Wilmington Nursing & Rehabilitation Center

Based on interview, record review and review of other facility documentation, it was determined that for one (R9) out of four residents reviewed for change in condition, the facility failed to ensure that a stat (at once) ordered chest x-ray was completed until 31 hours after it was ordered. In addition, the facility failed to ensure that R9's STAT chest x-ray result was reported to the physician in a timely manner. Findings include: Cross refer F580 and F684 Review of R9's clinical record revealed:6/5/26 9:21 AM - A nurse progress note documented, . [P2 NP] made aware (sic) she went to see [R9] . gave verbal order for STAT chest x-ray.6/5/26 3:00 PM - R9 had a physician's order for chest x-ray two views for cough and congestion.6/6/25 4:54 PM - A radiology results report documented R9's chest x-ray examination was done on this date and time.6/6/26 9:07 PM - A radiology results report documented R9's chest x-ray result with significant findings. 6/7/26 6:13 AM - A nurse progress note documented, .CXR (chest x-ray) results are back and MD (physician) will review them and give further…

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 record reviews, it was determined that for one (R11) out of 4 residents reviewed for nutrition, the facility failed to maintain clinical records that meet professional standards of practice when R11's missing nutrition assessments were completed and signed by another Registered Dietitian on 5/5/26, one month after R11 was discharged from the facility on 3/26/26. Findings include:Review of R11's clinical record revealed: 1/17/26 - R11 was admitted to the facility.1/19/26 - R11's nutrition assessment was completed by C1 (contract RD/ Registered Dietitian).3/26/26 2:00 PM - A nurse progress note documented that R11 was transferred to the hospital.5/4/26 - A review of R11's electronic health record under the evaluation/assessment tab revealed only one nutrition assessment completed by C1 on 1/19/26.5/4/26 3:00 PM - In an interview, E2 (DON) confirmed that R11 was discharged from the facility on 3/26/27. E2 further stated that R11 did not return to the facility after she was transferred to the hospital on 3/26/26. 5/5/26 3:25 PM - E2 presented to the surveyor…

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 documents, it was determined that the facility failed to identify and correct R11's significant medication errors involving blood sugar checks, heparin and insulin injections. Findings include:Cross refer 7605/8/26 3:15 PM - During QAPI interview, E1 (NHA) confirmed that the facility failed to identify and correct quality issues for R11's nutrition and hydration status requiring emergent hospitalization on 3/26/26.5/8/26 3:50 AM - In a follow up interview, E1 further confirmed that facility failed to identify and correct R11's significant medication errors involving blood sugar checks, heparin and insulin injections from 2/15/26 to 3/18/26. 5/11/26 12:30 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E4 (CRN) during the Exit Conference.

Based on observations, interviews and review of records and the facility's policy and procedure, it was determined that for two (R29 and R30) out of 31 residents sampled during the survey, the facility failed to ensure infection control and prevention practices were followed. Findings include:According to the Center for Disease Control's (CDC) website, the Infection Control Guidance: Preventing Methicillin-resistant Staphylococcus aureus (MRSA) in Healthcare Facilities, dated 6/27/25, stated, . The prevention of MRSA infections is a priority for CDC . Based on the current evidence, CDC recommends the use of Contact Precautions for MRSA-colonized or infected patients . The facility's policy and procedure entitled Transmission Based Precautions, effective 2/6/2020, stated, . Transmission based precautions are designed for patients documented as suspected to be infected or colonized with highly transmissible or epidemiologically important pathogens for which additional precautions beyond standard precautions are needed to interrupt transmission . 3. Contact precautions (e.g., MRSA . C.…

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 residents' rights to a dignified existence and self-determination when the facility failed to develop a system that notified residents of the daily menu. Findings include:9/18/25 8:53 AM - During resident screening R50 stated, They don't give us menus. We never know what we having until it gets here. Then, if you don't want it you have to wait cause you ordering something else. I said something to them, and they said they don't have to give us a menu. 9/18/25 9:46 AM - During resident screening, R83 stated, It's great here, only complaint I have is there's no menu or calendar of what's being served, but if you get it and don't like it, they will bring something else.9/18/25 11:40 AM - During a tour of the facility, the surveyor observed that the facility's common room for dining and activities displayed a posting of the daily menu at the entrance on both the first and second floors. 9/18/25 12:48 PM - During an interview, E36 (CNA) confirmed that residents were not provided a menu or made aware…

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 (R150 and R35) out of five residents reviewed for infection control, the facility failed to initiate and maintain Enhanced Barrier Precautions (EBP) for contact with a resident with wounds and an indwelling medical device and failed to use appropriate disinfection practices. Also, the facility failed to prevent the risk of exposure to infectious and communicable diseases by not safely disposing a full sharps container. Findings include: An infection prevention and control facility policy titled, Standards of Practice dated, 2/6/20, documented, . Procedure 8 Environmental Cleaning/Disinfection: . DO NOT USE Alcohol based- disinfectants; alcohol-based disinfectants are not effective against C. difficile and should not be used to disinfect environmental surfaces. Review of R35's clinical records revealed: 9/20/25 – R35 had a physician's order for contact precautions for C-diff (bacterial overgrowth that releases toxins that attack the lining of the intestines). 9/22/25 11:00 AM - The Surveyor observed 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 and interview, it was determined that for two (R11 and R62) out of 38 sampled residents, the facility failed to provide dignity and respect when facility staff called R11 and R62 feeders. Findings include: 9/26/25 1:00 PM - During a dining observation inside R11's room, E5 (LPN, UM) told the Surveyor that R11 and her roommate [R62] were both feeders and that a staff should be in the room to assist and feed them.9/26/25 1:30 PM - Finding was discussed with E5.9/29/25 1:00 PM - Findings were discussed with E1 (NHA), E2 (DON) and E3 (Corporate Nurse). 9/29/25 1:25 PM - Finding was reviewed with E1 , E2 and E3 during the exit conference.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that for one (R150) out of one resident reviewed for admission orders, the facility failed to ensure wound treatment orders were entered. Findings include: Review of R150's clinical records revealed:9/16/25 - R150 was readmitted to the facility with diagnoses including diabetes mellitus, congestive heart failure, and epilepsy.9/19/25 - A readmission Wounds Assessment Report for R150 completed by P1 (NP) documented treatment orders for four wounds, noted as present on admission.9/22/25 3:30 PM - Review of R150's clinical record revealed no current orders for wound care.9/24/25 2:15 PM - During an interview, the Surveyor asked E14 (RN) if R150 had treatment orders for wound care since he was readmitted on [DATE]. E14 stated, I don't see the orders, but I have been doing his wound care and dressing changes. 9/24/25 3:00 PM - During an interview E14 (RN) stated, Orders were put in today for dressing changes to begin tomorrow. 9/26/25 2:49 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 (R16) out of one resident reviewed for dental services, the facility failed to accurately code R16's dental assessments for two MDS (Minimum Data Sets) review periods. Findings include:Cross refer F791Review of R16's clinical records revealed:2/11/25 - R16's quarterly MDS section L (Oral/Dental Status) revealed that R16 had no mouth or facial pain, discomfort or difficulty chewing.3/23/25 - A Dental Report of Consultation recommended R16 . To return to restore cavities, [sic] teeth that are extensively decayed and root tips would need to be extracted in the future if symptoms or swelling begin.5/14/25 - R16's quarterly MDS section L revealed no mouth or facial pain, discomfort or difficulty chewing.8/12/25 - R16's Annual MDS section L revealed no cavities or broken natural teeth, inflamed or bleeding gums, loose natural teeth, mouth or facial pain, or discomfort or difficulty with chewing. 9/23/25 2:45 PM - During an interview, E28 (RN MDS) stated that she was the one who coded and completed R16's…

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

Based on record review and interview, it was determined that for one (R10) out of two residents reviewed for PASARR review, the facility failed to refer the resident for a PASSAR screening following a newly evident condition and qualifying medications. Findings include: The facility clinical guidelines for PASARR [undated] indicated, While admitted if a resident has a change in condition, a PASARR evaluation may be required if there is a significant change in the individual's mental or physical health status since their last evaluation, or if the facility suspects the individual may have a serious mental illness, intellectual disability or related condition not previously identified. Review of R10's clinical record revealed:6/13/25 - A PASARR Level I was completed for R10 that documented the resident had no mental health diagnoses, received no mental health medications and that no further screening was required.7/25/25 - R10 was admitted to the facility.7/27/25 - A physician's order was written for R10 to receive quetiapine, an antipsychotic medication at bedtime for psychosis.…

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 (R11) out of three sampled residents reviewed for ADLs (Activities of Daily Living), the facility failed to ensure each dependent resident received the necessary services to promote adequate nutrition. Findings include:Cross refer F692Review of R11's clinical records revealed:5/8/25 - R11 was re-admitted to the facility with diagnoses including malnutrition.9/10/25 - An OT (Occupational Therapy) Evaluation documented that R11 was dependent with eating.9/10/25 - A facility nutrition assessment documented that R11 required full assistance with feeding.9/26/25 12:45 PM - A facility staff person was observed entering R11's room and placed R11's food tray on the overbed table standing against the wall. The staff left the room.9/26/25 12:46 PM - Another facility staff person, E33 (CNA), was observed entering R11's room and attempted to shut the door. This Surveyor followed the CNA and told E33 that Surveyor will do R11's lunch observation. E33 told this Surveyor that she was going to feed R11 her lunch,…

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 (R54) out of one resident reviewed for activities, the facility failed to provide an ongoing person-centered activity program for R54, who chooses to remain in her room all day. Findings include:Review of R54's clinical record revealed: 3/9/25 - The annual MDS assessment documented that R54 had moderate difficulty of hearing (speaker has to increase volume and speak distinctly), had impaired vision (sees large print, but not regular print in newspapers/books), BIMS score of 14 (cognitively intact), had active diagnoses that included but were not limited to dementia and bilateral hearing loss, and activity preferences were as follows:-to be around pets are very important;-to have books/newspapers/magazines to read and to listen to music the resident liked were somewhat important;-to do things with groups of people and to go outside for fresh air when the weather is good and to participate in religious services were not very important; and-to keep up with the news was not important at all. 3/15/25…

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 (R54) out of three residents reviewed for pressure ulcers, the facility failed to ensure that R54's low air loss mattress device was plugged in, turned on and functioning as a preventative intervention and per an active physician order. Findings include: 6/5/25 3:15 PM - R54 had a physician's order for Alternating air loss mattress check placement and function every shift for fragile skin. 7/25/25 - The quarterly MDS assessment documented that R54 was at risk for pressure ulcers. Observations during the survey revealed: 9/22/25 9:45 AM - Observed R54 asleep in bed, laying on her left side facing the hallway, and her low air loss device was not turned on. 9/22/25 1:28 PM - Observed R54 asleep in bed, laying on her left side facing the hallway, and her low air loss device was not turned on. 9/23/25 9:27 AM - Observation with E43 (LPN) revealed that R54's low air loss mattress device was not plugged into the wall outlet located behind R54's head of the bed. Once the device was plugged into the wall…

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 (R149) out of nine residents reviewed for activities of daily living the facility failed to ensure documentation regarding urostomy and pelvic drain output was recorded as ordered. Findings include: Review of R149's clinical record revealed:7/22/25 - R149 was admitted to the facility with a history of bladder cancer and recent urinary tract infection, pelvic infection a urostomy and pelvic drain. 7/22/25 - A physician's order was written for R149's pelvic drains to be emptied and the drainage amounts to be recorded.7/22/25 - A care plan was created for R149's care of urostomy that included the intervention to empty the urostomy drainage bag and change it as needed and record the amount [ML's].7/23/25 - A care plan was created for R149's care of pelvic drains that included the intervention to empty the pelvic drain as ordered. 7/29/25 - A physician's order was written for R149 that directed staff to empty the urostomy drainage bag and record the amount every shift. August 2025 - Review of R149's TAR lacked evidence…

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 (R11 and R143) out of three sampled residents reviewed for nutrition, the facility failed to maintain acceptable parameters of nutrition and/or hydration. Findings include:Cross refer F677 1.Review of R11's clinical records revealed: A facility policy titled, Weight Monitoring and Tracking, dated 1/29/24, documented, Procedure.2. Patients will be weighed on admission/re-admission and weekly x 4 weeks thereafter, or until the Interdisciplinary Team determines weight is stable, then monthly thereafter 6. Weekly weights should continue greater than 4 weeks if one or more of the following criteria are met: Significant unplanned weight change, Identified trends in weight change.Patients < (less) 100 pounds.8. The team will notify the provider and responsible party of significant weight changes. A. Weight Monitoring 5/8/25 – R11 was re-admitted to the facility with diagnoses including chronic wounds, diabetes, dementia, acute kidney injury and moderate protein calorie malnutrition. 5/8/25 – An OT…

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

Based on record review and interview, it was determined that for one (R1) out of one resident reviewed for dialysis, the facility failed to provide dialysis related care and services to meet the needs of the resident when pre-dialysis information was not completed on the dialysis communication form. Additionally, some dialysis communication forms were absent from the medical record. Findings include: Review of R1's clinical record revealed:9/3/25 - R1 was admitted to the facility with multiple diagnoses including end-stage renal disease requiring dialysis. 9/3/25 - A physician's order was written for R1 to receive dialysis three times a week. September 2025 - Review of R1's Dialysis communication forms lacked completion of pre-dialysis information for R1 including meals, medications, change of condition and a signature of the person completing the form.9/15 - Pre-dialysis communication form documentation incomplete; only R1's blood pressure and pulse were documented.9/17 - Pre-dialysis communication form documentation incomplete, only R1's blood pressure, pulse and a staff signature…

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 (R6) out of five residents reviewed for unnecessary medication review the facility failed to act upon a recommendation documented in the residents MRR. Findings include: The facility policy on MRR last updated, 8/2020, indicated Recommendations are acted upon and documented by the facility staff and/or the prescriber.Review of R6's clinical record revealed:4/24/25 - was initially admitted to the facility.5/1/24 -7/15/24 - Was discharged from the facility due to being hospitalized . 7/15/25 - R6 was re-admitted to the facility with multiple diagnoses including dementia, anxiety, and major depressive disorder with psychotic symptoms.7/15/25 - An admission MDS assessment documented that R6 was receiving antipsychotic medications. 7/15/25 - A care plan for use of antipsychotic medications was created for R6 with an intervention to monitor behaviors.7/15/25 - An MRR documented that R6's antipsychotic requires monitoring; the recommendation was signed by R6's physician on 7/18/25. 7/16/25 - A physician's order was written…

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 (R149) out of one resident reviewed for change in condition, the facility failed to ensure ordered labs were completed timely. Findings include: The facility policy on laboratory and diagnostic testing last updated 1/29/24 indicated, Laboratory, radiology and other diagnostic services are provided to the center by way of written contractual agreements. The contracted service vendor is to provide services to the center that ensure safe and effective patient testing and timely delivery of results.Review of R149's clinical record revealed:7/22/25 - R149 was admitted to the facility with a urostomy tube. 7/28/25 - A physician's order was written for R149 to receive urinalysis culture and sensitivity testing for recurrent UTIs and blood in the urine. 7/28/25 8:59 pm - A progress note in R149's clinical record documented, resident noted with some reddish urine in her urostomy bag. [MD] notified new order for urinalysis culture and sensitivity to rule out UTI. 7/29/25 - Review of the facility lab tracking form documented…

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 one resident reviewed for dental services, the facility failed to promptly provide routine and emergency dental care for R16 when he was recommended for follow up visits to restore his cavities and extract his extensively decayed root tips after his dental exam on 3/23/25. Findings include:The facility's policy titled, Dental Service Needs dated 1/29/25 documented, . Procedure . 2. Nursing will collaborate with the Social Services Department to identify and secure designated and/ or centered contracted community available resources for dental services. 3. Nursing will. assist the patient in making appointments . Review of R16's clinical records revealed:Cross refer F64111/25/22 - R16 was admitted to the facility.8/26/24 - A care plan was developed for R16 related to his independence with oral care and R16's goal was to be free from dental complications through the review period. R16's interventions included to perform oral exams as needed and to refer to a dentist as indicated. 3/23/25 - 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 observations and interviews, it was determined that the facility failed store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Findings include: 9/19/24 8:45 AM - During the initial kitchen tour the following was observed: - The lack of hand drying towels at the handwashing sink. - A cooked pork roast left uncovered on a counter, with flying insects (gnats) observed in the kitchen. -Pork sausage patties in open unsecured plastic bag in walk in freezer. 9/23/24 approximately 10:00 AM - Observations revealed the following: -the walk-in freezer temperature was reading 27°F. -review of the walk-in freezer temperature logs for July revealed temperatures between -6°F and 35°F. 9/23/24 1:45 PM - During an interview, E7 (Director of Dietary Services), confirmed the findings. 9/23/24 12:30 PM - During the survey of the facility at approximately 12:30 PM, the first-floor nourishment refrigerator was observed to have spilled substances at the base of the refrigerator, the presence of unlabeled resident food items, and open juice…

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 six (R26, R81, R89, R103, R326 and R328) out of 46 residents reviewed for care plans, the facility failed to develop and implement a comprehensive person-centered care plans for each resident. For R81, R89, R103 and R328, the facility failed to develop care plans based on assessment to restore and maintain their bladder and bladder continence to the extent possible. For R326, the facility failed to develop a person-centered care plan for R326 despite a high fall risk assessment. For R26, the facility failed to develop a pressure ulcer care plan. Findings include: Cross refer F690. 1. Review of R81's clinical records revealed: 1/19/23 - R81 was admitted to the facility with diagnoses including dementia and difficulty walking. 9/13/24 - R81's annual MDS documented a BIMS score of 15, indicating an intact cognitive status. R81's annual urinary MDS assessment documented, Occasionally incontinent of urine . 9/13/24 - R81's toileting care plan documented, Occasional incontinent of bladder and continent of…

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

Based on interview and record review, it was determined that for one (R116) out of seven residents sampled for incontinence and one (R26) out of one resident sampled for hospice, the facility failed to review and revise each residents' care plan. Findings include: 1. Cross refer F690, example 5 R116's clinical record revealed: 8/20/24 - R116 was admitted to the facility. 8/20/24 at 9:50 PM - The admission Nursing Collection Tool documented that R116 was cognitively intact upon arrival, continent of bowel and bladder with an intervention to supervise or cue to toilet as needed and required partial/moderate assistance for toileting transfer and toileting hygiene. 8/26/24 - The admission MDS assessment documented that R116's BIMS was a 9 (moderate cognitive impairment), required partial/moderate assistance for toileting transfer and toileting hygiene and was frequently incontinent of bowel and bladder. 10/1/24 at 10:48 AM - During an interview, E47 (MDS Coordinator) stated that the MDS Coordinator was responsible for the resident's care plan. E47 confirmed that R116 was frequently…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, it was determined that for five (R81, R89, R103, R116 and R328) out of seven residents reviewed for bowel and bladder assessments, the facility failed to conduct bowel and bladder assessments to develop an individualized care plan to restore and maintain their bladder and bladder continence to extent possible. Findings include: 11/1/19 - A facility document titled, Assessment for Bowel and Urinary Toileting Program documented, Licensed nurse will perform a bowel and/or urinary assessment on admission, readmission, annually, and PRN using the RAI process .Bowel and urinary toileting approaches will be documented in the care plan .evaluation of the toileting program will be documented in the Nurses Progress Notes. 1. Review of R81's clinical records revealed: 1/19/23 - R81 was admitted to the facility with diagnoses including dementia and difficulty walking. 9/13/24 - R81's annual MDS documented a BIMS score of 15, indicating an intact cognitive status. R81's…

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

Based on interview and review of the clinical record and other documentation as indicated, it was determined that for one (R26) out of one resident reviewed for hospice, the facility failed to ensure that R26 received hospice care and services as per the written agreement with the Hospice Provider. Specifically in reference to the deficiency cited at Severity Level 3, at F686, the facility failed to notify and collaborate with the Hospice Provider on developing and implementing a sacral pressure ulcer plan of care with interventions to meet the resident's needs. In addition, the facility failed to update the Hospice Provider that R26's eight medications were discontinued in January 2024; and ensure that current Hospice documentation was present and readily accessible in R26's facility clinical record. Findings include: Cross refer to F686, example 1, F656, F657, F697 8/9/23 - The General Inpatient and Respite Care Skilled Nursing Facility Agreement stated the following: . 3.3 Designation of an Interdisciplinary Group Member. Facility will designate a member of the Facility's…

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

Based on observations, interviews and record reviews, it was determined that for four ( R533, R105, R12 and R26) out of four residents reviewed for infection control, the facility failed to establish and maintain an infection control program using enhanced barrier precautions. R12, R105 and R533 had indwelling feeding tubes which met the criteria for Enhanced Barrier Precautions (EBP). Findings include: As per CDC (Centers for Disease Control and Prevention) definition (6/28/24), Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). 1. Review of 533 clinical record revealed: 9/10/24 - R533 was admitted to the facility after being hospitalized ; R533 had a PEG tube inserted into his stomach for nutrition…

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 four (R9, R30, R53 and R76) out of five residents sampled for Covid-19 vaccinations, the facility failed to provide education regarding the benefits and potential side effects of Covid-19 immunizations to each resident or the resident's representative and then offer the immunization. Findings include: 1. R9's clinical record lacked evidence that the resident was offered an up to date Covid-19 vaccination. The last documented Covid-19 vaccination was received on 4/9/21. 2. R30's clinical record lacked evidence that the resident was offered an up to date Covid-19 vaccination. The last documented Covid-19 vaccination was received on 11/22/23. 3. R53's clinical record lacked evidence that the resident was offered an up to date Covid-19 vaccination. The last documented Covid-19 vaccination was received on 12/6/22. 4. R76's clinical record lacked evidence that the resident was offered an up to date Covid-19 vaccination. The last documented Covid-19 vaccination was received on 9/10/21. 10/2/24 at 3:00 PM - Reviewed during the…

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

Based on record review and interview, it was determined for one (R118) out of the survey sample reviewed for planning and implementing care, the facility failed to provide R118 the right to be informed of and participate in her treatment. Findings include: Delaware Medical Orders for Scope of Treatment (DMOST) is a form, that when completed and signed by the patient and a medical provider, documents the medical orders that indicate the level of life sustaining care a person wishes to have performed on them if they have no pulse or stop breathing. Review of R118's clinical record revealed: 8/28/24 - R118 was admitted to the facility with a physician order Do Not Resuscitate. 9/4/24 - A Minimum Data Set (MDS) assessment indicated that R118 had a BIMS of 15, meaning that R118 was cognitively intact. 9/20/24 2:30 PM - A review of R118's electronic medical record (EMR) contained a document titled Delaware Medical Orders for Scope of Treatment (DMOST) form which was signed by R118 and E50 (Nurse Practitioner) on 9/3/24. R118's DMOST form indicated that she wished to have full treatment…

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 (R76) out of four residents reviewed for resident rights, the facility failed to identify and facilitate the resident's self-determination through support of resident choice with respect to his scheduled shower times. Findings include: R76's clinical record revealed: 4/29/24 - The admission MDS assessment documented that R76's response to While you are in this facility, how important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? R76's response was very important. 10/11/24 (last revised) - R76 was care planned for requiring one staff person assist for bathing. According to the November 2024 CNA Documentation Survey Report, R76 was scheduled showers every Tuesday and Friday during day shift and as needed. However, closer review of the Report revealed that the report was setup for staff to document during day shift every Monday and Thursday and PRN (as needed). Four out of four scheduled opportunities from 11/18/24 to 11/30/24, no showers were provided to R76 nor was it documented that R76…

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 (R26) out of five residents reviewed for pressure ulcers, the facility failed to accurately reflect R26's medical status in the annual MDS assessment. Findings include: The October 2023 RAI Manual stated the following under Section M: Skin Conditions: - Moisture Associated Skin Damage defined, . superficial skin damage caused by sustained exposure to moisture such as incontinence, wound exudate, or perspiration . MASD with skin erosion has superficial/partial thickness skin loss . the tissue is blanchable and diffuse and has irregular edges. Inflammation of the skin may be present. Necrosis is not found in MASD. If pressure and moisture are both present, code the skin damage as a pressure ulcer/injury in M0300. If there is tissue damage extending into the subcutaneous tissue or deeper and/or necrosis is present, code the skin damage as a pressure ulcer in M0300 . R26's clinical record revealed: 8/13/24 - The Wound Assessment Report by C1 (WCC) revealed: -Location: sacrum -Measurements: 1 cm x 2 cm x 0.30 cm…

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

2. According to the Mayo Clinic, May 2022, Orthostatic hypotension is a form of low blood pressure that happens when standing after sitting or lying down. Orthostatic hypotension can cause dizziness or lightheadedness and possibly fainting. A care provider might review medical history, medications and symptoms and conduct a physical exam to help diagnose the condition. A provider also might recommend orthostatic blood pressure monitoring. This involves measuring blood pressure while sitting and standing. A drop of 20 millimeters of mercury (mm Hg) in the top number (systolic blood pressure) within 2 to 5 minutes of standing is a sign of orthostatic hypotension. A drop of 10 mm Hg in the bottom number (diastolic blood pressure) within 2 to 5 minutes of standing also indicates orthostatic hypotension. Review of R127's clinical record revealed: 7/23/24 - R127 was admitted to the facility with multiple diagnoses including kidney disease, high blood pressure, and anemia. 7/31/24 - Physician's orders were written by E4 (Medical Director) for the following medications to be administered to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, it was determined that for one (R105) out of two residents reviewed for mobility, the facility failed to provide assistance to maintain or improve mobility. For R105, the facility failed to ensure the resident's therapy devices were applied per physician orders. Findings include: Review of R105's clinical record revealed: 4/30/24 - R105 was admitted to the facility with a diagnosis of a stroke. 7/29/24 - A care plan for R105 indicated that the resident requires assistance with ADLs (activities of daily living) related to having a previous stroke and is dependent with self-care and mobility. A care plan intervention was to apply a therapy carrot to the left hand and wear it as tolerated during the day. 8/8/24 - An additional intervention to the ADL care plan was created to apply the palm guard to the right hand and wear it as tolerated during the day. A review of R105's orders revealed a physician's order to apply palm guard to right hand and wear as tolerated…

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, it was determined that for one (R64) out of two residents reviewed for accidents, the facility failed to ensure that R64 received supervision to prevent accidents. Findings include: 9/3/24 - R64 was admitted to the facility with diagnoses including dementia and muscle weakness. R64's admission assessment documented a fall score of 18, which indicated a high fall risk. 9/4/24 - R64's fall care plan included, At risk for falls related to cognitive impairment, poor balance, and muscle weakness. The interventions included, Low bed, and place items within reach of resident. 9/9/24 - R64's admission MDS assessment documented a BIMS score of 00, indicating severe cognitive impairment. R64's ADLs (Activities of Daily Living) documented, Dependent for bed mobility/turning and repositioning. 9/12/24 10:30 AM - R64's clinical records documented, . Notified that resident [R64] fell out of bed while receiving care . A scrape and hematoma were located separately on the right upper forehead . Sent to the hospital for evaluation . Staff education on…

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 record review, it was determined that for one (R83) out of four residents reviewed for nutrition, the facility failed to maintain acceptable parameters of nutrition. Findings include: Review of a facility policy titled, Weight Monitoring and Tracking, effective 1/29/24, indicated Policy: The center has a system in place to weigh, monitor, and track patient's weights. Weights are tracked, monitored, and analyzed by the Interdisciplinary Team. Procedure . 2. Patients will be weighed on admission/readmission and weekly x 4 weeks thereafter, or until the Interdisciplinary Team determines weight is stable, then monthly thereafter . 6. Weekly weights should continue greater than 4 weeks if one or more of the following criteria are met: .Patients < 100 pounds . Review of R83's clinical chart revealed: 7/19/24 - R83 was admitted to the facility with multiple diagnoses including pneumonia, malnutrition, swallowing disorder, and dementia. R83's weight was 96.6 pounds (lbs). 7/23/24 - Review of 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 and interview, it was determined that for one (R105) out of four residents reviewed for tube feeding, the facility failed to ensure that the standard of care for the proper labeling and dating of tube feeding bottles was followed. A review of R105's clinical record revealed: 4/30/24 - R105 was admitted to the facility with a diagnosis of a stroke, and difficulty swallowing food and liquids. 9/19/24 10:40 AM - During an observation, the tube feeding bottle was being administered at R105's bedside. No date was written on the tube feeding bottle. 9/20/24 11:30 AM - During an observation, the tube feeding bottle was administered at R105's bedside. No date was written on the tube feeding bottle. 09/20/24 11:54 AM - During an interview, E24 (RN) confirmed that the tube feed bottle had no date written on it. 10/2/24 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E46 (VPO) and a representative from the Ombudsman's Office.

Based on observation, interview and record review, it was determined that for one (R3) out of three sampled residents reviewed for respiratory care, the facility failed to ensure that R3 was provided respiratory care consistent with her physician orders and comprehensive person-centered care plan. Findings include: Review of R3's clinical record revealed: 4/22/24 - R3 was readmitted to the facility. 5/28/24 - R3 had a physician's order for oxygen therapy at 2 liters per minute via nasal cannula (a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels). 5/28/24 11:09 PM - A nurse progress note documented that R3 had a new physician's order for oxygen therapy for SOB (shortness of breath). 6/30/24 - R3's quarterly MDS (Minimum Data Set) assessment revealed that R3 was receiving oxygen therapy during the review period. 7/30/24 (created 5/12/21) - R3 was care planned for cardiac disease related to .and SOB. R3's interventions including but not limited to administering oxygen as ordered. During multiple random observations, R3's 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 observation, interview and record review, it was determined that for one (R26) out of five residents reviewed for pressure ulcers, the facility failed to ensure R26's pain management during wound care was consistent with her care plan and professional standards of practice. Findings include: According to the Lippincott Manual of Nursing Practice, 11th Edition, Chapter 2 entitled, Standards of Care and Ethical and Legal Issues . Nonmaleficence. 1. The principle of nonmaleficence . obligates the professional nurse not to harm the patient directly . it is common for the nurse to cause pain or expose the patient to risk of harm when such actions are justified by the benefits of the procedures or treatments . Cross refer to F686, example 1 R26's clinical record revealed: 4/11/24 revised - R26 was care planned for at risk for pain related to advanced age, osteoarthritis pain in right shoulder, right leg, back, neck, buttocks, knee pain, left foot, being more sedentary/bedbound related to poor prognosis. The approaches included, but were not limited to, observe for physical…

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, review of facility documentation and staff interviews, it was determined that the facility failed to post the required federal staffing information in a conspicuous area that was readily accessible to residents and visitors. Findings include: 1. 10/2/24 9:27 AM - An observation in the facility's main lobby revealed a state agency staffing worksheet encased in an acrylic sign holder. The sign holder was placed on top of the small round table at the lobby's corner near facility entrance door. The staffing worksheet had information of the facility's average daily census, care hours per resident and staffing ratios by daily shift with a date range from 9/22/24 through 9/28/24. There was a lack of federal staffing posting in the lobby with the daily (10/2/24) census, correct date and licensed RNs/LPNs and CNA worked hours per shift. 10/2/24 9:28 AM - During interview, E29 (HR Director) stated that the staffing worksheet displayed in the lobby was the facility's staff posting. 2. 10/2/24 - Observations of the four units: Arcadia, New Castle, Heritage and Dover from…

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 (R116) out of two residents reviewed for hospitalizations, the facility failed to monitor and hold R116's blood pressure medication based on physician ordered parameters. Findings include: 1a. R116's clinical record revealed: 8/20/24 - R116 was admitted to the facility with diagnosis of high blood pressure among other medical conditions. 8/22/24 - A physician's order stated, Norvasc oral tablet 5 MG . Give 1 tablet by mouth one time a day . hold if sbp (systolic blood pressure) less than 110. Review of R116's eMARs and nurse's notes for August 2024 and September 2024 lacked evidence that R116's blood pressures were taken prior to administration of her daily blood pressure medication for: -four out of nine opportunities from 8/23/24 through 8/31/24; and -three out of five opportunities from 9/1/24 through 9/5/24. 1b. R116's clinical record revealed: 8/20/24 - R116 was admitted to the facility with diagnosis of high blood pressure among other medical conditions. 8/22/24 - A physician's order stated, Norvasc oral…

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 (R116) out of three residents reviewed for nutrition, the facility failed to order and provide an Ensure drink based on the admission nutrition assessment and resident preference. Findings include: R116's clinical record revealed: 8/20/24 - R116 was admitted to the facility. 8/22/24 at 5:10 PM - A nutrition note by E13 (Dietician) documented, . Her oral intake varies between 26-100%, and she eats independently without any issues with chewing or swallowing. No supplements are currently ordered, and food preferences were obtained through a conversation with her [family member, F1]. [F1] reports that resident enjoys drinking Ensure and would like for her to receive one in between meals. Will recommend to add Ensure once daily . 9/13/24 - A physician's order stated to give Ensure two times a day for optimal PO (oral) intake . 9/30/24 at 4:00 PM - During an interview, F1 (R116's family member) stated that during the care conference on 8/26/24, the request for Ensure drink was brought up again. The facility failed 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 three (R9, R53 and R76) out of five residents sampled for influenza and pneumococcal vaccinations, the facility failed to provide education regarding the benefits and potential side effects of either/both influenza and pneumococcal immunizations to each resident or the resident's representative and then offer the immunization. Findings include: 1. R9's clinical record lacked evidence that the resident was offered an up to date pneumococcal vaccination. R9 received the PCSV23 on 9/23/22. 2. R53's clinical record lacked evidence that the resident was offered an influenza vaccination during year 2023. 3. R76's clinical record lacked evidence that the resident was offered a pneumococcal vaccination. 10/2/24 at 3:00 PM - Discussed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), E46 (VPO) and a representative with the Ombudsman's Office.

Based on observations and interview, the facility failed to provide a safe, sanitary, environment for residents, staff and the public. Findings include: 9/23/24 1:30 PM - An observation of three trash dumpsters located were located next to the facility. Two of the dumpsters contained full clear trash bags, and the third dumpster was full of ripped up boxes. The two dumpsters with the clear bags revealed the following: -Both dumpsters had opened lids, with clear bags of facility trash hanging over sides of dumpsters. -Both dumpsters had open bags of trash with the contents of the bags, including contaminated feces soiled resident briefs and used PPE gloves on the ground surrounding the dumpsters. 9/23/24 1:40 PM - During an interview, E1 (NHA) confirmed the above findings. 9/23/24 4:00 PM - An observation of the trash dumpsters revealed that the two dumpsters with resident trash had been emptied, but that the soiled resident briefs and used PPE gloves on the ground remained. 9/23/24 4:30 PM - During an interview, E1 confirmed the 4:00 PM findings. 9/24/24 8:00 AM - An observation…

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 clinical record and additional documentation as indicated, the facility failed to notify and update C5 (Optum NP) of changes to R3 after her fall on 4/5/24 to determine if further interventions were needed. Findings include: Cross refer to F684, example 2b 4/8/24 at 6:08 PM - C5's medical note documented, . seen and evaluated s/p (status post) fall on 4/5/24. Nursing called provider after hours and reported fall from bed with minor injury- skin tear to left elbow and bruising to face. No bleeding noted and neurochecks were WNL (within normal limits). Today, resident noted with multiple bruising to face - right eye orbit bruised, right forehead, bruise to left (sic) chin and hematoma to left forehead . does not appear to be in pain . 4/8/24 at 9:30 PM - An order note documented, New orders received to hold ASA (aspirin) x 5 days, start Acetaminophen 650mg . BID (twice a day) and to apply cool compress to right eye TID (three times a day) . 4/10/24 at 10:49 AM - During an interview, C5 (Optum NP) stated that she was contacted by the facility staff…

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 F686 - Based on observation, interviews, and record review, it was determined that for one (R10) out of one resident reviewed for the treatment/services to prevent/heal pressures, the facility failed to initiate treatment and monitoring when R10 was readmitted on [DATE] with a sacral pressure ulcer. Findings include: A facility policy dated 1/29/24, and titled, Wounds/Skin Impairments, documented, .The skin observation tool will be completed by a licensed nurse at least every seven (7) days, detailing any wound/skin impairments. Notify provider with updates and/or changes to the skin impairments, obtain new orders as necessary, provide treatments as ordered . Review of R10's clinical records revealed: 4/13/24 2:16 PM - R10 was readmitted to the facility from the hospital with past medical diagnoses including cerebrovascular disease affecting the left dominant side and muscle weakness. R10's readmission skin assessment documented, .Open area to sacrum (large triangular bone at base of spine). 6/3/24 10:00 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 interview and review of the clinical record and other documentation as indicated, it was determined that for one (R2) out of one resident reviewed for physician ordered bladder scanning, the facility failed to ensure that the resident, who was incontinent of bladder, received appropriate treatment and services to prevent an urinary tract infection. Findings include: According to the Lippincott Manual of Nursing Practice, 11th Edition, Benign Prostatic Hyperplasia (BPH) is enlargement of the prostate that constricts the urethra, causing urinary symptoms . Clinical Manifestations: . 2. Obstructive symptoms - . sensation of incomplete emptying of the bladder, urinary retention . Diagnostic Evaluation: . 6. Optional diagnostic studies for further evaluation: . b. Measurement of postvoid residual volume; by ultrasound or catherization . According to the Cleveland Clinic website, last reviewed on 2/9/24, . A post-void residual (PVR) test measures the amount of pee left in your bladder after you urinate. High PVR levels mean you have urinary retention, which could be caused by 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the facility assessment, emails and interview, it was determined that the facility failed to update the facility assessment to include all personnel classifications which provide services to facility residents. Findings include: 4/8/24 - A review of the facility employee list revealed two employees with the job classification of Non-Certified Nursing Assistant. 4/18/24 - A review of the Facility Assessment - [NAME] Nursing and Rehab, updated 1/26/24, section 3.2 Staffing Plan, Position: In addition to nursing staff, other staff needed for behavioral healthcare and services (list other staff positions/roles) revealed the lack of a job position for a Non-Certified Nursing Assistant. 4/9/24 3:48 PM - A review of an email from E1 regarding the job duties of a non-certified nursing assistant revealed the following response: They don't provide care for the residents. They are used primarily for 1:1 and making beds. If we are doing any events in the building they help with activities. 4/10/24 3:30…

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 were observed during the initial kitchen tour on 7/13/23 from 8:45 AM through 10:00 AM. - The kitchen lights covers were in disrepair in the dry storage, food prep, and dish washing area; - The walls in the areas near the entrance, and dish washing room in were disrepair; - There were water pooling on the floor in the walk-in. Findings were reviewed and confirmed by E77 (FSD) on 7/13/23 at approximately 10:00 AM. Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), E4 (Corporate Nurse), and E18 (Vice President of Operations) on 7/31/23, at approximately 2:00 PM.

Based on interview and record review of the facility's Infection Surveillance Monthly Report, it was determined that the facility failed to provide an ongoing system of surveillance designed to identify possible communicable diseases and infections. Findings include: Review of the following months of surveillance data for residents treated for urinary tract infections revealed: February 2023 - for three residents signs and symptoms were lacking; for seven residents the facility lacked data on name of organism, and culture dates and results were not provided. March 2023 - for three residents signs and symptoms were lacking, for five residents the facility lacked data on name of organism, for four residents culture dates and results were not provided; and for one resident reference was made to a laboratory report but organism name, culture dates or results were not provided. April 2023 - for three residents organism name, culture dates and results were not provided. May 2023 - for one resident signs and symptoms were lacking; for ten residents organism name and culture dates 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 observations and interviews, it was determined that the facility failed to maintain required kitchen equipment to prepare food for residents were in safe working order. Findings include: The following were observed during the initial kitchen tour on 7/13/23 from 8:45 AM through 10:00 AM: - The dishwasher food grinders were out of service and unable to dispose of food waste; - The ovens in the food preparation area are not functional. Findings were reviewed and confirmed by E77 (FSD) on 7/13/23 at approximately 10:00AM. Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), E4 (Corporate Nurse), and E18 (Vice President of Operations) on 7/31/23, at approximately 2:00 PM.

Based on record review and staff interviews, it was determined that the facility failed to ensure that two (R75 and R579) out of 30 residents in the investigative sample were offered the opportunity to formulate an advance directive. Findings include: The facility's admission Packet [undated], included a Skilled Nursing Rehabilitation Centers Patient Information Handbook, n.d. stated, Advance Directives: You have the right to make decisions about your own health .should you be unable to communicate your wishes. You have the right to make an advance directive, such as a living will or durable power of attorney for health care .If you would like more information about advance directives, please contact our Social Services Department. 1. Review of R75's clinical record revealed: 6/9/23 - R75 was admitted to the facility. 6/15/23 - R75's admission Minimum Data Set (MDS) assessed resident to have a BIMS (Brief Interview for Mental Status) of 15. (Scores of 13-15 mean cognitively intact). 6/21/23 - R75 started Hospice services. 7/13/23 - During an interview, R75 was unaware of what 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation of four out of four units toured, it was determined that the facility failed to provide a safe, clean, and homelike environment. Findings include: 1. 7/19/23 11:04 AM - During an observation of the Heritage unit, room [ROOM NUMBER]A was observed with ant traps around the room brought in by the resident's family, also the room had wallpaper peeling off the wall. It was observed that room [ROOM NUMBER]A also had wallpaper peeling from the wall. room [ROOM NUMBER]A had dirty floors and one area of the floor had what appeared to be dried, crusted liquid that was white in color, stuck to floor. room [ROOM NUMBER]A's bathroom floor was filthy with brown grime and dirt on the floor tiles around the bottom of the toilet. Also, the walls in the room had peeled wallpaper and the bed had been made with dirty linen with holes. Furthermore, the carpet in the Heritage unit's hallway was dirty, dingy in color and sticky in some areas. 2. 7/19/23 11:17 AM - During an observation of the Dover…

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

2. Review of R129's clinical record revealed: 8/18/21 - R129 was admitted to the facility. 11/29/21 - A review of facility grievance log revealed that R129's responsible party filed a grievance related to R129's care. 7/27/23 - A review of R129's concern form from the grievance (11/29/21) revealed the facility lacked evidence of a response to the concern. An interview with E4 (Corporate Consultant) confirmed the facility lacked evidence of a response to the grievance. 7/27/23 2:45 PM - Findings reviewed with E1 (NHA) and E4 (RCD). 7/31/23 at 2:00 PM - Findings were reviewed during the Exit Conference with E1, E2 (DON), E4 and E18 (VPO). Based on observations, interviews, and reviews of a clinical record and facility documentation, it was determined that the facility failed to ensure that information on how to file a grievance/concern was available to the residents/resident representatives on two out of two resident floors. Additionally for R129, the facility failed to ensure that concerns received by the facility included prompt efforts to resolve the resident's problems. 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 observations, interviews and record review, it was determined that the facility failed to protect the residents' rights to be free from physical abuse for one (R26) out of 14 sampled residents reviewed for abuse. R26 physically abused seven (7) (R480, R35, R481, R41, R117, R95 and R116) residents over a fifteen month period. Findings include: The facility's policy and procedure titled Abuse/Neglect/Misappropriation/Crime Administrative reference Guide, dated 1/23/20, stated, .Physical Abuse - a. Striking the patient with a part of the body or with an object .shoving, pushing .b. Physical contact intentionally or through recklessness that results in .physical injury, pain . Review of R26's clinical record and the facility's incident report documentation revealed: 9/9/20 - R26 was first admitted to the facility. 9/9/20 (revised 9/22/22) - A care plan was developed for R26's risk for behavior symptoms related to depressive disorder, bipolar disorder, constantly pacing up and down the hallways stating he can't stop walking .attempting to push other residents and staff to get…

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 three (R65, R71 and R141) out of five residents reviewed for care planning, the facility failed to review and revise their care plans to reflect individual identified needs. For R65 and R71 the facility failed to facilitate an interdisciplinary care plan. For R141, the facility failed to have the required interdisciplinary team members at the care plan conference, Findings include: The facility's policy on Care Planning dated 11/01/2019 documented, . Each patient's care plan will be discussed at the care plan conference by the IDT [interdisciplinary team] under the leadership of a licensed nurse . Notes will be kept for each patient's care plan discussed at the conference. A designated staff member attending the conference will include an electronic progress note summarizing the conference and stating all who attended, including the patient and any family members who were present. 1. Review of R141's clinical record revealed: 6/21/23 - R141 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 5. Review of 133's clinical record revealed: 4/8/21 - R133 was admitted to the facility with multiple diagnoses including heart failure. 4/15/21- A Physician's order was written for R133 to be weighed daily and to notify the physician if R133 had a weight gain of 3 pounds (lbs.) in 24 hours or 5 lbs. in 1 week. R133's weights: 4/19/21 - 199.8 lbs. 4/26/21 - 219.0 lbs. Weights were not obtained on R133 for five (5) consecutive days, from 4/20/21 thru 4/25/21. R133 experienced a twenty-pound (20) weight gain during the week of 4/19/21 - 4/26/21. 6. Review of 138's clinical record revealed: 5/31/21 - R138 was admitted to the facility with diagnoses including cardiac disease and high blood pressure. 5/31/21 - R138's care plan for heart disease had an intervention that stated to call the physician if R138's heart rate was less than 50. 6/1/21 - A Physician's order was written for Metoprolol 25 milligrams (mg) by mouth daily for high blood pressure. 6/3/21 - A Physician's order was written to take a temperature and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, it was determined that for one (R86) out ___ resident reviewed for bowel and bladder, the facility failed to ensure that R86 received the care and services necessary to restore or maintain bladder function. Findings include: 11/1/19 - The facility's nursing policies and procedures titled Assessment for Bowel & Urinary Toileting Program included but not limited to: 1. A licensed nurse will perform bowel and/or urinary assessment on admission, readmission, annually and PRN (as needed) using the RAI (Resident Assessment Instrument) process. 2. A licensed nurse will initiate, and CNAs (Certified Nursing Assistants) will implement toileting approaches and encourage the patient to participate. Document Data Collection Trial for Bowel and Urinary Toileting Training Program. The following was reviewed in R86's clinical records: 10/24/22 - R86 was admitted to the facility with diagnoses including Chronic Kidney Disease, Acute Kidney Failure, and weakness/paralysis…

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

2. Review of R134's clinical record revealed: 8/4/21 - R134 was admitted to the facility with a diagnosis of chronic pain. 8/4/21 - R134 was ordered oxycodone (a pain medication). 8/4/21 - R134's admission assessment documented that she had frequent pain, and at the time of the assessment R138 expressed that her pain level was an eight out of ten. Review of R 134's medication administration record revealed: 8/4/21 8:30 PM - R134 was administered pain medication for a pain level of nine out of ten. The post pain medication assessment was documented as E (effective) and did not include a numerical score. 8/5/21 - R134 was administered pain medication at 1:25 AM for a pain level of six out of ten, 10:10 AM for a pain level of five out of ten and only documented as effective. In addition, R134 was administered pain medication at 5:55 PM for a pain level of seven out of ten and only documented as U ineffective. R134 was then transferred to the hospital. 7/26/23 1:09 PM - During an interview E4 (Regional Clinical Director) confirmed R134's medication administration record lacked evidence…

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.

3. Review of R101's clinical record revealed: Cross refer F758 8/3/22 - R101 was admitted to the facility. 9/8/22 9:34 AM - A review of the MRR revealed a recommendation to consider a dose reduction or discontinue to Risperidone 0.75mg by mouth at bedtime. 7/27/23 11:00 AM - A review of the Physicians order sheet for R101 revealed that the above recommendation for Risperidone had not been acknowledged. 4. Review of R129's clinical record revealed: 8/18/21 - R129 was admitted to the facility. 4/6/22 - A review of the MRR revealed a recommendation to reevaluate the use of triple antidepressant therapy and consider dose reduction or discontinue one of the medications: Sertaline 50 mg, Trazadone 25 mg, and Remeron 7.5 mg. The MRR was not signed by the Physician. 5. Review of R179's clinical record revealed: 2/18/21 - R179 was admitted to the facility. 7/27/23 11:30 AM - A review of R179's MRR revealed the facility lacked evidence that the MRR's were completed for the following months: March 2023, April 2023, May 2023, and June 2023. 7/27/23 12:30 PM - An interview with E4 (Corporate)…

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 maintain a quality assessment and assurance committee consisting of the required minimum members. Findings include: 8/31/22 - Quarter 3 2022 Quality Assurance and Performance Improvement Committee Meeting Attendance record documented that the Director of Nursing (DON) was not present at the meeting. 5/25/23 - Quarter 2 2023 Quality Assurance and Performance Improvement Committee Meeting Attendance record documented that the Director of Nursing (DON) was not present at the meeting. Findings were reviewed with E1 (NHA), E2 (DON), E4 (RCD) and E18 (VPO) at the Exit Conference on 7/31/23 at 2:00 PM.

Based on interview and review of facility documentation, it was determined that the facility failed to provide required in-service training (12 hours per year) for five out of five CNAs reviewed. Additionally, the facility failed to ensure E15, E74, and E76 had training on dementia management, care of the cognitively impaired, abuse and neglect. Findings include: The facility was provided a list of five names selected at random and instructed to provide documentation of the required 12 hours per year of in-service training. 7/28/23 3:00 PM - During a brief interview E16 (HRD) revealed, she thought continuing education units submitted for CNA renewal (Certified Nursing Assistant) met the required 12 hours per year of in-service training. 7/31/23 8:30 AM - Review of facility documentation submitted for staff training had not met the required in-service training's for E15, E54, E74, E75 and E76. The facility failed to provide 12 hours of annual in-service training's as required for five out of five staff CNA's. 7/31/23 at 2:00 PM - Findings were reviewed during the Exit Conference 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, it was determined that for three (R4, R22 and R43) out of 43 residents sampled and general observations on one of four units, the facility failed to ensure that each resident was treated with respect and dignity. Findings included: 1. An observation in the Arcadia locked dementia unit's dining room on 10/25/23 at 1:24 PM revealed that R4, R22, R22's family member, and R43 were sitting at a table in the dining room after finishing their lunch and the table was cleared. R4's one-to-one (1:1) assigned staff person, E27 (Non-Certified Nursing Assistant), returned from lunch break with food in a disposable container. E27 sat down next to R4 at the table and placed her food on the table in front of three residents and a family member. E27 was observed opening the food container and eating from it while seated at the table with the residents. 10/25/23 at 2:12 PM - During a combined interview with E2 (DON) and E3 (RCD), the Surveyor's observation was reviewed. Surveyor was informed…

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 the clinical record and other documentation as indicated, it was determined that for one (R131) out of nine residents reviewed for change of condition, the facility failed to provide immediate access to R131 during the 11:00 PM to 7:00 AM shift on 3/8/23 when 911 was called and both BLS (Basic Life Support) and ALS (Advanced Life Support) crews had difficulty entering the facility in order to provide emergent aid to R131. Findings include: Review of R131's clinical record revealed: 9/23/22 - R131 was admitted to the facility. 3/8/23 at 1:29 AM - E49 (RN) documented, On call NP (Nurse Practitioner) notified of change in mental status with elevated vitals; 173/116 (blood pressure), 136 (heart rate); 30 (respirations); 101.9 (temperature); 94% RA (pulse ox on room air). Increased respiration with periods of shallow breathing noted. Pt. (Patient) unable to respond to verbal commands. Nurse received order from NP to transfer pt to ER (Emergency Room) for evaluation. 911 called. Patient transferred to (name) hospital. Message left for family to call…

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 (R113) out of one resident reviewed for notification of change in condition the facility failed to consult with the resident's physician in a timely manner. Findings include: A policy and procedure titled Significant Change of Condition documented .All staff members shall communicate any information about patient status change to appropriate licensed personnel immediately upon observation .3. This assessment shall be reported to primary physician or designated alternate .4. Responsible party will also be notiifed of a change of condition. Review of R113's clinical record revealed: 1/6/23 - R113 was admitted with a diagnosis of Dementia and Osteoarthritis. 2/11/23 11:53 AM - A progress note documented .noted bruise light/blue/purple and swelling to the right upper arm.Complained of pain, as needed Tylenol given, (E3 MD) made aware, new order for X-ray two views to arm (E64 RP) present and aware of bruise/swelling and new order. 2/11/23 11:17 PM - A progress note documented .X-ray provider called and stated, they were…

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

Based on interview, record review and review of other facility documentation it was determined that the facility failed to ensure that two (R45 and R41) out of 14 sampled for abuse were free from involuntary seclusion. R41 and R45's room door had been secured closed with an elastic stocking on the night shift. Findings include: A facility policy titled, Patient Protection effective date 1/23/20 documented, There is a zero tolerance for mistreatment, abuse, misappropriation of property, or any crime against a patient of the Health and Rehabilitation Center. 1. Patients of the Center have the legal right to be free from . involuntary seclusion . except in an emergency and/or authorized in writing by a physician. 1. R45's clinical record revealed: 3/29/19 - R45 was admitted to the facility with a diagnosis of Stroke, Anxiety, and Vascular Dementia. 4/4/19 - Review of R45's care plan for Place self on floor off chair, while ambulating refuses to wear socks or shoes related to cognitive impairment, and poor safety awareness documented 1. Keep busy with desirable activities such as…

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 (R179) out of 14 residents reviewed for abuse, the facility failed to have evidence of thorough investigation. Findings include: 1. Review of R179's clinical record revealed: 2/18/21- R179 was admitted to the facility 7/24/23 11:28 AM - Interview with FM1 (daughter) revealed an allegation of abuse from R179 during his stay at the facility. R179 alleged he was beaten all the time by staff during care. 7/24/23 12:00 PM - An allegation of abuse was reported to E1(NHA) and E4 (Corporate Consultant) by the surveyor as revealed by FM1. 7/24/23 1:38 PM - An allegation of abuse was submitted to State Agency. 7/26/23 - Investigation of the allegation of abuse was received by the State agency. The investigation included the incident report and interviews from the following staff: social worker, unit manager and the DON. The investigation lacked interviews with direct care staff. The facility lacked evidence of a thorough investigation related to abuse. 7/27/23 2:45 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 record review, it was determined that for two (R3 and R179) out of four residents reviewed for PASARR, the facility failed ensure that a referral for a PASARR screening was completed following a new diagnosis of psychotic disorder which was not listed on the previous PASARR. Findings include: 1. Review of R179's clinical record revealed: 2/18/21- R179 was admitted to the facility. 10/26/19 - An admission PASARR was completed for R179. 1/19/23 - A progress note from E19 (Psychiatrist) revealed a new diagnosis of Schizophrenia. 7/24/23 10:26 AM - An interview with E9 (SW) and E20 (SW) confirmed a PASARR was not completed when the new diagnosis of Schizophrenia was identified. 7/24/23 10:30 AM - An interview with E21 (RN-MDS coordinator) confirmed the new diagnosis of Schizophrenia was not added to the medical record at the time of diagnosis. The facility failed to ensure that a referral for a PASARR screening was completed following a new diagnosis of a psychotic disorder. 7/27/23 2:45 PM - Findings reviewed with E1 (NHA) and E4 (Corporate consultant). 2. Review…

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

Based on record review and interview it was determined that for four (R87, R129, R281 and R101) out of twenty-seven residents in the investigative sample, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan. Findings include: The facility's policy on Care Planning dated 11/01/2019 documented, A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the mental, and psychosocial well-being of the patient. 1. Review of R129's clinical record revealed: 8/18/21 - R129 was admitted to the facility. 8/19/21 - A care plan for pain related to arthritis. 8/24/21 - A review of an admission MDS revealed R129 was receiving a routine pain medication. 5/10/22 - A review of facility incident report revealed R129 had an injury of unknown origin noted. The report revealed R129 had a bruise to the right hip and was limping when ambulating. Area was slightly edematous and tender to touch. 5/10/22 - A 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.

2. Review of R79's clinical record revealed: 1/21/23 - R79 was admitted to the facility with a diagnosis of Dementia and Chronic kidney disease. 1/23/23 - Review of R79's care plan for ADL self-care deficit related to cognitive deficits and impaired mobility revised on 6/29/23 documented: 1. Will receive assistance necessary to meet ADL (Activity of Daily Living) needs. 2. Will be clean, well dressed, and well-groomed daily to promote dignity and psychosocial wellbeing. 3. Assist with daily hygiene, grooming, oral care and eating as needed. 4/29/23 - A quarterly MDS Assessment documented, that R79 was severly cognitively impaired and required extensive assist with one-person physical assist for bed mobility, transfers, eating, toileting, and personal hygiene. 6/8/23 - Review of R79's care plan for risk for falls revised 6/29/23 documented the use of non-skid socks while out of bed. 7/17/23 10:32 AM - A random observation revealed R79's nails were long and had dark thickened debris underneath all fingernails on the right and left hand. 7/17/23 12:46 PM - An interview with E28 (LPN)…

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

2. Review of R65's clinical record revealed: 11/29/20 - R65 was admitted to the facility. 3/30/23 - Due to a complaint of a decrease in hearing, R65 completed a hearing assessment that recommended a follow-up with an ENT (Ears, Nose, and Throat Doctor). 5/22/23 - During R65's ENT follow-up, R65 was found to have cerumen (earwax) accumulation in the left ear with instructions for treatment stating, debridement and treatment of ear drops Acetasol HC both ears 3 drops BID (twice a day) x 14 days. 6/9/23 - R65's quarterly MDS (Minimum Data Set) assessment evaluated the resident to have adequate hearing. 7/13/23 11:05 AM - An interview with R65 and FM2 revealed that the M.D. (Medical Director) recommended a hearing evaluation for R65 who is hard of hearing. FM2 said I have to speak loudly and clearly to [my] mom because she can hardly hear . she turns the TV volume up because she can hardly hear . They were supposed to have a hearing evaluation done because she may need hearing aids . 7/17/23 - During record review, it was determined the facility lacked evidence of following up 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, it was determined that for two (R16 and R36) of three residents reviewed for range of motion (ROM), the facility failed to ensure that residents received the care and/or treatment to maintain or improve ROM. Findings include: 1. R36's clinical record revealed: 7/10/23 - R36 was admitted the facility with multiple diagnoses including cerebral infarction (disrupted blood flow to the brain) which caused paralysis to his left side, and muscle weakness. 7/11/23 - R36's occupational therapy record documented, . left upper extremity strength to shoulder, elbow and forearm impaired . No functional limitations present due to contracture. The clinical records lacked evidence of contracture measurements. 7/25/23 - R36's MDS documented, . No active or passive range of motion exercises . (exercises that the resident participates with staff to straighten arms/legs). A review of R36's record lacked evidence of a care plan for the management of current contractures, and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of facility documentation, it was determined that for two (R26 and R91) out of fifteen(15) residents sampled for accidents, the facility failed to ensure that R26 and R91received adequate supervision and assistance to prevent an accidents. Findings include: 1. Cross refer to F725, example 5 Review of R26's clinical records revealed: 9/15/20 - R26 was admitted to the facility. 9/9/20 (revised 6/13/23) - R26's care plan was developed for falls and risk for falls with the goal to minimize risk for injury related to falls. R26's interventions included but not limited to: activity assessment, administer medication per physician's order, encouraging rest periods when tired during ambulation/wandering episodes, encourage to use wheelchair when tired, frequent safety checks during wandering episodes, head helmet on at all times as tolerated . 6/28/21 (revised 3/31/23) - A care plan was developed for R26's disruptive/compulsive, verbal/physical agitation/aggressive, can be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, it was determined that for one (R49) out of one resident sampled for tube feeding, the facility failed to ensure that the tube feeding formula and water flush were labeled with the name, date, time, and rate of infusion on 10/22/23. Findings include: The facility policy, dated 11/1/19, and titled, Care of Patient with Feeding Tubes - general principles related to feeding tubes, documented . Properly label . with the individual's name, room number, date, type of feeding, rate and start time . 3/8/21 - R49 was admitted to the facility with multiple diagnoses including a stroke. 10/20/20 - R49's MAR (Medication Administration Records) documented, Continuous Enteral Feeding - Glucerna 1.5 at 40 ml per hour . run until 640 ml is infused via PEG Tube (Percutaneous Endoscopic Gastrostomy - a tube is passed into the stomach through the abdominal wall, used to provide feeding when oral intake is not adequate), and 75 ml of water infusing while tube feeding is running.…

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 (R3) out of seven residents reviewed for unnecessary medications, the facility failed to monitor side effects of a psychoactive medication. Findings include: 1. Review of R3's clinical record revealed: 5/12/21 - R3 was admitted to the facility. 9/2/22 - R3 had an active physician's order for seroquel 50 mg (milligrams) by mouth three times a day for restlessness and agitation and unspecified psychosis. 5/12/23 - A Consultant Pharmacist Recommendations to Nursing Staff documented an AIMS (Abnormal Involuntary Movement Scale) completed on 4/24/23 showing a score of 7, with abnormal movements identified in many categories. R3 did not have a prior assessment in the electronic health record. The recommendation was to compare this AIMS assessment to the prior assessment and if there has been an increase in abnormal movement, to let medical (physician) know so they can reassess her Seroquel therapy. 5/16/23 - A facility response from the nursing staff documented, Repeat AIMS. 7/28/23 2:00 PM - Further review of R3'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 observations and interviews, it was determined that for two (R8 and R21) out of two residents reviewed for menus, the facility failed to follow the menu items listed on the menu. Findings include: 1. R8's clinical record revealed: 10/11/23 - R8 was admitted to the facility with multiple diagnoses including end stage renal disease. R8 was ordered a renal diet, which is a diet that balances fluids and foods to align with diseased kidney function needs. 10/24/23 8:30 AM - An observation of R8's breakfast tray revealed that R8 was served orange juice. Orange juice is a restricted item on a renal diet, and R8 said that she knew that she was not supposed to drink the orange juice. Further observation revealed that R8's standard meal tray dietary ticket was not present on the tray. Upon interview, R8 stated that her meal trays come with a piece of paper that is a copy of the menu selection that she had made for that meal. R8 stated that she has not had a typewritten meal tray ticket on her dining trays since…

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 review of facility documentation, it was determined that for one (R100) out of one residents sampled for preferences, the facility failed to provide the resident's food preference for breakfast. Findings include: 7/24/23 at 8:50 AM - During an interview at the centralized nurse's station on the second floor, R100 stated to the Surveyor, in the presence of E56 (Dietician), that he did not receive eggs for breakfast this morning and it was listed on his meal ticket. E56 asked R100 if he still wanted eggs and R100 replied no too late. The Surveyor observed R100's meal tray and meal ticket, which stated scrambled eggs . Tray Notes: . LIKES EGGS . R100 stated that other residents on the Dover hallway were served eggs. 7/31/23 at 2:00 PM - Finding was reviewed during the Exit Conference with E1 (NHA), E2 (DON), E4 (RCD) and E18 (VPO).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interview, it was determined that for three (R1, R30 and R36) out of three residents reviewed for falls, the facility failed to ensure that resident fall assessments accurately documented the resident's status. Findings include: 1. Review of R1's clinical record revealed: 9/29/23 - R1's admission fall assessment was completed using the facility's Fall Assessment Scoring Tool and the score was 17. According to the facility Fall Risk Scoring Tool, a score greater that or equal to 12 indicates a high risk for falling. 10/2/23- A physician progress note was written in the Emr that R1 was considered a fall risk because she had previous falls in the year prior to her admission to the facility. 10/3/23 7:00 PM - A nursing progress note was written in the Emr that R1 fell while walking in the hallway earlier in the day. R1 hit her head during the fall and was sent to the hospital emergency room for evaluation and treatment. 10/3/23 - A post fall risk assessment was completed 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 record review, facility policy review, and interview, it was determined that the facility failed to have an Infection Preventionist (IP) responsible for the facility's IPCP (Infection Prevention and Control Program) that had completed specialized training in infection prevention and control prior to assuming the role of the IP. Findings include: The facility's policy on, Infection Preventionist, last revised November 17, 2020, reads, .The IP must: Possess knowledge of infection surveillance, prevention and control of infections and has completed specialized education on infection prevention and control . 6/12/23 - E24 (former ADON/IP) provided the facility with a formal notification of resignation from the position. 7/13/23 - In response to documentation requests during the Survey's Entrance Conference, the facility provided evidence of specialized infection prevention and control training of E24 as the facility's IP. 7/21/23 - E24's last day as ADON/IP at the facility. 7/26/23 11:52 AM - During an interview, E40 (RN/Staff Development) stated that she took over the IP role…

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 observation, it was determined that the facility failed to ensure adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two in the Arcadia unit. Findings include: 7/21/23 3:00 PM - EHS (Environmental Health Specialist) toured the Arcadia unit. 7/21/23 3:45 PM - During an interview with E39 (Director of Maintenance), it was stated that Arcadia's hall AC unit was out of service and the facility was waiting on a back ordered part to have replaced. 7/21/23 3:50 PM - E39 confirmed poor ventilation on the Arcadia unit. Findings were reviewed with E1 (NHA), E2 (DON), E4 (RCD) and E18 (VPO) at the Exit Conference on 7/31/23 at 2:00 PM.

Based on interview and review of facility documentation, it was determined that the facility failed to ensure that the required training for new and existing staff was completed for one (E53) out of five staff for the Facility Assessment. Findings include: 2/22/23 - (E53) was hired for the housekeeping position. 8/9/23 - The facility was provided a list of five randomly selected staff members for facility assessment training and instructed to provide documentation of the required training requirement for new and existing staff. 8/9/23 3:45 PM - During an interview with E16 (HRD) revealed E53 (CNA) had not completed all required trainings. A copy of E53's orientation check list was requested during the interview. Additionally, E16 said, the general orientation check list would be different for the housekeeper position. Further review of documentation revealed a general orientation check off list for E53 had not been provided. 8/11/23 12:12 PM - E2 (DON) documented in an email correspondence E53 had not been due for other educational items until 8/31/23. The facility failed to provide…

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 the required training for Resident Rights was completed for one (R53) out of five staff. Findings include: 2/22/23 - (E53) was hired for the housekeeping position. 8/9/23 - The facility was provided a list of five randomly selected staff members for Resident Rights training and instructed to provide documentation of the required training. 8/9/23 3:45 PM - During an interview with E16 (HRD) revealed E53 (CNA) had not completed all required trainings. A copy of E53's orientation check list was requested during the interview. Additionally, E16 said, the general orientation check list would be different for the housekeeper position. Further review of facility documentation revealed, Residents Right training for E53 had not been provided. 8/11/23 12:12 PM - E2 (DON) documented in an email correspondence that E53 had not been due for other educational items until 8/31/23. The facility failed to provide training for Resident Rights which is required for all direct and indirect…

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 the required training on abuse, neglect, exploitation and misappropriation of resident property was completed for three (E32, E53 and E54) out of 11 randomly sampled staff members. Findings include: 1. Review of E32 (LPN) personnel records revealed: 2/20/18 - The date of E32's most recent abuse and neglect training. 12/9/22 - E32's last date of employment at the facility. 7/24/23 11:00 AM - A verbal confirmation from E16 (HR) was provided that E32's most recent abuse training was 2/20/18. 2. Review of Review of E53 (Housekeeping) personnel records revealed: 2/22/23 - E53's date of facility hire. 7/24/23 - E53's personnel file did not have evidence of abuse and neglect training. 7/24/23 11:10 AM - E16 provided verbal confirmation that E53 did not have abuse training and neglect training upon hire. 3. Review of Review of E54 (CNA) personnel records revealed: 2/20/18 - The date of E54's most recent abuse and neglect training. 7/24/23 11:15 AM - A verbal confirmation from…

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 the required training for QAPI (Quality Assurance and Performance Improvement) was completed for one (R53) out of five staff. Findings include: 2/22/23 - (E53) was hired for the housekeeping position. 8/9/23 - The facility was provided a list of five randomly selected staff members for QAPI training and instructed to provide documentation of the required training. 8/9/23 3:45 PM - During a brief interview with E16 (HRD) revealed E53 (CNA) had not completed all required trainings. A copy of E53's orientation check list was requested during the interview. Additionally, E16 said, the general orientation check list would be different for the housekeeper position. Further review of facility documentation revealed QAPI training for E53 had not been provided. 8/11/23 12:12 PM - E2 (DON) documented in an email correspondence E53 had not been due for other educational items until 8/31/23. The facility failed to provide training for QAPI which is required for all direct and…

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

Based on interview and review of facility documentation, it was determined that the facility failed to ensure that the required training for Compliance and Ethics was completed for one (R53) out of five staff. Findings include: 2/22/23 - (E53) was hired for the housekeeping position. 8/9/23 - The facility was provided a list of five randomly selected staff members for Compliance and Ethics training and instructed to provide documentation of the required training. 8/9/23 4:00 PM - During a brief interview with E16 (HRD) revealed E53 (CNA) had not completed all required trainings. A copy of E53's orientation check list was requested during the interview. Additionally, E16 said, the general orientation check list would be different for the housekeeper position. Further review of facility documentation revealed Compliance and Ethics training for E53 had not been provided. 8/11/23 12:12 PM - E2 (DON) documented in an email correspondence E53 had not been due for other educational items until 8/31/23. The facility failed to provide training for Compliance and Ethics which is required for…

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

Based on interview and review of facility documentation, it was determined that the facility failed to ensure that the required training for Behavioral Health Training was completed for one (R53) out of five staff. Findings include: 2/22/23 - (E53) was hired for the housekeeping position. 8/9/23 - The facility was provided a list of five randomly selected staff members for Behavioral Health training and instructed to provide documentation of the required training. 8/9/23 3:45 PM - During a brief interview with E16 (HRD) revealed E53 (CNA) had not completed all required trainings. A copy of E53's orientation check list was requested during the interview. Additionally, E16 said, the general orientation check list would be different for the housekeeper position. Further review of facility documentation revealed Behavioral Health training for E53 had not been provided. 8/11/23 12:12 PM - E2 (DON) documented in an email correspondence E53 had not been due for other educational items until 8/31/23. The facility failed to provide training for Behavioral Health which is required for all…

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.