Delaware Court Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Board of Executives of Long-Term Services and Supports (BELTS) website review review and staff interview, and BELTS Representative interview, the facility failed to ensure the Administrator had an active license. This affected all 52 residents in the facility during the annual survey. The census was 52. Findings include: Review of the Board of Executives of Long-Term Services and Supports (BELTS) website on [DATE] revealed the facility's Administrator's license had expired on [DATE]. Interview on [DATE] at 11:55 A.M., with the Administrator revealed he was unaware his license had expired until surveyor notification during the annual survey. Interview on [DATE] at 11:30 A.M., with the Board of Executives of Long-Term Services and Supports Representative confirmed the Administrator had been practicing for six months with an expired license and would be receiving disciplinary action from the board. She revealed the Administrator did not apply for renewal of licensing until [DATE].

Based on record review, policy review and staff interviews, the facility failed to ensure an infection surveillance plan was in place for identifying, tracking, and monitoring outbreaks. This had the potential to affect all 52 residents. Facility census was 52. Findings include: Review of the infection control tracking logs revealed resident infections were monitored for location with a facility map, but signs symptoms, labs and cultures were not included. There was no evidence of the use of evidence-based surveillance criteria to define infections and determine appropriateness of treatment options. There was no evidence the facility determined percentage of nosocomial (community based infections) for facility each month as a tracking tool. There was no evidence that notes, cultures, labs, treatments and multi-drug-resistant organism statuses were tracked upon transfer to and from acute care hospitals. Interview on 10/19/23 at 12:25 P.M., with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #127 revealed if a resident has signs of infection they will talk with the…

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

Based on observation and staff interviews, the facility failed to ensure the plumbing equipment was maintained in a safe and sanitary conditions . This had the potential to affect 50 of 50 residents who receive meals from the kitchen. excluding two (#3 and #305) residents who recive tube feeding. The faciltiy census was 52. Findings include: Tour of the kitchen on 10/16/23 at 9:30 A.M., revealed a red plastic coffee can under the three compartments sink on the right side. The pipe had a slow drip. Observations on 10/18/23 from 11:18 A.M. to 11:45 A.M., while observing puree food preparation, the kitchen floor became flooded, instantly water appeared from the floor under the three compartments sink to the far right under the oven and to the far left of the walk in freezer. The water was approximately one quarter inch deep. Employees were observed walking through the water unaware of how the water appeared. Observation of the area under the three compartment sink revealed the drain and tiles around it under the sink were raised. No water was draining into the drain. The red plastic…

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 financial records, Personal Needs Account Procedures review and staff interviews the facility failed to ensure resident care needs account was in an interest-bearing account. In addition, none of the 12 residents or their representatives signed an authorization form for the facility to handle their personal care need accounts. This affected all 12 (#36, #11, #5, #29, #7, #15, #14, #13, #42, #44, #34 and #33) residents personal care need accounts which the facility is representative payee. The census was 52. Findings include: Review of Resident #36, #11 and #7's monthly bank statements for their personal care needs account revealed the accounts are in a checking account with a local bank. The account does not bear any interest. Interview on 10/16/23 at 2:30 P.M., with Business Office Manager #159 confirmed all 12 personal care need accounts (#36, #11, #5, #29, #7, #15, #14, #13, #42, #44, #34 and #33) are at the local bank, in a checking account that does not bear interest. She confirmed she does not have a personal care need account authorization form signed by each…

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 financial record reviews, resident interviews and staff interviews, the facility failed to ensure residents receive a quarterly statement for their personal care need account. This affected 12 (#36, #11, #5, #29, #7, #15, #14, #13, #42, #44, #34 and #33) of 12 residents with personal care need accounts. The census was 52. Findings include: Interview on 10/15/23 from 10:00 A.M. to 10:15 A.M., with with Resident #13 and Resident #14 revealed they do not receive a statement for her personal care need account. Review of the excel sheet from 10/23/22 to 10/03/23 for Resident #7, #11, #33, #36, and #44 revealed it is not an official statement for the personal care need account or a bank statement for each resident. The excel sheet does not have the resident's name or account number, or interest earned on it. Interview on 10/16/23 at 2:30 P.M., with Business Office Manager #159 confirmed the facility receives monthly checking account statements for Resident (#36, #11, #5, #29, #7, #15, #14, #13, #42, #44, #34 and #33) personal care needs accounts and the statements are filed in…

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, medical record reviews, dentist roster review, Dental Mobile Office Representative interview, resident interview and staff interviews, the facility failed to offer dental services to residents. This affected one (#13) of one resident reviewed for dental services. This had the potential to affect 20 (#1, #3, #5, #36, #8, #10, #11, #13, #14, #15, #16, #17, #22, #24, #26, #27, #29, #34, #36, #42 and #46) additional resident who consented to see the dentist. The census was 52. Findings include: Review of the medical record for the Resident #13 revealed an admission date of 09/16/22. Diagnoses included chronic obstructive pulmonary disease , chronic pulmonary edema, and chronic respiratory failure with hypoxia. Resident #13 obtained Medicaid benefits on 10/06/22 . Observation on 10/16/23 at 3:34 P.M., with Resident #13 revealed she is without teeth and without dentures. Interview at the time of the observation revealed Resident #13 revealed she would like to have dentures. She requested them in the past and no one has spoken to her about seeing a dentist. Interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, email communication review and policy review, the facility failed to ensure antibiotics were ordered and used appropriately for residents with potential infections. This affected four (#21, #35, #37, #47) of four residents reviewed for antibiotic stewardship. Facility census was 52. Findings include: 1. Review of the medical record for the Resident #21 revealed an admission date of 09/08/21. Diagnoses included end stage renal disease, diabetes, anxiety, blindness, and hypothyroidism. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively intact and required extensive assistance of two staff members for bed mobility and was totally dependent for transfers. Review of the plan of care revealed no mention of infection or treatment of infection, besides COVID infections. Review of the physician order dated 08/10/23 revealed orders for wound care to cleanse right leg with warm soapy water and use 0.9 normal saline flush over, apply…

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 financial record reviews and staff interview, the facility failed to ensure residents who are insured by Medicaid do not exceed $2,000.00 in their personal care needs accounts. This affected three Medicaid residents (#7, #11 and #36) of three accounts reviewed with funds above the $2,000.00 limit. The census was 52. Findings include: Review of Resident #7's Checking Account Bank Statement and excel sheet revealed a balance of $5,140.52 as of 10/11/23. A notification of spend letter was not available. Review of Resident #11's Checking Account Bank Statement and excel sheet revealed a balance of $4,008.79. as of 10/11/23. A notification of spend letter was not available. Review of Resident #36's Checking Account Bank Statement and excel sheet revealed a balance of $4,777.46 as of 10/3/23. A Spin Down notification letter was sent to Resident #36 representative on 04/05/23. Interview on 10/16/23 at 2:30 P.M., with Business Office Manager #159 stated the families or guardians have been notified of the account balances, however, the balances remain above the Medicaid amount. She…

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, policy review and staff interview, the facility failed to ensure a residents code status was accurately reflected in the medical record. This affected one (#10) of two residents reviewed for advanced directives. The facility census was 52. Findings include Review of the medical record for the Resident #10 revealed an admission date of 03/03/18. Diagnoses included chronic atrial fibrillation, cerebral infarction, cognitive deficit, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively impaired with a BIMS of 3 and required extensive assistance of one to two staff members for bed mobility and transfers. Review of the code status sheet signed by the physician dated 03/02/18 revealed Resident #10 was code status DNRCC-A. This was documented in the paper medical record. Review of physician orders dated 03/14/22 identified orders for resident code status of DNRCC in the electronic medical record. Review of the plan of care dated…

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 staff interview, record review and policy review, the facility failed to ensure beneficiary notices were provided prior to a reduction of skilled services. This affected one (#206) of two residents reviewed for beneficiary notices. The facility census was 52. Findings include 1. Review of the medical record for the Resident #206 revealed an admission date of 06/10/23 and discharge on [DATE]. Diagnoses included surgical aftercare, diabetes, heart failure, arthritis and dyspnea. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #206 was cognitively intact and required supervision assist with mobility and transfers. Interview on 10/17/23 at 1:25 P.M., with Social Services #120 revealed Resident #206 went to a physician appointment and was informed his skilled services could end. Resident #206 was not provided with Notice of Medicare noncoverage (NOMNC) prior to discharge in case he wanted to appeal the decrease in services. The facility was unable to provide evidence this was a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, statement reviews, and policy review, the facility failed to report an alleged allegation of abuse, neglect, and misappropriation to the state agency. This affected one (#21) of one resident reviewed for abuse/neglect. The facility census was 52. Findings include: Review of the medical record for Resident #21 revealed an admission date of 09/21/22. Diagnoses included end stage renal disease, diabetes, legal blindness, cerebral infarct, weakness, vascular disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively intact with a BIMS of 15 and required extensive assistance of two staff members for bed mobility and was totally dependent for transfers. Review of the plan of care dated 06/22/23 revealed Resident #21 had an activities of daily living (ADL) self-care performance deficit and required assistance for bathing and transfers. Residents care plan did not include any evidence of behaviors or…

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, resident interview, statement review, staff interview and review policy, the facility failed to complete a thorough investigation for an alleged allegation of abuse, neglect, and misappropriation. This affected one (#21) of one resident reviewed for abuse/neglect. The facility census was 52. Findings include: Review of the medical record for Resident #21 revealed an admission date of 09/21/22. Diagnoses included end stage renal disease, diabetes, legal blindness, cerebral infarct, weakness, vascular disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively intact with a BIMS of 15 and required extensive assistance of two staff members for bed mobility and was totally dependent for transfers. Review of the plan of care dated 06/22/23 revealed Resident #21 had an activities of daily living (ADL) self-care performance deficit and required assistance for bathing and transfers. Residents care plan did not include any evidence of behaviors or…

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 medical record review, review of facility communication emails, review of policy, and staff interview, the facility failed to notify the Ombudsman when residents were transferred/discharged from the facility. This affected two (#52 and #53) of two residents reviewed for discharge home. The facility census was 52. Findings include: 1. Review of the medical record for Resident # 52 revealed an admission date of 04/14/23, with no cognitive deficits. Diagnoses included seizures, aortic stenosis. hyperlipidemia and chronic pulmonary embolism. Resident #52 was discharged home on [DATE]. 2. Review of the medical record for Resident #53 revealed an admission date of 05/17/23 with no cognitive deficits. Diagnoses include chronic anemia, hiatal hernia, deep vein thrombosis and atrial fibrillation. Resident #53 was discharged to a long term care facility on 08/25/23. Review of the Social Service Designee #120 notification emails to the Ombudsman Office from 10/01/22 to 10/17/23, revealed the Ombudsman Office 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 Based on medical record review and staff interview, the facility failed to have a care plan for a psychotropic medication. This affected one (#305) of five residents reviewed for unnecessary medications. The facility census was 52. Findings include: Review of Resident #305's medical record revealed he was admitted to the facility on [DATE], with a diagnoses of hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, aphasia and dysphasia following cerebral hemorrhage, atrial fibrillation, encounter for attention to gastrostomy. Review of the Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #305 was cognitively impaired and required extensive assistance of one to two staff for all activities of daily living. Review of the physician orders for October 2023 revealed Resident #305 was ordered an antidepressant Prozac HCl Capsule 10 milligrams (mg), give one capsule via Percutaneous Endoscopic Gastrostomy (peg-tube) in the evening for depression.…

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 medical record review, staff interviews and policy review, the facility failed to ensure a recapitulation of the resident's stay was provided when residents were discharge from the facility This affected two (#52 and #53) of two residents reviewed for discharged . The census was 52. Findings include: 1. Review of the medical record for Resident #52 revealed an admission date of 04/14/23, with no cognitive deficits. Diagnoses included seizures, aortic stenosis, hyperlipidemia and chronic pulmonary embolism. Resident #52 was discharged home on [DATE]. Review of Resident #52's Discharge Summary Sheet (one page) revealed no recapitulation of Resident #52 care at the facility. There were two pages to a Discharge Summary Report, Resident #52 did not receive a complete Discharge Summary Report when Resident #52 was discharged home on [DATE]. Interview on 10/17/23 at 11: 37 A.M., with Social Service Designee #120 confirmed the facility does not have evidence of a Discharge Summary Report or a recapitulation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure pharmacy recommendations were reviewed timely by a physician and also failed to ensure recommendations reviewed had the recommendations acted upon as agreed upon by the physician. This affected two (#36 and #38) of five residents reviewed for pharmacy recommendations. Facility census was 52. Findings include: 1. Review of the medical record for the Resident #38 revealed an admission date of 07/14/22. Diagnoses included depression, hypertension, dementia, anxiety, cognitive communication deficit and unsteadiness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was cognitively impaired and with a BIMS of 9 and required extensive assistance of one for bed mobility and supervision for transfers. Review of physician orders dated 02/28/23 for Abilify 5 milligram (mg) revealed no attempts to complete a dose reduction for this medication. Physician order for oxybutynin ER 5 mg revealed on 09/21/23, an order 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 Based on record review and staff interview, the facility failed to ensure a resident was free from unnecessary medication. This affected one (#3) of six residents reviewed for unnecessary medication. The facility census was 52. Findings include: Review of the medical record for the Resident #3 revealed an admission date of 05/12/21. Diagnoses included encephalopathy, heart disease, diabetes, osteoarthritis and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively impaired and required extensive assistance of one to two staff members for bed mobility and transfers. Review of physician orders for 04/16/22 identified orders for gentamicin 0/3% eye drop with instructions to administer 1-2 drops into eye for pink eye. Review of the medical record found no evidence of resident being diagnosed or seen for pink eye. Review of Medication Administration Record dated April 2022 to July 2022 revealed the resident had a new order for gentamicin eye drops in April 2022…

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, policy review and staff interviews, the facility failed to ensure the texture of a modified diet was provided to the physician ordered consistency. This affected (#3) one of one residents reviewed for a modified diet. The census was 52. Findings include: Review of the medical record for Resident #3 revealed an admission date of 05/12/21. Diagnoses included encephalopathy, heart disease, diabetes, osteoarthritis, and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively impaired and required extensive assistance of one to two staff members for bed mobility and transfers. Review of Resident #3 physician orders for October 2023 revealed Resident #3 is on a puree diet. Interview on 10/18/23 at 11:18 A.M., with Dietary Aid #151 revealed there was only one resident who received a puree diet. The menu for lunch included corn beef briquet, green beans and Italian potatoes. Observation of Dietary Aid #151 on 10/18/23 from 11:18 A.M. to 11:42…

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, medical record review, resident interview, and staff interviews, the facility failed to ensure call lights were in proper working order. This affected one (#5) of one resident reviewed for environment. Facility census was #52. Findings include: Review of the medical record for the Resident #5 revealed an admission date of 10/31/19. Diagnoses included diabetes, encephalopathy, heart disease, epilepsy, alcoholic cirrhosis, muscle weakness, hemiplegia and hemiparesis, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively impaired and required extensive assistance of two staff members for bed mobility and transfers. The MDS revealed resident had impairment to one side including the upper and lower extremity. Review of the plan of care dated 07/25/23 revealed Resident #5 had an Activity of Daily Living (ADL) self care deficit with interventions to support his left side during transfers and staff to set up…

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, staff interview, and review of the facility policy, the facility failed to ensure advanced directives for the code status were signed by the physician. This affected two (#7 and #20) residents reviewed for code status in a total facility census of 47. Findings include: 1. Review of the record for Resident #20 revealed the resident was admitted on [DATE]. Diagnosis included atherosclerotic heart disease, dementia with behavioral disturbance, major depressive disorder, anxiety disorder, hypertension, macular degeneration and glaucoma. Review of the admission minimum data set (MDS) assessment dated [DATE], revealed a brief interview of mental status score of three, indicating impaired cognition. Review of undated document titled, DNR (Do Not Resuscitate) Comfort Care DNR Identification Form, revealed an unsigned copy of an advanced directive for code status by the physician. The document was signed by the Power of Attorney (POA). Review of document titled, DNR Comfort Care DNR Identification…

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, staff interview and review of an undated form titled, Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, the facility failed to ensure appropriate beneficiary notices were provided to residents. This affected one (#295) of three residents reviewed for provision of beneficiary notices. The facility census was 47. Findings include: Review of the record for Resident #295 revealed an admission on [DATE] and discharged to the hospital on [DATE]. Resident #285 did not return to the facility. Diagnosis included orthopedic aftercare, discitis lumbar region, fusion of spine, urinary tract infection, history transient ischemic heart attack, cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery and history of COVID-19. Review of the discharge return not anticipated minimum data set (MDS) assessment dated [DATE], revealed a planned discharge to the community with a discharge date of 04/28/21. Resident #295 had a Medicare-covered stay…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews with staff and residents, and review of the facility policy's, the facility failed to ensure care plans were revised to include an accurate code status, updated fall interventions, and updated dental concerns. This affected three (#9, #16 and #37) of sixteen residents reviewed for revision of care plans. Additionally, the facility failed to ensure care conferences were conducted. This affected one (#10) of one resident reviewed for care conferences. The facility census was 47. Findings include: 1. Review of medical record for Resident #9 revealed an admission date of 04/21/21. Diagnosis included encephalopathy, anemia, heart disease, hypertension, Type II diabetes, major depression disorder single episode, retention of urine, hemorrhoids, history of malignant neoplasm of prostate, unsteadiness on feet and pain in right shoulder. Review of the Admission/Medicare 5-day Minimum Data Assessment (MDS) dated [DATE], revealed a brief interview for mental status score (BIMS) of five,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interview, and review of the facility policy, the facility failed to ensure fall interventions were implemented. This affected one (#9) of two residents reviewed for implementation of fall interventions. The facility census was 47. Findings include: Review of medical record for Resident #9 revealed an admission date of 04/21/21. Diagnosis included encephalopathy, anemia, heart disease, hypertension, Type Two diabetes, major depression disorder single episode, retention of urine, hemorrhoids, history of malignant neoplasm of prostate, unsteadiness on feet and pain in right shoulder. Review of Admission/Medicare 5-day Minimum Data Assessment (MDS) dated [DATE], revealed a brief interview for mental status score (BIMS) of five, indicating severely impaired cognition. Resident #9 required extensive assistance of two or more persons physical assist for bed mobility, transfers and toilet use. Resident #9 required supervision of two or more persons physical assistance 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.