straight catheterize if more than 400 ml of urine was present in the bladder. 3/29/23 - A quarterly MDS assesment documented that R163 had a urinary catheter. 4/10/23 - An order was written for R163 to have a Foley catheter inserted for urinary retention. 4/19/23 - A care plan was developed for R163's Foley urinary catheter related to urinary retention. The care plan included interventions for Foley catheter care to be provided each shift. This care plan was developed greater than thirty days after R163's straight cath order and nine days after R163's Foley catheter order. During an…

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

Based on observation, interview, and record review it was determined that for two (R126 and R139) out of two residents reviewed for bowel and bladder management, the facility failed to ensure that appropriate assessments, treatments, and services were rendered to achieve normal bowel and bladder continence to the extent possible. Findings include: A review of the facility's policy titled Assessment for Bowel and Urinary Toileting Program dated 11/1/19 revealed that licensed nurses will assess patients for unusual bowel patterns or urinary patterns, habits, and continence status. Assessments findings will determine selection of patients who may benefit from participating in a bowel or urinary retraining program. 1. Review of R126's clinical records revealed: 5/24/23 - R126 was admitted to the facility with diagnoses including but not limited to cerebrovascular disease (a group of conditions that affect blood flow and blood vessels in the brain), major depressive disorder, slurred speech, congenital malformation syndromes (developmental delay primarily involving the limbs.) 5/24/23 -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of R75's clinical records revealed: 7/6/23 - R75 was admitted to the facility with diagnoses including dementia. 7/12/23 - R75's admission MDS assessment revealed that R75 was cognitively impaired and required supervision of one staff member assist with eating. R75 was holding food in mouth/cheek or residual food in mouth after meals. 7/10/23 - R75 had a care plan for an actual or potential nutritional problem related to dementia .with interventions including but not limited to: encourage to eat .record meal % intake .therapeutic diet as ordered . 8/18/23 1:27 PM - A nursing progress note documented that R75 was rescheduled for an endocrinologist appointment for Monday (8/21/23) at 1:30 PM at (hospital). 8/21/23 - Multiple observations of R75 seated on his rock and go chair from 10:30 AM through 1:00 PM revealed that the facility lacked evidence that the nursing staff offered a pre-arranged lunch for R75 nor offered him a bagged lunch before he left for a doctor's appointment at 1:00 PM. 12:40 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 observation, interview and record review. it was determined that for one (R132) out of four sampled residents reviewed for respiratory care, the facility failed to ensure that R132 was provided respiratory care consistent with his physician order and comprehensive person-centered care plan. Findings include: Review of R132's clinical records revealed: 6/21/23 - R132 was readmitted in the facility with diagnoses including CHF (Congestive Heart Failure) and low blood pressure. 6/28/23 - R132 had a care plan initiated for respiratory complications secondary to COPD (Chronic Obstructive Pulmonary Disease) and supplemental O2 (oxygen) use with interventions including but not limited to administering oxygen as ordered. 7/21/23 - R132 had an active physician's order for oxygen therapy at 1 L (liter)/min (minute) via nasal cannula (a tube placed into nostrils to deliver oxygen) every shift for monitoring. 8/16/23 - R132's quarterly MDS assessment revealed that the resident was cognitively intact and receiving oxygen therapy. Multiple random observations of R132 receiving oxygen…

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

Based on record review, interview, and review of other facility documentation, it was determined that for one (R49) out of two residents reviewed for dialysis services, the facility failed to review a medication order conveyed by R49's dialysis communication form upon return to facility after dialysis. In addition, the facility failed to clarify the recommended order to ascertain whether the dosage/frequency of the medication and whether it was to be administered at the facility, or to be administered at dialysis. The facility also lacked evidence that six out of eight opportunities R49's post dialysis communication documentation sheets were reviewed by the facility for any pertinent information or recommendations. Findings include: Review of R49's clinical record revealed: 3/28/23 - R49 was admitted to the facility with kidney disease requiring dialysis. 8/10/23 - A facility dialysis communication form was returned to the facility with R49 after dialysis. The post dialysis portion of the form documented: Pt (patient) has new prescription for cinacalcet 30 mg (milligrams) to take…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and reviews of clinical records, the facility failed to ensure that for one (R172) out of seventy-six residents in the investigative sample that were reviewed for medical care supervised by a physician, the facility failed to ensure that one of R172's medication orders contained accurate medication administration instructions. Findings include: Cross refer to F684. Review of R172's clinical record revealed: 5/10/22 - R172 was admitted to the facility with multiple diagnoses including a recent (4/22) left foot surgical toe removal and anemia (reduced ability of red blood cells to carry oxygen to organs, causing tiredness). 5/11/22-5/19/22 - R172 was hospitalized for foot wound care and for the monitoring of his anemia. 5/19/23 -R172 was readmitted to the facility. Review of the hospital discharge summary revealed that R172 received treatment for his chronic anemia while hospitalized , which included a transfusion (receiving blood products into a vein) of two (2) units of blood. R172's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined that for four (R25, R26, R59 and R75) out of seven residents reviewed for unnecessary medication review the facility failed to ensure residents were free from unnecessary psychotropic medication use. For R25 the facility failed to ensure an ordered psychotropic medication had the correct indication for use. For R75, the facility failed to ensure R75's medication regimen was free from unnecessary medications when he was prescribed and started using Trazodone Q 6 hours PRN for agitation. In addition, for R26, R59, and R75 the facility failed to initiate AIMS assessment for the use of anti-psychotic medication. Findings include: 1. Review of R25's clinical record revealed: 2/17/23 - A physicians order was written for R25 to have Buspar HCl Oral Tablet 15 MG by mouth three times a day for depression. According to https://www.drugs.com/buspar.html the indications for use of Buspar is anti-anxiety. 3/20/23- An MRR documented the following recommendation, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined that for two (2) out of three medication rooms the facility failed to ensure that medications that required refrigeration were stored under the proper temperatures. Additionally, in one (1) out of three medication rooms the facility failed to securely store a Schedule II controlled drug in a locked and permanently attached compartment. Findings include: 8/16/23 12:30-1:30 PM - Observations of the [NAME] and [NAME] Unit medication rooms and refrigerators revealed: - The [NAME] Unit refrigerator temperature control log was missing the daily recorded temperatures for the August 1, 2, 3, 13 and 14, 2023. Drugs that required refrigeration were present in the refrigerator. -The [NAME] Unit medication room had an unlocked refrigerator that contained a 15 ml bottle of Morphine Sulfate 20 mg/ml, which was in an unlocked container that was not permanently attached to the refrigerator. 8/16/23 1:30 PM - During an interview, E4 (RN UM) confirmed the above. 8/16/23 - 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 interview and record review, it was determined that for one (R182) out of ten residents reviewed for change of condition, the facility failed to obtain laboratory services. Findings include: Cross refer to F684, example 4 Review of R182's clinical record revealed: 7/12/23 at 12:10 PM - A physician's order, entered by E17 (NP), stated, BMP every night shift every Sunday. R182's clinical record lacked evidence of a BMP lab. 8/28/23 at 10:57 AM - During an interview, E3 (Interim DON) confirmed that the ordered lab was never done. 9/8/23 at 12:30 PM - Finding was reviewed with E1 (NHA), E2 (RCD) and E3 (Interim DON).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that for one (R182) out of ten residents reviewed for a change of condition, the facility failed to ensure that her medical record was complete. Findings include: Cross refer to F684, examples 4 and 5 R182's medical record revealed: Despite only being in the facility from 7/3/23 to 7/20/23, R182's July 2023 CNA Documentation Survey Report lacked evidence of documentation for: -18 out of 50 meal intakes; -9 out of 17 bedtime snacks; -21 out of 52 shifts of her [NAME] (care plan) reviewed by CNAs; -22 out of 51 shifts of bowel/bladder elimination; -20 out of 52 shifts of transferring Activity of Daily Living (ADL); -20 out of 52 shifts of toilet use ADL; -2 out of 5 scheduled shower opportunities; -13 out of 34 shifts of personal hygiene (included combing hair, brushing teeth, washing face and hands) ADL; -13 out of 34 shifts of eating (self performance/support provided) ADL; -13 out of 34 shifts of dressing (self performance/support provided) ADL; and -20…

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 one (R136) out of five residents sampled for COVID-19 Immunization the facility failed to provide R136 education for COVID-19. In addition, R136's clinical record lacked evidence that R136 had consented or declined to be given the COVID-19 vaccination. Findings include: Review of R136's clinical record revealed: 6/12/23 - R136 was admitted to the facility with a diagnosis of schizoaffective disorder bipolar type. 9/5/23 - Review of R136's record lacked evidence of COVID-19 immunization. In addition, R136 had not been provided an informed consent and or declination for COVID-19. 9/6/23 1:35 PM - An email from E2 (RCD) confirmed that R136 had not been provided education for the COVID-19 vaccination and that a consent and or declination form had not been found in R136's clinical record. 9/8/23 11:30 AM - Findings were reviewed with E1 (NHA), E2 (RCD) and E3 (DON).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that for one (R35) out of three residents reviewed for notification of changes, the facility failed to notify R35's emergency contact when R35 fell and was transferred to the hospital. Findings include: Review of the facility policy titled, Documentation and Notification, effective 11/01/19, Procedure #1: The Charge Nurse is responsible for notifying the Physician (MD) and/or the Responsible Party (RP) whenever there is a change related to the care of the patient. Notification will occur when there is a: . -Fall -New order requiring the patient to leave the Center for a treatment or diagnostic test . Review of R35's clinical record revealed: 11/30/23 - A progress note written in the EMR revealed that R35 fell in her room and hit her head during the fall. A physician's order was written by E5 (MD) to transfer R35 to the hospital to be evaluated. R35 was subsequently admitted to the hospital. The following interviews were obtained on 12/15/23: -8:30 AM -…

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

Based on observation, interview and record review, it was determined that for one (R103) out of one resident reviewed for activities the facility failed to implement resident centered activities programs that incorporates the resident's interests, hobbies, and cultural preferences. R103 was Mandarin speaking. Findings include: 5/4/23 - R103 was admitted to the facility. Date - The MDS indicated that the resident's primary language is Mandarin. 5/10/23 - According to the speech therapy notes, R103 was assessed using the BIMS, which scored a 2. This indicates that the resident has severe cognitive impairments in the areas of memory, safety, and problem solving. 5/9/23 - The careplan stated that R103 will participate in self-directed activities such as watching the news/tv in patient language which was Mandarin. 8/21/23 - Interview with R103's son at approximately 11:50 AM stated that the facility does not provide culturally relevant activities or tv/news in Mandarin. 8/21/23 - Observation on from 1:30 PM through 2:46 PM observed R103's TV only playing English programming. Findings…

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 (R160) out of three reviewed for hospitalization the facility failed to ensure that R160 was free of significant medication errors. For R160 the facility failed to administer a seizure medication for three days and anti-coagulant therapy. Findings include: 1. Cross refer F41 and F655 The following was reviewed in R160's clinical record: 5/21/23 - R160 was diagnosed with an occlusive deep vein thrombosis (DVT) in her right arm. Per the U.S Food and Drug Administration, enoxaparin (Lovenox) is indicated for an acute DVT without pulmonary embolism (PE), the standard dosage and treatment duration in the inpatient setting is 1 mg (milligram) per kg (kilogram) subcutaneously (under the skin) every 12 hours. (October 2015) Per the American Society of Hematology 2020 Guidelines for Management of Venous Thromboembolism: treatment of deep vein thrombosis and pulmonary embolism, the initial management of a DVT spans the first 5 to 21 days following the diagnosis of a new DVT. Primary treatment continues anticoagulant therapy…

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 interviews, it was determined that the facility failed to provide and store food in accordance with professional standards for food service safety. Findings include: The following was observed on 5/5/22 at approximately 9:05 AM during the initial kitchen tour: - The hand washing sink by the dish washer does not have a hand washing sign, - The water is pooling on the floor at the walk-in refrigerator below the condensor, - There was a container of moldy macaroni noodles. Findings were reviewed with E2 (DON) on 5/10/22 at 1:15 PM.

Based on observation and interview it was determined that the facility failed to ensure a call bell was in reach for one (R55) out of 89 residents reviewed. Findings include: During an observation on 5/3/22 at 9:58 AM, R55 was observed in bed wearing a gown that was visibly soiled with a soft brown odorous substance indicative of bowel movement. R55's call bell was out of reach and clipped to R55's bed. The surveyor activated the call bell and at 10:01 AM E12 (CNA) responded to the call bell and confirmed that R55's call bell was out of reach. During an observation on 5/3/22 at 11:46 AM, R55 was observed in bed and the call bell was on the floor underneath R55's roommates bed. E10 (RN) confirmed the finding and reported she would place it within R55's reach. Findings were reviewed with E2 (DON) on 5/10/22 at 1:15 PM.

Based on interviews and record review, it was determined that for two residents (R12 and R16) out of 39 sampled residents, the facility failed to review and revise the comprehensive person-centered care plan. Findings include: 1. Review of R12's clinical record revealed: 6/15/15 - R12 was admitted to the facility. 1/17/22 (last revised) - A care plan was initiated on 3/3/21 for COVID-19 recovered, fully vaccinated. 1/25/22 - The Patient Vaccination: Information Acknowledgement Form documented that E4 (RN, UM) provided information and discussed the benefits for receiving the COVID-19 vaccine and that R12 refused the vaccine. 2/2/22 - The annual MDS indicated R12's BIMS score was 13 (able to independently make decisions regarding daily life). 4/11/22 - The Patient Vaccination: Information Acknowledgement Form documented that E4 (RN, UM) provided information and discussed the benefits for receiving the COVID-19 vaccine and that R12 refused the vaccine. 5/11/22 1:20 PM - During an interview, E16 (Infection Control Practitioner) provided written and verbal confirmation that R12 refused…

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 monitor if the fluid restriction was maintained for one (R388) out of four residents reviewed for hydration. Findings include: Review of R388's clinical record revealed the following: 4/20/22 - R388 was admitted to the facility for rehabilitation and was on hemodialysis due to kidney disease. 4/20/22 - A care plan was initiated for R388 for Risk for alteration in hydration related to fluid restriction with a goal of Maintain adequate hydration. Interventions included, Maintain fluid restriction as ordered. The total amount of fluid restriction and the amount allotted to dietary or nursing was not included in the care plan. 4/20/22 - A Physician's Order was written for a fluid restriction of 1,000 cc / day. 4/20/22 through 5/11/22 - Review of the Treatment Administration Records revealed that licensed nursing staff only document that the fluid restriction was maintained every shift. There was no documentation of the amount of fluid allotted to nursing either in a day (24 hours) or in a shift. 4/20/22…

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

Based on observation, interview, and record review, it was determined that for one (R16) out of six (6) residents sampled for unnecessary medication review, the facility failed to properly label and store the medication. Findings include: Review of the facility's guidance, dated 11/17 and titled Medication Administration: Self-Administration of Medications, stated, .Medications, if stored at the patient's bedside, are to be secured in a locked storage unit until use . Review of the Lilly's manufacturer information for the insulin (medication) documented, .Throw away the Insulin Injection Pen you are using after 28 days . Review of R16's clinical records revealed: 12/4/20 - R16 was admitted to the facility. 11/2/21 - A care plan for self administration of medication included an intervention that medications and supplies are maintained in a locked drawer at the bedside or in the medication cart. 5/10/22 1:25 PM - During an interview, R16 stated she self- administered her insulin when she was on leave of absence from the facility for part of the day, usually a few days per week 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 observation, interview and record review it was determined that for one (R53) out of three residents reviewed for food preferences, the facility failed to accommodate R53's food preferences or choices. Findings include: 3/4/22 - R53 was admitted to the facility. 5/3/22 11:49 AM - During a dining observation, R53's hot tea was not included on the lunch tray despite her meal ticket showing hot tea for a beverage. 5/3/22 11:52 AM - In an interview with R53, it was revealed that R53 has a TPN feeding that runs overnight, but the resident is allowed to have a full liquid diet for breakfast, lunch and dinner. R53 stated, I have requested to the CNA's, Nurses and the Dietitian that I want hot tea, cream of mushroom soup, cream of chicken soup, tomato soup and some grits. The facility has responded by telling me they will make a note of it, but every meal my tray has something wrong. They don't send my hot tea, they send me jello and puddings that I don't like despite that I let them know what I prefer to eat. When they send soup - most of the time it's not warm enough - it's cold…

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 the facility failed to provide special adaptive equipment, built-up grip utensils for one (R16) resident during a random meal observation. Findings include: Review of R16's clinical record revealed: 12/4/20 - R16 was admitted to the facility. 5/3/22 12:31 PM - During a random lunch observation, R16 was provided a meal with regular utensils. Review of R16's meal ticket on the tray documented built-up spoon, fork, and knife. No built up spoon, fork and knife to consume the meal was provided to R16. 5/3/22 12:35 PM - An interview with E7 (LPN) confirmed that no built-up utensils were provided to R16. 5/9/22 (Most recent revision date) - CNA Visual/Bedside [NAME] Report stated, .Adaptive equipment: built-up grip utensils . 5/12/22 3:15 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).