How many inspection deficiencies does EXCELCARE AT NEWARK LLC have?

EXCELCARE AT NEWARK LLC has 48 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at EXCELCARE AT NEWARK LLC?

EXCELCARE AT NEWARK LLC has a four-star staffing rating from CMS with 0.70 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is EXCELCARE AT NEWARK LLC located?

EXCELCARE AT NEWARK LLC is located in NEWARK, DE. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does EXCELCARE AT NEWARK LLC have?

EXCELCARE AT NEWARK LLC has 101 certified beds.

Who owns EXCELCARE AT NEWARK LLC?

EXCELCARE AT NEWARK LLC is a for profit - corporation facility and is part of the EXCELCARE chain.

What questions should families ask when visiting EXCELCARE AT NEWARK LLC?

Families visiting EXCELCARE AT NEWARK LLC should ask about daily routines, communication with families, how they handle medical emergencies. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does EXCELCARE AT NEWARK LLC compare to other nursing homes?

EXCELCARE AT NEWARK LLC has a 4-star overall rating, placing it above average compared to other nursing homes in DE. Higher-rated facilities typically have better inspection results and staffing levels.

EXCELCARE AT NEWARK LLC

Name: EXCELCARE AT NEWARK LLC
Address: 4949 OGLETOWN-STANTON ROAD, NEWARK, DE, 19713, US
Telephone: (302) 998-6900
Rating: 4.0

4949 OGLETOWN-STANTON ROAD, NEWARK, DE 19713 · (302) 998-6900

For profit - Corporation 101 Beds EXCELCARE Data: November 2025

Trust Grade

55/100

#19 of 43 in DE

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EXCELCARE AT NEWARK LLC nursing home in NEWARK, DE - Photo 1 of 2

Photo by Excelcare at Newark

EXCELCARE AT NEWARK LLC nursing home in NEWARK, DE - Photo 2 of 2

Photo by Excelcare at Newark

Last Inspection: February 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

ExcelCare at Newark LLC has a Trust Grade of C, indicating it is average compared to other nursing homes. Ranked #19 out of 43 facilities in Delaware, it falls in the top half, while its county rank of #10 out of 25 shows that there are only a few local options that perform better. The facility is currently improving, with the number of issues decreasing from 21 in 2024 to 8 in 2025. Staffing is a strength, rated 4 out of 5 stars with a turnover rate of 40%, which is slightly below the state average, suggesting that staff are experienced and familiar with the residents. However, there are concerns, including $29,309 in fines, which is average but indicates some compliance issues, and specific incidents where residents were not adequately supervised, leading to falls and injuries. Additionally, there were issues with food safety and cleanliness that could affect all residents. Overall, while there are notable strengths, families should consider the highlighted weaknesses when making their decision.

Trust Score: C
In Delaware: #19/43
Safety Record: Moderate
Inspections: Getting Better
Staff Stability: 40% turnover. Near Delaware's 48% average. Typical for the industry.
Penalties: $29,309 in fines. Lower than most Delaware facilities. Relatively clean record.
Skilled Nurses: Each resident gets 42 minutes of Registered Nurse (RN) attention daily — more than average for Delaware. RNs are trained to catch health problems early.
Violations: 48 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★★☆

4.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★★★

5.0

Care Quality

★★★☆☆

3.0

Inspection Score

↔

Stable

2024: 21 issues

2025: 8 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
5-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (40%)
8 points below Delaware average of 48%

Facility shows strength in staffing levels, quality measures, fire safety.

The Bad

Staff Turnover: 40%

Near Delaware avg (46%)

Typical for the industry

Federal Fines: $29,309

Below median ($33,413)

Moderate penalties - review what triggered them

Chain: EXCELCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 48 deficiencies on record

2 actual harm

Feb 2025 8 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of one resident (R)72 reviewed for accidents /safety in the sample of 28 revealed that R72 was smoking outside the facility unsupervised, fell and was found on the ground with a bloody nose and swollen, purplish color 5th finger, which was later identified by x-ray as a right hand 5th finger proximal phalanx fracture. Findings include: Review of R72's Face Sheet located in electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary disease (COPD), acute and chronic respiratory with hypoxia, muscle weakness, cognitive communication deficit, and dependence on supplemental oxygen. Review of R72's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/14/24 and located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated moderate cognitive impairment. Review of R72's Care Plan, dated 10/09/24 and located in the residents' EMR under the Care Plan tab revealed, Potential for safety hazard to self or others as evidenced by non-compliance with prescribed safety measures as evidenced by smoking on facility grounds. Review of the facility's Incident Report/5-day follow-up dated 10/22/24 revealed the resident had a fall on 10/18/24, following the fall, the right (R) hand 5th digit was slightly swollen and purplish in color. She was able to move all digits upon command and denied any difficulty in use of hand/extremity, on 10/20/24 to 10/21/24, the swelling and bruising persisted, and an order was received for a Xray of the R hand. Xray result showed a 5th proximal phalanx fracture. Review of R72's Physician Orders dated 08/09/23 and located in the EMR under the Orders tab revealed oxygen at 3 liters per minute (LPM) via nasal cannula. Review of Progress Note dated 10/18/24 at 1:07 PM written by Registered Nurse (RN)1 revealed resident found outside by another resident who notified nursing. The resident was bending and leaning forward to pick up her glasses and fell forward. Resident noted with a bloody nose and a skin tear to right upper eyelid. Nurse Practitioner (NP) notified. Resident safely brought back inside facility and vitals obtained. Review of Radiology Results Report dated 10/21/24 located in the residents EMR under the Misc tab revealed reason acute pain due to trauma. Further review revealed 5th proximal phalanx fracture with mild displacement. During an interview on 02/17/25 at 4:16 PM R72 stated that on 10/18/24 she went out the front door and that nobody told her she could not go outside. She was out there about 30 minutes, but she was not sure if she was supposed to let anyone know. She said she smoked at the time and had a cigarette and lighter with her. She did not know she was not supposed to smoke at the time. She said she took her nasal cannula off and hung it on the back of her wheelchair. She said she took precautions. She fell out of the seat and hit her face on the ground and her arm and hand were sore. She stated she broke one of her fingers. She is not allowed to go outside without staff now, but she was unsure of what the rules were. But she thinks she can still go outside and sit by the bench. During an interview on 02/18/25 at 11:56 AM, RN1 stated that residents who had a BIMS of 12 or higher and were their own responsible person used to be allowed to go outside in front of the facility and hang out on the front porch. But they were not allowed to go to any other area on the facility grounds. They were supposed to make their assigned nurse aware and let the receptionist know. The receptionist was supposed to verify with their nurse if they were allowed to go outside. She said there was no structured process to monitor/supervise residents s while they were outside. She said the facility was a nonsmoking facility. R72 was a smoker prior to being admitted but she was unaware of any time that R72 had attempted to smoke on facility grounds or had smoking materials in her possession. On 10/18/24 another resident (unsure who) was coming back into the facility and notified staff up front (unsure who) that R72 was on the ground. She notified the Assistant Director of Nursing (ADON), the Director of Nursing (DON) and one of the unit managers. She said they all went outside and found the R72 out front by the flagpole near a bench . This was an area that residents were not supposed to be because you were unable to see them from the front door due to bush blocking the front of the bench. She said R72 was sitting up on the grass and her nose was bleeding and she had a skin tear on her eyebrow. She told staff she wanted to come outside and have a moment to herself somewhere quiet. She was unsure if R72 told her nurse she was going outside. She was not sure if there was a change to R72's plan of care. There was an Interdisciplinary Team (IDT) meeting, but she was unsure what was changed. But she assumed R72 would require supervision after that. When asked about the care plan intervention on 10/09/24 that was initiated by her regarding R72 being noncompliant with smoking. she said, I forgot about that. But she was unsure what had occurred to require that change in the resident's care plan. She said she thinks R72 may have had a lighter in her room and that R72 had been caught smoking outside before. But she did not know any specifics. She was unsure what if anything was done to ensure R72 did not have smoking materials or that she was supervised when she went outside. She thinks they took the lighter away from R72 but can't remember. She said she did not remember seeing anything outside on 10/18/24 that suggested R72 was smoking before she was found on the ground. During an interview on 02/18/25 at 12:22 PM, Licensed Practical Nurse ( LPN)1 said in the past residents who had been deemed mentally competent and physically safe to be outside were allowed. But she was unsure how that was decided. She said she would have to ask which residents were allowed to go outside. She was also unsure how or who was responsible for monitoring the residents while they were outside. She is not sure if residents are still allowed outside but she is not aware of any specific residents that can and do go outside without staff supervision. R72 was allowed to go outside without supervision but she is no longer able to without supervision because R72 had a fall outside. She said she was R72's assigned nurse that day on 10/18/24 but she did not see the actual fall, but was told R72 was outside on the ground. She said the R72 did not let her know she was going outside. She said R72 was found behind the bush by the bench next to the flagpole. She said R72 was hiding behind the bush because she was smoking, and she knew she was not supposed to be. She stated that she, along with the DON, ADON, and RN1 went out there. R72 was sitting on her bottom in front of her wheelchair and there was a lit cigarette right by R72 on the ground that was almost a burnt to the butt. She was unsure where the lighter was. She asked the R72 why she was out there and at first she lied but then admitted that she just had a couple of puffs. She was unsure if she was sitting in the wheelchair that had the oxygen tank on the back or on the bench while she was smoking but she did see the nasal cannula hanging over the back of the chair/tank. She said the nasal cannula was not on her face. She said she was unsure if anyone asked R72 about the fact that she was smoking close to her oxygen tank. After that she was not allowed to go outside unassisted without staff anymore. She said staff were not allowed to let any residents outside. During an interview on 02/18/25 at 4:36 PM, the ADON said residents were allowed to go outside who had a BIMS score higher than a 12 or 13 and were not an elopement risk or exit seeking. She said there was no formal process to monitor residents while there was outside but there was an expectation that any staff going by should look for them. The receptionist or another staff at the front desk would have to put in the code for the front door to open. She said the staff at the front desk would usually call the nurses station to see if the resident was allowed to go outside. There was no set time for how long they could be out there, but they did consider things like weather. She said staff had observed R72 smoking when she was not supposed to be, and it was more than once. But she was unsure what was put into place besides educating her and the family member about nonsmoking and with her oxygen near. On 10/18/24 she said R72 was outside, down by the park bench, and had reached to pick up her glasses and fell. She said the staff asked her if she was smoking and she said no and there were no smoking materials around. During an interview on 02/18/25 at 5:01 PM the former receptionist said when residents wanted to go outside she would ask the Activity's Director if they were allowed and would let her know when a resident went outside and that the Activity's Director or the assistant would periodically monitor them. She said residents were not allowed to go to the bench by the flagpole because it was too far for staff to see. R72 had been warned several times about being outside smoking. On 10/18/24 she said she notified the Activity's Director when R72 went outside. She said when she was found R72 she was on the ground, and she was covered by some bushes. She said that was exactly why R72 went out behind the bushes because she was hiding to smoke because she had an oxygen tank, and she knew she wasn't supposed to smoke with it. She said the person who reported seeing the resident on the ground reported that she was out there smoking. She was unable to remember who that person was. But she was unsure how long R72 had been out there before she was observed on the ground. She was unsure if anyone had checked on her before she was found. During an interview on 02/18/25 at 5:20 PM, the Activity's Director said residents that were deemed alert and oriented and were safe to be outside were allowed to be outside without staff supervision. She said staff would keep an eye on them every 15 to 20 minutes. But residents had to remain in the front door area. She said on 10/18/24 she could not remember anyone telling her that R72 went outside and that she did not go outside to check on her during that time. During an interview on 02/19/25 at 4:27 PM the DON stated that on 10/18/24 she was in the office and heard the receptionist yell out. She ran outside along with other staff and observed R72 on the ground. She did not remember seeing any smoking materials. There was history of R72 being non-compliant with smoking after staff had seen her with a cigarette and a vape and that she was on continuous oxygen. She said residents with a BIMS score of 13 and up were allowed to go outside and sit out there during the summer months without staff. She said the Activities Director, or the Activities staff would check them periodically. She said when residents were outside that she expected staff would monitor them and she was unaware that no staff were monitoring R72 on 10/18/24. She also stated that since R72's BIMS prior to 10/18/24 was only a 10 and it was under 13 than R72 should not have been allowed to go outside. She said at that time there was not really a process in place to monitor residents at that time. But that after R72's first noncompliance with smoking in August 2024 and her low BIMS score, she should not have been allowed outside on 10/18/24.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, document review and staff interview, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNOC) notification was provided timely for one of three residents (Residents (R) 303) reviewed for beneficiary notification. This had the potential to affect all residents being discharged from services. Findings include: 1. Review of R303's admission Record located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy. Review of R303's SNF Beneficiary Notification Review form revealed Medicare Part A skilled services start date was 10/09/24 and the last day covered was 11/04/24. Further review revealed no ABN notification was provided prior to the last date of services. During an interview on 02/19/25 at 2:14 PM the Social Service Worker (SSW) stated that she was under the impression that R303 would discharge home on [DATE] since that was the resident's initial projected discharge date . She stated due to some back and forth with the daughter the facility became aware on 11/01/24 that the resident would not be discharged from the facility. At that time, an ABN notice should have been provided to the resident and RP, but it was not. During an interview on 02/19/25 at 7:37 PM the Director of Nursing (DON) stated she expected staff to provide the required documentation to residents and their representatives timely.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure an incident of resident-to-resident abuse was thoroughly investigated for two of five residents (Resident (R)7 and R12) reviewed for abuse out of 23 sample residents. This had the potential to affect residents in the facility who were at risk for abuse. Findings include: 1. Review of R7's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia, major depressive disorder, anxiety disorder and bipolar disorder. Review of R7's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/24 and located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was severely cognitively impaired. 2. Review of R12's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, dementia, major depressive disorder, and cognitive communication deficit. Review of R12's quarterly MDS with an ARD of 01/11/25 and located in the EMR under the MDS tab revealed a BIMS score of 11 out of 15, which indicated the resident was moderately cognitively impaired. Review of R12's Nurse's Note, dated 05/06/24 and located in the EMR under the ''Notes'' tab, written by Licensed Practical Nurse (LPN) 4 revealed, R12 was in her doorway and staff heard her yell out for R7 to get out of her room, when staff walked to doorway to redirect R7 and R12 said she kicked me Review of the facility's Incident Report/5-day follow-up dated 05/10/24 revealed on 05/06/24 Nurse heard yelling coming from down the hallway, she observed resident [R7]sitting in her wheelchair in the doorway of resident [R12] nurse approached the room to separate the residents .Resident [R12]reported that resident [R7] came into her room and accused her of stealing her sweater and when resident [R12] said she did not have her sweater, resident [R7] kicked resident [R12] in the leg Further review of the investigation revealed no evidence of an investigation. The investigation did not contain staff or resident statements. During an interview on 02/19/25 at 3:43 PM the Assistant Director of Nursing (ADON) she was the one responsible for completing the resident-to-resident investigation in to the incident that occurred on 05/06/24. As part of the investigation, she would make sure to talk to anyone involved and have them write a statement. The supervisor at the time of the incident would also complete a progress note/risk management. She said whatever documentation was in the file was all that was part of the investigation, and she was unsure why there were no statements by staff or residents and there should have been. She did not know why there was no other documentation in the investigation other than a summary. During an interview on 02/19/25 at 7:37 PM the Director of Nursing (DON) stated that the investigation would include staff and witness statements. The DON stated that she expected that all facility investigations to have been completed thoroughly. Review of the facility's policy titled Freedom from Abuse, Neglect, and Exploitation dated 05/01/24 revealed, the facility will investigate different types of incidents and have evidence that all alleged violations are thoroughly investigated.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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Based on record review, interview, and review of facility policy, the facility failed to ensure that staff appropriately assessed residents with a change in condition for one Resident (R )153 from a sampled 28 residents. Additionaly staff failed to hold laxatives when the resident was having loose stools. Findings include: Review of facility's policy titled, Medication Administration dated 05/01/24 documents Medications are administered under written orders of the attending physician. lf a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse call the provider pharmacy for clarification before the administration of the medication. lf necessary, the provider pharmacy contacts the physician for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate . Review of R153's admission Record located in the resident's electronic medical records (EMR) section titled Profile revealed the resident was admitted to the facility 1/22/24 with diagnoses that included gas gangrene, cerebral infarct, rupture abdominal aortic aneurysm, cognition impairment and unspecified constipation. Review of R153's Medication Administration Record (MAR) for December 2024 located in the resident's EMR revealed the resident was started on Senna tablets (laxative) eight point six milligrams daily for constipation on 05/06/24 Review of R153's Bladder and Bowels Sheets for December 2024 and January 2025 provided by the facility revealed the resident had loose/watery stools on the following days: 12/2/24 12/3/24 (twice) 12/4/24 (twice) 12/5/24 12/6/24 12/7/24 12/8/24 (twice) 12/9/24 12/11/24 12/15/24 12/17/24 12/18/24 (twice) 12/19/24 12/21/24 (twice) 12/23/24 (twice) 12/24/24 12/25/24 (twice) 12/26/24 12/27/24 12/28/24 (twice) 12/30/24 (twice) 12/31/24 01/02/15 (twice) 01/03/25(twice) 01/04/25 (three times 01/05/25 (twice) 01/06/25 01/07/25 01/08/25 01/09/25 Review of R153's MAR for December 2024 and January 2025 located in the EMR revealed the resident received the Senna laxative on the following dates from the assigned nurses: Licensed Practical Nurse (LPN)4 administered the laxative on 12/06/24, 12/14/24 12/15/24, 12/20/24, 12/24/24, 12/28/24, and 12/29/24. In January, LPN4 administered the laxative on 01/02/25 and 1/03/25. LPN5 administered the laxative on 12/01/24 LPN6 administered the laxative on 12/10/24 Registered Nurse (RN)2 administered the laxative on 12/02/24, 12/03/24, 12/04/24, 12/05/24, 12/07/24, 12/08/24, 12/09/24, 12/11/24, 12/12/24, 12/13/24, 12/16/24, 12/17/24, 12/18/24, 12/19/24, 12/21/24, 12/22/24, 12/25/24, 12/26/24, 12/27/24, 12/30/24 and 12/31/24. January revealed 01/01/25, 01/04/25, 01/05/25, 01/06/25, 01/08/25, and 01/09/25. RN4 administered the laxative on 12/23/24. Review of R153's Nurses Notes dated 12/01/24 through 01/09/15 located in the resident's EMR section titled Progress Notes revealed no documentation of the resident having loose water/diarrhea stools or notification to the resident's physician or Nurse Practitioner (NP). Review of R153's Nurses Notes located in the resident's EMR section titled Progress Notes dated 01/09/25 at 5:11PM revealed a note written by the NP that indicated the resident had experienced a change in condition, the resident noted with lethargy, slightly increased respirations, and low blood pressure (BP). Upon assessment, resident is grimacing as if in pain but unable to quantify or describe. Lungs were clear with no abdominal distention. Ordered intravenous fluids (IVF), immediate chest x-ray, Complete Blood Count (CBC), basic metabolic panel (BMP), and urinalysis (UA) C&S (culture and sensitivity). Resident was straight catheterized, and urine noted to be milky, thick, and malodorous. The resident was later transferred to the emergency room for treatment on 01/09/25 and was hospitalized until 02/15/25. No further information was available as to what caused the residents change of condition. Interview on 2/18/25 at 1:24PM, LPN2 revealed that on 01/09/25, the assigned certified nursing assistant (CNA)2, notified RN2 that R153 was experiencing diarrhea and a change in mental status. LPN2 stated the RN continued to pass medications and did not assess the resident. LPN2 added that RN2 continued to pass medications. LPN2 further stated CNA2 approached RN2 and expressed concern that R153 had a change in condition. LPN2 stated that she went to assess the resident and determined that he had a change in condition. LPN2 instructed RN2 that she needed to assess R153 immediately and notify the NP. LPN2 stated that she had received calls from the NP asking her to reassess residents that RN2 had called her about. LPN2 stated if the resident was having diarrhea for several days, the nurses should not have administered the Senna medication. Interview on 2/18/25 at 2:15PM, CNA2 revealed that on 01/09/25 she informed RN2 that R153 was having loose stools for the past few days and appeared to have a change in mental status. CNA 2 stated RN2 continued to pass medications and did not come to assess the resident. CNA2 stated that she returned to the resident's room to continue monitoring him. CNA2 stated the resident's condition continued to decline and she again approached RN2 voicing her concerns that the resident's mental status had changed. CNA2 stated RN2 came to the resident's room and looked at him and stated the resident was dehydrated. CNA2 stated RN2 did not perform a physical examination of the resident. CNA2 stated RN2 returned to passing medications. CNA2 stated that she felt the resident needed to be assessed immediately so she notified LPN2 (Charge Nurse) of R153's change in condition. CNA2 stated LPN2 immediately went to assess R153. During an interview with the RN1 on 02/19/25 at 2:20PM, RN1 stated that if the resident had been experiencing loose stools for several days, the Senna medication should not have been given. It was an expectation that RN2 should have immediately assessed R153's condition when the CNA made her aware of the resident's change in condition. Interview on 02/19/25 at 4:20PM, RN2 revealed she remembered the 01/09/25 incident with R153. RN2 stated that CNA2 approached her while she was passing medications about R153 having a change in mental status. RN2 stated CNA2 never informed her the resident had loose stools for several days. RN2 stated she finished passing medications to a resident, then went to assess R153. RN2 stated that she assessed the resident's lung, and bowel sounds, and noticed the resident had low blood pressure. However, RN was unable to explain if she assessed the resident's abdomen for distension or signs of a possible ileus. Interview on 02/19/25 at 4:40PM with the NP revealed that when she arrived on the unit on 01/09/25 to assess R153 she asked that the resident be straight catheterized. However, the NP stated she did not feel comfortable with RN2 performing the catheterization, so she did the procedure herself. NP stated that she has voiced her concerns about RN2's assessment skills to RN1, and the Director of Nursing (DON). The NP also stated that if the resident was having loose stools/diarrhea and continued to receive the laxative, this could have contributed to his dehydration. Interview on 2/19/25 at 06:00PM, the DON and Administrator revealed they were unaware of any problems with RN2's performance. The DON stated that RN2 had employed less than a year for the evening shift. DON stated RN2 was transferred to the LTC unit 2 months and received additional training for that unit. Both DON and the Administrator stated that they had never been approached by the NP regarding RN2's performance.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policy, the facility failed to ensure that expired medications and syringes were removed from one of one medication storage room. The failure has the potential for staff to inadvertently use the expired items. Findings include: Review of the facility's policy titled Storage of Medications dated 05/01/24 indicated, .Drug containers that have missing, incomplete, improper, or incorrect, labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biological are returned to the dispensing pharmacy or destroyed . Observation of the facility's main medication storage room next to the nurses' station on 02/17/25 at 1:17 PM revealed the following concerns: Six of six Magellan three-centimeter (cc) syringes with hypodermic need safety needle 23 gauge one inch with an expiration date of 07/31/21 The facility's Intravenous (IV) tray contained the following expired items: one bottle of Imipenem Hydrochloride (synthetic antibiotic) 500 milligrams (undiluted) with an expiration date of 10/24 Six female luer lock caps (used to prevent leakage) with the following expiration dates 03/26/24 (two syringes); 03/27/24 (one syringe); 05/07/24 (two syringes; and 05/08/24 (one syringe) One [NAME] Fluid Dispenser for filling dose syringe from large size syringe with expiration date 12/31/23 Interview on 02/17/25 at 02:10 PM, the Floor Supervisor Licensed Practical Nurse (LPN)2 confirmed the observations and stated that Central Supply was responsible for checking the medication storage for expired items.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected multiple residents

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Based on interview, document review and policy review, the facility failed to act promptly to the concerns and /grievance of the resident council to noise level at shift changes, staff use of phones, earbuds when providing care, and choices offered for breakfast meals for nine of nine (R)60, R4, R21, R37, R14, R39, R5, R73, and R76 sampled residents. This failure could place the residents at risk for decreased quality of life and feelings of hopelessness. Findings include: Review of the facility policy titled Grievance Program dated 05/01/2024, documented grievances could be reported verbally or in writing, and the right to receive prompt efforts by the facility to resolve resident grievances. The actions that should be taken in response to grievances or concerns included, but not limited to, investigation and most practicable resolution, routing the grievance to the appropriate departments for ongoing improvement, identifying trends in care, service delivery, and system organization, and developing long term solutions, implementing changes to improve care/service systems. The policy also stated that a written decision was issued to the person(s) filing the grievance, and to include the collected documentation of grievances in the facility quality improvement program. The policy designated the Social Services Director and/or the Administrator as the key contact responsible to implement the Grievance Procedure, and that the grievances will be logged on the facility grievance log. During an interview on 02/16/25 at 3:15 PM, R76 stated she has had ongoing complaints about the kitchen and had notified staff. The complaints included receiving dirty silverware, cold food, burned food, no yogurt available, burned toast and requesting not to be served cranberry juice but continues to receive it on her tray. During a group meeting on 02/18/25 at 3:30 PM, with nine residents (R)60, R4, R21, R37, R14, R39, R5, R73, and R76, in attendance, they said they had reported excessive noise levels during all shift changes that disrupt their sleep at night and that it is very distracting and intrusive to conversations with family members and other residents. R73 stated, would give anything for a choice at breakfast and also stated that she would like to eat in the dining room for breakfast because it gave her the opportunity to get out of her room and socialize. R76 stated she was not sure why there were no choices for breakfast but quite often does not like what she was given and asks for another option. She said she continues to get cranberry juice even though she has requested not to get it. Review of the electronic medical record (EMR) revealed the following: R60 with a quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/20/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicated R60 was cognitively intact. R4 with a quarterly MDS with an ARD of 11/01/24 revealed a BIMS score of 15 of 15, which indicated R4 was cognitively intact. R21 with a quarterly MDS with an ARD of 11/04/24 revealed a BIMS score of 12 of 15, which indicated R21 had moderately impaired cognition. R37 with a quarterly MDS with an ARD of 01/10/25 revealed a BIMS score of 15 of 15, which indicated R37 was cognitively intact. R14 with an annual MDS with an ARD of 01/02/25 revealed a BIMS score of 15 of 15, which indicated R14 was cognitively intact. R39 with a quarterly MDS with an ARD of 12/13/24 revealed a BIMS score of 15 of 15, which indicated R39 was cognitively intact. R5 with a quarterly MDS with an ARD of 10/05/24 revealed a BIMS score of 12 of 15, which indicated R5 had moderately impaired cognition. R73 with a quarterly MDS with an ARD of 11/19/24 revealed a BIMS score of 15 of 15, which indicated R73 was cognitively intact. R76 with a quarterly MDS with an ARD of 10/10/24 revealed a BIMS score of 15 of 15, which indicated R76 was cognitively intact. Review of Resident Council Meeting Notes for 02/2024 through 01/2025 indicated grievances regarding noise level at shift change were reported March 2024, April 2024, May 2024, August 2024, September 2024, October 2024, and November 2024. The grievance regarding no choices offered for breakfast was reported in September 2024 and the grievance regarding cell phone use was reported in September 2024 and November 2024. During an interview on 02/18/25 at 5:42 PM, the Activities Director (AD) stated the dining room was closed because the facility had an outbreak of COVID last year. She stated the dining room was open 10/2024, 11/2024 and 12/2024 but has been shut down except for lunch since the first of the year. The AD stated the reason it continued to be closed is because the facility does not have enough staff. The AD stated that during resident council meetings they have discussed when it would be open, and residents have stated they would like it open. During an interview with the Administrator, Social Service Worker (SSW), and the Staff Development Coordinator, and the Activity Director (AD) on 02/19/25 at 10:36 AM, the Administrator stated that she has not actually tracked patterns and trends of resident grievances. The AD stated that she tracks the concerns/grievances quarterly, then reports the data to the Quality Improvement committee. The Staff Development Coordinator stated sound levels at shift change had not been audited. The AD stated that she has been communicating with a concern form to the Dietary Manager regarding the grievance requesting a breakfast menu that offered choices. She said she does not follow up with the concern forms and she thought the department managers were supposed to conduct the follow up to the resident council meeting grievances. The AD said she does not follow-up with the grievance or the response to the residents for resolution. The Administrator said she had addressed the grievance voiced by the resident council in June 2024 regarding loud sound levels at shift change. She said she thought the concern had improved and was not aware that the concern was ongoing. She said the resident council grievances had not been addressed since June 2024. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review Resident Assessment Instrument (RAI) Manual, the facility failed to ensure that three residents (Resident (R) 23, R71, and R153) in the sample of 28 were accurately assessed for falls and one resident (R54) was accurately assessed for insulin. Findings include: Review of the RAI Manual dated 10/01/19 indicated, . It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set [MDS] items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. 1. Review of R23's admission Record located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included history of falls, dementia, and chronic obstructive pulmonary disease. Review of the facility's accident and incident log dated 2024 revealed that R23 sustained falls on the following dates: 04/14/24 witnessed a fall with injury 04/21/24 unwitnessed fall without injury 05/14/24 unwitnessed fall without injury Review of R23's quarterly MDS with an Assessment Reference Date (ARD) 05/15/24 revealed the MDS section N did not capture the falls that occurred on 04/14/24, 04/21/24 and 05/14/24. 2. Review of R71's admission Record located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that include dementia, unsteady gait, and major depressive disorder. Review of the facility's accident and incident log dated 2024 revealed R71 sustained falls on the following dates: 04/09/24 unwitnessed fall 05/25/24 witnessed fall Review of R71's annual MDS with an ARD of 06/12/24 located in the EMR under the MDS tab revealed Section N failed to capture the falls the resident sustained during the assessment period. Review of R71's quarterly MDS with an ARD of 09/12/24 located in the resident's EMR section titled MDS revealed section N failed to capture the falls the resident sustained during this assessment period. 3. Review of R153's admission Record located in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnosis that include cerebral infarction. Review of the facility's accident and incident log dated 2024 revealed the resident sustained falls on the following dates: 08/06/24 witnessed fall 09/16/24 unwitnessed fall Review of R153's quarterly MDS with an ARD of 11/18/24 located in the EMR under the MDS tab revealed section N of the MDS failed to capture the falls that the resident sustained during the assessment period. 4. Review of R54 admission Record located in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnosis that included diabetes mellitus type II. Review of R54's Physicians' Orders dated 05/29/24 located in the EMR under the Orders tab revealed the resident was to receive Semglee Subcutaneous Solution 100 units (Insulin Glargine) 17 units at bedtime. Review of R54's annual MDS with an ARD of 06/27/24 located in the EMR under the MDS tab revealed section N (Medications) of the MDS did not reflect the resident received insulin daily at bedtime. Review of R54's quarterly MDS with an ARD of 12/28/24 located in the EMR under the MDS tab revealed section N (Medications) of the MDS did not reflect the resident received insulin at bedtime. Interview on 02/19/25 at 10:44 AM, the Corporate MDS Coordinator (CMDSC) acknowledged that the MDS assessments for R23, R54, R71, and R153 were inaccurate.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, interviews, and facility policy review, the facility failed to ensure containers with rice and pasta were labeled, dated and cleaned; the inside and outside of the oven and microwave were not clean and grease/debris on the handles; the floor under the three-tiered rack had grease and debris; and during meal service the chicken and mixed vegetables were not served at the appropriate temperature on the steam table. This deficient practice had the potential to affect 95 of 95 residents who received meals prepared in the facility. This failure had the potential to affect the spread of food borne illness. Findings include: Review of the undated facility policy titled, Equipment Cleaning Policy provided by the facility indicated, The director of Dining Services or designee will ensure that all equipment is maintained, kept clean and in a sanitary condition before and after each use .Conventional/Convection Ovens: Clean after each use, inside and out, using soap and water .Microwave: Clean after each use, inside and out, using soap and water. Review of the undated facility policy titled, Hot Food Policy provided by the facility indicated, Hot food should be at 135 degrees or above at the time food is served to the residents. During the initial kitchen tour on 02/16/25 at 9:20 AM with the [NAME] (CK1), the following observations were made: 1. In the dry goods pantry there were three large plastic containers that had a visible powder substance on the inside and crumbs on the top. The lids were visibly dirty and had a gritty feel to them. One container contained approximately 2 of loose rice and did not have a date. One container has approximately ½ loose elbow macaroni and a bag sitting on top of the macaroni dated 2/11. CK1 was uncertain if the date on the bag was the date the bag was opened. The third container had loose spaghetti with a sticker that read 11/02/24. CK1 said they usually keep pasta for thirty days. 2. In the prep area in the kitchen there was a three-tiered rack that held pots and pans. On the floor was a black mat. There was grease on the floor, crumbs, and scraps of paper. 3. The door handles of each side of the oven and the door handle of the microwave was covered in a thick greasy substance and food particles. During the second kitchen tour on 02/17/25 at 4:00 PM with the Dietary Manager (DM), the following observations were made: 1. In the dry goods pantry, there were three large plastic containers that continued to have visible powder substance on the inside and crumbs and the lids were visibly dirty and had a gritty feel to them. The containers held rice, elbow macaroni, and spaghetti. 2. The door handles of each side of the oven and the door handle of the microwave continued to have a thick greasy substance and food particles. On 02/17/25 at 4:15 PM, the dinner meal was observed and CK2 confirmed the food was ready to be served to the residents. CK2 stated the dinner meal was pizza and Dijon chicken as the alternate with peas and carrots. The DM inserted the digital thermometer into a piece of Chicken, the temperature was 112 degrees Fahrenheit (F), while leaving the thermometer in the chicken, the temperature dropped to 110 degrees F then to 108 degrees F. The chicken was placed back into the oven. The chicken was removed at 4:21 PM and the temperature was 128 degrees F. The chicken was placed back into the oven until 4:45 PM when it was removed it was 203 degrees F. During this same time a thermometer was inserted into the mixed vegetables, the temperature was 124 degrees F. The mixed vegetables were placed in the oven and removed at 4:21 PM. The vegetables were 181 degrees F. The DM and CK2 agreed both the chicken and the vegetables were not at the correct temperature when they started the dinner service. On 02/19/25 at 9:45 AM, the Administrator said the temperature for the chicken should have been higher to be served. On 02/19/25 at 3:54 PM, the Registered Dietician (RD) stated she would do a monthly kitchen audit and would look at general labeling and dating. The RD stated she never really looked at the cleanliness of the kitchen. She stated the temperature for the chicken should be 165 degrees F on the steam table.

Mar 2024 21 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

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Based on observation, interview and record review, it was determined that for two (R248 and R6) out of six residents reviewed for accidents, the facility failed to ensure residents were free from accident hazards and/or were provided adequate supervision to prevent accidents. R248 sustained harm when the facility failed to ensure staff provided supervision and assistance with care resulting in a fall with facial bone fractures. For R6 the facility failed to ensure the resident environment was free of an accident hazard. Findings include: 1. Review of R248's clinical record revealed the following: 5/15/23 - R248 was admitted to the facility with diagnoses including but not limited to history of fall(s) and a broken pelvis (the lower part of the trunk between the abdomen and thighs). 5/15/23 - R248 was care planned for self care deficit related to decrease in functional mobility, strength, balance and endurance and interventions included: - one person assist with bed mobility, one person assist with transfers, toileting, bathing and dressing, Set up assist with eating; - Encourage independence in ADL care, but offer assistance as needed. 5/16/23 - A PT (Physical Therapy) Evaluation documented that R248's functional assessment for bed mobility was SBA (Stand - by Assist). In addition, the PT assessment summary noted, .pt (patient) presents with reduced activity tolerance and strength needed to return to PLOF (previous level of function), Pt c/o (complained of) 7/10 pain (pain scale for severe pain in a scale of 0-10) in B (bilateral) hips and low back which limits ability to return to PLOF Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for falls and further decline in function. 5/20/23 10:43 AM - A nurse progress note documented, .resident lying on her left side on the floor . c/o (complained of) 'pain all over body' & yelled when left shoulder and left hip palpated .unable to indicate how she got to floor . send to (hospital) as per order via . NP (Nurse Practitioner). 911 notified .Resident left the facility at 10:30 . 5/20/23 12:20 PM - Review of the [hospital ER] physician record documented, .Patient states that she was in her usual state of health .in her bed when she rolled out into the floor while sleeping .She struck her head on the floor sustaining bruising of her face .states that she is having pain over her face .left shoulder right hip pain . 5/20/23 9:55 AM - Facility incident report revealed that, Resident was observed lying on the floor in her room. When asked what happened, she did not respond to the question during assessment, she complained of pain to her L (left) shoulder and L hip. Order was received to send her out to the ER for further evaluation .Resident was transferred to the ER at 10:30 AM . The Facility's 5 day follow up summary documented, .resident complained of generalized body pain including left shoulder and left hip pain which was exacerbated by movement .resident was sent to ER (Emergency Room) and returned 5/20/23 2300 (11:00 PM) .CT (computerize tomography scan, an imaging test that takes detailed pictures of the inside of the body) of the facial bone was positive for an acute left tripod fracture (facial bone fracture) .Interview with staff showed that the fall was witnessed. The fall occurred when the assigned aid (CNA)was providing care to the resident who is a 1 person assist with bed mobility. The aid turned the resident to her side, at which time the resident suddenly rolled off the bed before the CNA could break the fall . 5/22/23 - R248's admission MDS (Minimum Data Set) assessment revealed that R248 had a moderately impaired cognition, required extensive assist of one person for bed mobility and toileting during the review period. An extensive assist of one person staff means that a resident is involved in an activity but the one person staff provides the weight bearing support. Review of R248's May 15, 2023 through May 20, 2023 CNA flowsheet revealed that R248 was an extensive assist of one person staff in 6 out of 14 opportunities, two times on the 3-11 shift and four times during the 11-7 shift. 3/12/24 11:00 AM - Review of the facility's incident report and investigation revealed an undated written statement by E36 (CNA) and documented, I was changing [R248] (sic) I raised the bed to my waist. She crossed her leg over but put her leg over to (sic) far and fell onto the floor. She fell onto the floor and began to complain of her face and left knee hurting. I notified the nurse immediately, her vitals were checked and I waited for the EMT (Emergency Medical Technicians) to come and take her to the hospital. 3/12/24 11: 42 AM - A telephone interview with E36 revealed that she was not familiar with the resident [R248] and it was her first time taking care of her. E36 also stated that she was at the resident's bedside to change her . CNA further stated that she raised the bed with R248 on the bed, turning to be changed. R248 crossed her leg to turn to her side but she crossed her leg way too far that she rolled on to the floor and fell. I did not touch and I did not hold to support her as she was moving on her own. She moved and crossed her legs on her own. Despite the history of a fall at home resulting in an injury and a subsequent hospitalization with a fall risk and high risk of injury designation, the facility failed to ensure R248's safety when E36 turned R248 to her side while providing personal care without touching or holding to support R248, at which time R248 rolled off the bed and had a fall which resulted in facial bone fractures. 2. Review of R6's clinical record revealed: Review of the facility's policy and procedure titled Fall Prevention last updated 4/1/20, documented . 1. Fall prevention is achieved through an interdisciplinary approach of managing risk factors and implementing appropriate interventions to reduce the risk of falls . 2. Potential interventions may include exercise, environmental modification, medication, assistive devices, footwear etc . 3. Develop a plan of care which can include general and specific interventions to reduce fall risks. 4/6/23 - Review of R6's care plan for falls revised 1/30/24 documented .1. At risk for falls related to cognitive deficits, impaired mobility, gait/balance problems, impulsiveness, and poor safety awareness . 2. Fall mats at both sides while in bed . 3. Resident needs a safe environment with even floors free from spills and or clutter . 4. Every one hour checks. 9/17/23 - R6 was readmitted to the facility with diagnoses include dementia, schizoaffective disorder bipolar type, Parkinson disease, osteoarthritis, abnormality of gait and balance and muscle weakness. 12/19/23 - Review of R6's quarterly MDS Assessment documented R6 was severly impaired for daily decision making with a BIMS of 5 and that R6 required partial moderate assist to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. Additionally, R6 required partial moderate assist to transfer to and from a bed to chair or wheelchair. 2/11/24 12:12 AM - Review of R6's fall evaluation form documented .1.Balance problem while standing. 2/29/24 11:30 AM - R6 was observed in her room sitting in the wheelchair. R6 had fall mats down on the floor at both sides of the bed, while R6 was not in bed. In addition, R6 was observed self-propelling her wheelchair towards the bed, stopped the wheelchair at the edge of the fall mat on the floor, stood up and walked on the fall mat and leaned over onto the bed to pick up R6's stuffed animal from the center of the bed. 3/1/24 11:02 AM - R6 was observed being assisted back to her room by E40 (CNA). E40 left the room and R6 remained sitting up in her wheelchair with fall mats on the floor at both sides of the bed. 3/1/24 2:26 PM - The third observation in R6's room revealed fall mats at both sides of the bed on the floor while R6 was sitting up in the wheelchair in her room. 3/5/24 10:09 AM - R6 was up and out of bed sitting in the wheelchair in her room. Fall mats at both sides of the bed on the floor. 3/5/24 11:02 AM - During an interview E40 revealed R6 had falls that's why the fall mats are down. 3/5/24 12:43 PM - During an interview E41 (LPN) revealed, [R6] is at risk for falls, and that the fall mats on the floor are a precautionary measure if R6 happens to fall at the bedside. 3/5/24 1:03 PM - During an interview E37 (RN) stated, the fall mats on the floor in [R6's] room provided a cushioned area for [R6] to fall on to if [R6] had a fall. After E37 reviewed R6's care plan for falls E37 confirmed, the fall mats should be on the floor when [R6] is in the bed. The fall mats in R6's room were picked up from the floor as R6 was observed to be sitting in the wheelchair in her room. The facility did not provide R6 a safe environment in her room. R6's care plan was not followed as fall mats were only to be placed on the floor at both sides of the bed when R6 was in bed. 3/13/24 3:45 PM -Findings were reviewed with E1 (NHA), E2 (DON), E3 (Corporate Clinical Operations) and E4 (Regional Clinical Specialist) and representatives from the Ombudsman Office.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R446's clinical record revealed: 2/21/24 - R446 was admitted to the facility with diagnoses, including but not limited to, end-stage renal disease on hemodialysis. 2/21/24 - E52's (MD) order in R446's EMR stated, Dialysis (Mom/Wed/Fri) at [hemodialysis center] Chair time 7:20 AM. Pick up time 6:00 - 6:30 AM. E52 also ordered, Shower .every evening shift every Saturday and every day shift every Wednesday. R446's care plan documented, The resident needs dialysis: hemo r/t (related to) renal failure with Interventions stating Dialysis (Mon/Wed/Fri) at [hemodialysis facility]. Chair time 7:20 AM. Pick up 6:00 - 6:30 AM. 2/29/24 11:35 AM - During an interview, R446 stated that she has only been bathed one time since her admission on [DATE]. 3/6/24 9:53 AM - During an interview, E30 (ADON) confirmed that R446 has hemodialysis scheduled on Monday, Wednesday and Friday day shift and that she typically returns after 4 PM. Surveyor reviewed nursing notes that documented R446's return time from her dialysis treatments Friday 2/23/24 at 4:32 PM, Monday 2/26/24 at 1:54 PM, Wednesday 2/28/24 at 5:17 PM and Friday 3/8/24 at 3 PM. 3/7/24 1:11 PM - During an interview, E30 (ADON) stated, Showers are assigned by the room number that the resident is in. Of course, we can personalize it if the resident requests it. Surveyor reviewed the CNA Tasks tab in PCC and in the Bathing section, it was documented that R446 had physical help in part of bathing activity on Saturday, 2/24/24 at 9:59 PM and Saturday, 3/2/24 at 10:52 PM. The CNAs documented on Wednesday, 2/28/24 and Wednesday, 3/6/24 that resident not available. Based on interview, record review and review of facility documentation it was been determined that for three (R102, R346, R446) out of twently-three residents reviewed for choices, the facility failed to ensure care preferences were being honored. Findings include: 1. Review of R346's clinical record revealed: 12/5/22 - R346 was admitted to the facility with diagnoses including stroke and aphasia (affects ability to communicate). 12/6/22 - Review of R346's care plan for communication problem related to aphasia revised 1/19/24 included interventions to allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, use simple brief words and cues. Other interventions included: resident is able to answer yes/no by nodding, points to things and is able to make needs know to staff at all times. 2/25/23 - Review of the facility's form for verification of investigation documented . 1. Following investigation and interview of witness the assigned CNA (Certified Nursing Assistant) refused to honor the residents' rights to refuse and make choices . 2. Instead, the CNA proceeded to force the resident to get changed. 2/27/23 Review of facility provided documentaton revealed: 2/27/23 - E2 (DON) interviewed E18 (CNA) and confirmed R346 was agitated (upset) when E18 was attempting to perform ADL care and personal hygiene. 2/27/23 - E2 interviewed E59 (CNA). During the interview E59 confirmed R346 was nodding no and pointing that the resident did not want care to be given by E18. 2/27/23 - E2 interviewed E60 (LPN). E60 heard screaming and yelling and walked into [R346's] room and asked what was wrong and said [R346] was gesturing to get E18 out of the room. E60 said E18 stated [R346] ripped the first diaper and now I am trying to put on a second one. E60 told E18 you need to go. 3/12/24 10:38 AM - During a telephone interview E18 revealed [R356] was frustrated about being cleaned up after the resident had a bowel movement. E18 said, I told [R346] I could not leave her like that, she always refused care, she needed to be cleaned up. E18 said, E59 told the nurse because she felt like I was being rough with [R346], and that I was making the resident do something that the resident did not want to be done. E18 stated, the other girl said that the way I turned [R346] it was a push instead of a turn and hold the resident. 3/12/24 10:50 AM - During a telephone interview E59 said, that happened almost a year ago. E18 asked me to help with changing the resident, when I went into the room [R346] pointed at me and I thought [R346] did not want me to help, but then [R346] pointed at E18, it's been a while, but I felt like E18 was pretty aggressive with changing [R346] and it upset me, and I reported it to E60. 3/12/24 12:27 PM - An interview with E2 revealed [R346] did not want E18 to provide care and that E18 was insistent on getting [R346] changed and that E59 felt like it was [R346']s right to refuse care. The facility failed to ensure that R346 was given the opportunity to exercise his/her rights of self-determination and choice of care giver and care and services provided. 3. Review of R102's clinical record revealed: 12/31/22 - R102 was admitted to the facility with diagnoses including a left kneecap fracture. R102's showers were scheduled for Tuesdays 7-3, and Fridays 3-11 shift. 1/6/23 10:18 PM - R102's medical records documented, RR, RR, RR - resident refused. R102's nursing progress notes lacked evidence that the nurse was informed of R102's refusal of the shower. 1/13/23 10:11 PM - R102's medical records documented, NA, NA, NA - not applicable. R102's nursing progress notes lacked evidence that the nurse was informed that R102 did not receive a shower. 3/7/24 10:35 AM - During an interview R30 (ADON) confirmed that R102's medical records lacked evidence that the nurse was informed that R102 was given a shower. E30 stated, The resident is supposed to be offered a shower three times, and the nurse should write a progress if she refused. The facility failed to provide R102 a shower on 1/13/23, and lacked evidence that the nurse was notified that showers were not given on 1/6/23 and 1/13/23. 3/19/24 3:45 PM -Findings were reviewed with E1 (NHA), E2 (DON), E3 (Corporate Clinical Operations), E4 (Regional Clinical Specialist) and representatives from the Ombudsman Office.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that for one (R96) of three residents reviewed for beneficiary notification, the facility failed to provide evidence that R96 or her responsible party was notified of Medicare non-coverage prior to her discharge on [DATE]. Findings Include: Review of R96's clinical record revealed: 11/18/23 - R96 was admitted to the facility with diagnoses, including but not limited to, ataxia (poor muscle control that causes clumsy movements) and weakness. 11/25/23 - R96's admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 11, which is reflective of moderate cognitive impairment. 12/20/23 - R96 was discharged from the facility. 3/11/24 2:19 PM -During an interview, E1 (NHA) confirmed that the facility did not have a Notice of Medicare Non-Coverage (NOMNC) form for R96. 3/13/24 3:45 PM - Findings were reviewed with E1, E2 (DON), E3 (Corporate Clinical Operations), E4 (Regional Clinical Specialist) and representatives from the Ombudsman office.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on record review and interview, it was determined that for one (R100) out of four residents reviewed for abuse, the facility failed to have evidence that R100's allegation of abuse was thoroughly investigated. Findings include: R100's clinical record revealed: 7/12/24 - R100's admission MDS assessment documented her BIMS as 13 (cognitively intact). 7/20/23 at 12:14 PM - R100 was sent to the hospital for an unrelated medical reason. 7/21/23 at 11:17 AM - The facility's incident report documented by E2 (DON) revealed the following: - . an allegation of abuse; - Resident is in the hospital where incident of abuse was first reported. - Resident is oriented to self . time . place; - Resident was sent to the hospital . During conversation with the case worker, she reported an allegation of physical abuse by someone posing as an aide. She refused to reveal the name of the aide for fear of being killed. - Yes, police were notified. The facility provided the following additional investigative documents in response to R100's allegation of abuse: - 7/21/23 typed statement of the conversation between R100's family member and E2 (DON). - Transcribed and typed individual statements signed by 14 nursing staff who worked on R100's assignment from 7/16/23 through 7/20/23. - R100's progress notes from 7/15/23 through 7/24/23. - Abuse in-service sign-in sheets of nursing staff completed by E2 (DON) on 7/21/23. 7/28/23 at 5:04 PM (late entry as it was created 8/17/23 at 5:09 PM) - A nursing note, by E2 (DON), documented, On 7/20/23, 2 Delaware State officers showed up in the facility and began to question staff about the resident who was currently admitted in the hospital. The officers did not divulge why the staff was being questioned. DON on 7/21/23 reviewed the DHIN (Delaware Health Information Network) information and found in the medical record that the resident had made an allegation of physical abuse against staff at the facility. The hospital did not inform the facility of the allegation of physical abuse made by the resident while at the ER (emergency room). Initial report was sent to DHCQ (State Survey Agency) based on note found in the medical record at the hospital through DHIN . Interview of all other residents in the team assignment where resident (R100's initials) is included was completed. There was no verbalized concern of someone who has been physically aggressive with them when care was provided. Residents interviewed reported feeling safe in the facility. An interview of staff ( nurses and nursing assistants ) from 7/16/23 to 7/20/23 who took care of resident (R100's initials) was completed. There was not a verbalization of concern or complaint by the resident to any staff member of abuse. The resident did not complain to any staff member of being hurt at any time during care. An interview via phone with the resident's (family member) by DON of the allegation of abuse was completed . Resident's medical record in DHIN showed that resident refused examination by the Forensic nurse for a head-to-toe assessment and photographic documentation. Resident did not verbalize any concerns of abuse while in the facility to staff . Resident's allegation of abuse is unsubstantiated. Despite learning about the allegation of abuse after the State Police visit and reviewing R100's hospital documentation through DHIN, the facility's investigation lacked documented evidence of: - attempts to interview R100 in the hospital and the hospital nursing staff person to whom R100 made the allegation to obtain more specific information; - the specific residents interviewed per E2's nursing note of 7/28/24 at 5:04 PM; and - the facility's Verfication of Investigation form that documented the following: 1. Resident observation summary of what happened; 2. Contributing factors and interventions; 3. Modified interventions to the plan of care to prevent re-occurrence (Derived from Root Cause Analysis); 4. Summary of factual investigative findings; 5. Signature and date of the Director of Nursing completing the Verfication of Investigation; and 5. Signature and date of the Executive Director. This form was not completed. 3/13/24 at 11:36 AM - During an interview, finding was reviewed with E1 (NHA), E2 (DON) and E3 (Corporate Clinical Operations). 3/13/24 at 3:45 PM - Finding was reviewed with E1, E2, E3, E4 (Regional Clinical Specialist) and representatives from the Ombudsman Office. No additional information was provided to the Surveyor.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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3. Review of R103's clinical record revealed: 7/1/22 - R103 was admitted to the facility with diagnoses including diabetes, muscle weakness and dementia. 2/21/23 - R103's care plan documented, .Actual impairment to skin integrity related to unstageable wound to sacrum. 9/1/24 - R103's medical records (face sheet) updated to included, Pressure -induced deep tissue of sacral region. 9/1/23 R103's medical records documented, Sacral wound 2 x 4 cm observed. 9/2/23 - R103's medical records documented, Deep tissue injury. 10/17/23 - E32 (Wound MD) documented, Pressure injury (unavoidable stage 3). 10/24/23 - E32 documented, .Pressure injury (unavoidable stage 3). 10/31/23 - E32 documented, .Pressure injury (unavoidable stage 3). 11/7/23 - E32 doumented, .Pressure injury (unavoidable). 11/8/23 - R103 was sent the the hospital, and was diagnosed with sepsis. 11/8/23 - R103's (Discharge/Anticipated Return) MDS documented, No pressure ulcer. 3/8/24 12:45 PM - During an interview E33 (MDS Coordinator) stated, The MDS assessments dated 11/8/23 did not include the pressure ulcers. The facility failed to accurately document R103's pressure ulcer in the discharge MDS assessment. 3/13/24 3:45 PM -Findings were reviewed with E1 (NHA), E2 (DON), E3 (Corporate Clinical Operations) , E4 (Regional Clinical Specialist), and representatives from the Ombudsman Office. 2. Review of R247's clinical records revealed the following: 12/20/23 - R247 was admitted to the facility. 12/20/23- R247 had a physician's orders for the following medications for Parkinson's Disease: - amantadine 100 mg 1 tablet daily; - carbidopa/levodopa 24/100 mg 3 tablets 3x a day; - entacapone 200 mg 1 tablet 3x a day. 12/21/23 - R247 was care planned for Parkinson's disease. Interventions included but not limited to give medications as ordered by the physician and to monitor for side effects and effectiveness. 12/26/23 - R247's admission MDS (Minimum Data Set) assessment lacked evidence that Parkinson's Disease was included and accurately coded under the Neurological Diagnoses section of the MDS. 3/11/23 10:24 AM - In an interview, E37 (RNAC) confirmed that R247's admission MDS was not accurately coded and that Parkinson Disease should be added in R247's list of neurological diagnosis. Based on record review and interviews, it was determined for three (R55, R103, R247) out of twenty three residents in the investigative sample, the facility failed to accurately completed the resident assessments . Findings include: 1. Review of R55's clinical record revealed: 2/8/23 - A physicians order was written for R55 to receive two liters of oxygen to be worn continuously. 1/30/24- A quarterly MDS assessment documented in the special treatments section that oxygen not in use by R55. January 2024 - Review of R55's MAR revealed R55 received oxygen daily. During an interview on 3/6/24 at 10:31 AM E33 (RNAC) confirmed the MDS assessment error.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on record review, it was determined that for one (R95) out of twenty-three residents reviewed for care plans, the facility failed to develop and implement a person-centered care plan that accurately reflected R95's medical needs. Findings include: Reviw of R95's record revealed: 12/18/23 - E46 (hospital Infectious Disease MD) documented in R95's Progress Note Infectious Disease, Sepsis - repeat [blood] culture - negative . Endocarditis-Vegetation is small .continue ceftriaxone for total of 6 weeks. Stop date will be January 19, 2024. 12/21/23 - R95 was admitted to the facility with diagnoses including, but not limited to, heart disease and anxiety. 12/22/23 - R95's care plan included a focus stating, the resident is on IV medications r/t (related to) sepsis with interventions that address the IV access. The interventions do not document the location (LUE) or type of access (PICC). The care plan also included a focus stating, the resident is on antibiotic therapy related to sepsis with interventions that fail to name the specific antibiotic and address the duration of the antibiotic. Both care plan focuses incorrectly identify the diagnosis warranting the therapy as sepsis. R95 no longer had active sepsis as proven by the negative blood culture documented by the Infectious Disease physician on 12/18/23. R95 was being treated with 6 weeks of IV antibiotics for endocarditis. 3/13/24 3:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (Corporate Clinical Operations), E4 (Regional Clinical Specialist) and representatives from the Ombudsman office.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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2. Review of R296's clinical record revealed: 6/30/23 - R296 was admitted to the facility with multiple diagnoses, including kidney cancer and chronic kidney disease. R296 was admitted to the facility directly from a hospital stay during which he had a nephrostomy tube (tube placed to drain urine) placed in his left kidney. R296's left kidney was unable to drain urine related to his kidney cancer. R296 was admitted to the hospital from the facility on the following dates because his nephrostomy tube became dislodged: 8/18/23, 10/14/23, 11/18/23, 12/19/23 and 1/24/24. 3/1/24 - A review of R296's 1/2/24 quarterly Resident Assessment Instrument and the comprehensive care plan, updated 2/28/24, revealed the lack of care plan revisions to reflect monitoring for nephrostomy tube dislodgement and the hospitalizations that R296's had for nephrostomy tube dislodgement on the above dates. 3/7/24 10:20 AM- E47 (LPN) confirmed that R296's care plan had not been revised to reflect his many hospitalizations since he was admitted to the facility. 3/13/24 3:45PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (Corporate Clinical Operations), E4 (Regional Clinical Specialist) and representatives from the Ombudsman Office. Based on record review and interview it was determined that for two (R31, and R296) out of twenty-three residents investigated facility failed to revise the care plan to reflect the current care needs. Findings include: 1. Review of R31's clinical record revealed: 2/1/24- A quarterly MDS assessment documented in the special services section that R31 received restorative services of walking training and range of motion (ROM). 2/1/24 - R31's restorative services care plan was reviewed/revised and included interventions of active ROM for 15 minutes, contractures measurements, document visual changes, report changes or discomfort, provide assistance with devices. Interventions listed did not include walking R31. Review of currently in use but undated CNA Task list for care of R31 indicated the resident is to participate in the restorative walking program and ambulate with walker 30 ft daily or as tolerated. During an interview on 3/6/24 at 10:10 AM E58 (RN) unit manager confirmed that interventions related to walking were not included in the restorative services care plan for R31.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0660 (Tag F0660)

Could have caused harm · This affected 1 resident

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Based on record review and interview, it was determined that for one (R96) out of three residents reviewed for discharge, the facility failed to assess R96's functional abilities and consider R96's caregiver's availability and capability to perform required care, to re-evaluate and update R96's changing needs, to show evidence of the Interdisciplinary team (IDT) involvement in the process and to document R96's community referrals and contact information. Findings include: Cross refer F582 Review of R96's clinical record revealed: 11/18/23 - R96 was admitted to the facility with diagnoses, including but not limited to, ataxia (poor muscle control that causes clumsy movements) and weakness. 11/25/23 - R96's admission Minimum Data Set (MDS) assessment documented that R96 had a Brief Interview for Mental Status (BIMS) score of 11, which is reflective of moderate cognitive impairment. 11/25/23 - R96's admission MDS documented in Section H Bowel and Bladder that R96 was frequently incontinent for both urinary and bowel continence. R96's admission MDS documented in Section GG Functional Abilities and Goals that R96's admission Performance for Toileting required substantial/max (maximum) assistance with R96's Discharge Goal for Toileting was set up or clean up assistance. In the week prior to R96's discharge (12/13/23 to 12/20/23), the CNAs documented 18 episodes of Toilet usage Self Performance in the CNA Task section of PCC. Of those 18 episodes, two were documented as limited assistance, which was defined as resident highly involved in activity; staff provided guided maneuvering of limbs or other non-weight bearing assistance,ten instances were documented as extensive assistance, which was defined as resident involved in activity, staff provide weight-bearing support, and six instances were documented as total dependence, which was defined as full staff performance. 11/25/23 - R96's admission MDS documented in Section GG Functional Abilities and Goals that R96's admission Performance for Mobility documented R96's Toilet transfer, Sit to stand transfer and Chair to bed transfer as Supervision or touching assistance with R96's Discharge Goal for Mobility being documented as Independent. 12/18/23 11:27 AM - E30 (ADON) documented in a fall note regarding fall on 12/14/23, .Resident is a/o (alert and oriented) x 2 (person, place) with periods of confusion. She requires 2 person assist with transfers/ambulation. She has a history of falls . 12/19/23 5:56 PM - E57 (PT) documented in the Physical Therapy Discharge Summary Long Term Goals- . 2. Patient will safely perform functional transfers with Modified Independence and 0% verbal cues and 0% Visual cues . PLOF (previous level of function [prior to onset]) Transfers I (Independent) Discharge (12/19/2023) Mod A (moderate Assist). Physical Therapy Discharge summary documented, Patient response: Progress and Response to Tx (treatment): Patient fluctuates between functional mobility levels of assist between sessions, pt (patient) fluctuates from min (minimum) to max (maximum) assist based on day. Pt will dc (discharge) home with family assistance for mobility. 12/20/23 11 AM - R96 was discharged from the facility to F1's (R96's granddaughter) care. R96 had lived with F1 for the past 13 years. The facility lacked evidence of educating F1 about R96's mobility levels prior to discharge to ensure R96's care and continued safety could be met. 3/8/24 1:52 PM - During a telephone interview, F1 (R96's granddaughter) stated, We thought Grandmom could walk to the bathroom so we did not order any new equipment. We had to go out and get a bedpan and bedside commode .It took three of us to get her into the car, me, my mom and one of the nurses helped us by pulling her into the car from the other side. She fell 5 times in the 2 days that she was home after being discharged from the facility. Prior to this hospitalization, Grandmom could walk independently and go outside with my kids. I work from home but I was not able to constantly supervise and assist her. We thought she could walk .They never contacted me to discuss plans about discharge. The facility was not able to provide evidence of social work or any employees contacting F1, whom R96 lived with, to discuss the discharge plans and process and to educate F1 regarding R96's care needs. 3/8/24 3:41 PM - During a second telephone interview, F1 (R96's granddaughter) stated, We weren't given any of her meds. They gave me a script for 2 new meds, Nortriptyline and Macrobid for a UTI (urinary tract infection). When I went to get the Macrobid filled at the pharmacy, they would not fill it- something about it was already filled per the insurance. The paperwork was terrible. It did not have the name of her PCP (primary care physician) and it didn't say which home care agency was contacted to come to the house. 3/11/24 9:35 AM - During an interview, E55 (Social Worker) stated that the social worker involved in R96's discharge no longer works at the facility. The process for discharge is once Social work services is aware from morning meeting/IDT (interdisciplinary team) meeting that a resident is going home, they initiate conversations with the resident/family about needs. I personally fax referrals to the home health agency and then document in the discharge plan the name and contact information for the home health agency. I don't put copies of the fax into PCC (Point click care). I do discuss with family if the resident is confused or has a cognitive impairment. The facility failed to document on the discharge plan the name and contact information of the home care agency that would be providing the care. 3/11/24 11:02 AM - During an interview, E30 (ADON) stated, The Unit Manager and Social Worker start the discharge plan of care and then the discharging nurse should update it before the resident leaves to go home. The resident or family then signs the paperwork and we keep the signed copy. The nurse should put the PCP name and contact information and the home health agency referral name and contact information on the form. 3/19/24 12: 00 PM- During an interview, E38 (Director of Rehab services) stated, [E96], about 8 days prior to her discharge, stopped doing the full therapy session. She would say that she was tired or didn't need to do that because I am going home. She would not fully participate. Up to that time, she was doing great. R96's daughter was here every day and I did speak to her about her mom not participating in the entire therapy session. The daughter said that she would talk to her mom but that her mom was stubborn. E38 also stated that she had called and offered F1 (R96's granddaughter) the opportunity to come in and get care training. The granddaughter [F1] did not feel she needed to be trained as she has been caring for R96 for the past 13 years. E38 also stated that the therapy department did recommend home therapy after discharge but the doctor writes the therapy prescriptions and social work contacts the home therapy companies. E38 was not aware that the home therapy company name and contact information was not documented on R96's discharge paperwork. 3/19/24 12:45 PM - During an interview, E1 (NHA) stated that one of their social workers, who was in charge of R96's discharge, walked out the door on 12/20/23 at 9:59 AM. she just got up and left the building and never came back. 3/19/24 1:15 PM - During an interview, E58 (RN unit manager) reported that the F1 came back in the facility after getting R96 in her car on 12/20/23 and she was upset that R96 struggled to get in the car. We offered to let R96 stay for more therapy as R96 still had remaining therapy days left. E58 reported that F1 (R96's granddaughter) stated that R96 did not want to come back for more therapy and maybe we will take her back to the hospital. 3/19/24 1:33 PM - During a telephone interview, E67 (hospital home care agency RN) stated that [home care agency] did receive referrals for R96 for nursing, PT (physical therapy) and OT (occupational therapy). Their agency never started services because R96 was discharged from the facility on 12/20/23 but then was readmitted to [hospital] on 12/21/23 and after that went to another rehab facility. 3/19/24 2:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (Corporate Clinical Operations).

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0661 (Tag F0661)

Could have caused harm · This affected 1 resident

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Based on record review and interview, it was determined that for one (R247) out of 3 residents reviewed for discharge, the facility's discharge summary failed to accurately capture and document R247's post-discharge plan of care. Findings include: Review of R247's clinical records revealed the following: 12/20/23 - R247 was admitted to the facility from the hospital. 1/18/24 4:36 PM - A nurse progress notes documented that R247 had an unwitnessed fall that resulted to a skin tear to his left arm and lacerations to the left eye and left cheek. 1/18/24 - R247 had the following physician's orders: - monitor steri strips (used for cuts or wounds that are not too severe); - cleanse skin tear to left cheek with soap and water, apply bacitracin and leave open to air; - cleanse skin tear to left elbow with soap and water, apply bacitracin and cover with dry dressing daily. 1/19/24 - R247 was discharged home via ambulance. 3/11/24 10:59 AM - Review of the form titled BVC - Discharge Instructions and Post Discharge Plan of Care - Version 3 revealed a lack of discharge instructions for wound care. 3/11/24 1:20 PM - During an interview, E37 (RN) confirmed that R247's wound care treatment orders were not documented in the discharge paperwork. 3/13/24 3:45 PM -Findings were reviewed with E1 (NHA), E2 (DON), E3 (Corporate Clinical Operations) and E4 (Regional Clinical Specialist) and representatives from the Ombudsman Office.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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Based on record review and interview it was determined that for one (R31) out of one resident reviewed for rehab and restorative the facility failed to ensure R31 received restorative services consistently when R31 was not walked daily. Findings include: Review of R31's clinical record revealed: 1/17/24 - The CNA Task list for the care of R31 was revised to include the resident is to participate in the restorative walking program and ambulate with walker 30 foot daily or as tolerated. 2/1/24- A Quarterly MDS assessment documented in the special services section that R31 received restorative services of walking training and range of motion (ROM). During an interview on 2/29/24 at 12:04 PM R(31) stated, I was told I had graduated to walking therapy but getting that has been hit or miss. February 2024 - Point of care (POC) CNA responses for assisting R31 to walk lacked evidence that the resident was assisted with walking on the following dates: 2/1, 2/2, 2/3, 2/4, 2/6, 2/10, 2/17, 2/18, 2/19, 2/20, 2/22, 2/24 and 2/25. During an interview on 3/5/24 at 1:00 PM E58 (RN) unit manager stated, I just talked with some of the aides, they said when an extra aide is assigned restorative they document n/a because then it's not their responsibility. When asked how nursing verifies that the walking was completed, E58 stated, They should be documenting that it's completed. 3/13/24 3:45 PM -Findings were reviewed with E1 (NHA), E2 (DON), E3 (Corporate Clinical Operations) , E4 (Regional Clinical Specialist) and representatives from the Ombudsman Office.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on record review and interviews, it was determined that for one (R63) out of one resident reviewed for respiratory, the facility failed to provide care consistent with the professional standards with regards to R63's albuterol nebulizer (neb) treatment. Findings include: Albuterol (Inhalation Route) Proper Usage- . The albuterol inhalation solution should be used with a jet nebulizer that is connected to an air compressor with good air flow .To use the inhalation solution in the nebulizer: -Use one container of solution or mix the exact amount of solution using the dropper provided for each dose. -Place the inhalation solution in the medicine reservoir or nebulizer cup on the machine -Connect the nebulizer to the face mask or mouthpiece. -Use the face mask or mouthpiece to breathe in the medicine. -Use the nebulizer for about 15 minutes, or until the medicine in the nebulizer cup is gone. Mayo Clinic, February 1, 2024 The facility's Nebulizer Therapy policy (dated 4/1/2020) stated, Policy: It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions .Care of the resident 15. When medication delivery us complete, turn the machine off. Treatment may be considered complete with the onset of nebulizer sputtering. 9/22/23 - R63 was admitted to the facility. 12/20/23 - R63's quarterly MDS assessment documented a BIMS score of 15, which reflected normal cognition. 1/24/24 - F3's (R63's former roommate) admission MDS assessment documented a BIMS score of 15, which was reflective as having normal cognition. 2/16/24 - E63 (NP) ordered R63 Albuterol sulfate inhalation nebulization solution (2.5 mg/3 ml) 0.083% 1 vial inhale orally four times a day for SOB (shortness of breath). The Surveyor confirmed that R63's medication administration record (MAR) for February and March listed the times of albuterol neb treatments as 9 AM, 12 noon, 5 PM and 9 PM. 2/29/24 3:55 PM - During an interview, F4 (R63's family member) stated, Last week, after [R63] was given his night time neb (albuterol) treatment. [R63] gets a breathing treatment from the little machine that lasts about 15 minutes. Those treatments make [R63] anxious; he does not like the facemask on his face. Well, no one came back to take the facemask off [R6] after about an hour and [R63] was getting upset. His roommate, [F3] had to call his family member at home to have her call the front desk to have someone come down to take the treatment facemask off [R63]. 3/1/24 10:20 AM - During an interview, F3 reported, A few nights ago, after [R63] got his evening neb, which is suppose to be a 10 minute thing, they left it on for an hour. At first, I rang the call light and when no one came, I started to call out, 'Is there a nurse?' because we were both in bed. I must have yelled numerous times. Then I was planning on calling his family member (F4) but [R63] said, 'She would be in bed because it was after 10 PM.' So I called my family member and she called the front desk. Then a male nurse came in and took it (the facemask) off without saying a word. 3/1/24 10:30 AM - R63 confirmed during an interview that the incident with the neb facemask being left on his face for over 45 minutes did occur. 3/13/24 3:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (Corporate Clinical Operations), E4 (Regional Clinical Specialist) and representatives from the Ombudsman office.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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Based on record review, observation and interview, it was determined that for one (R446) out of one resident reviewed for dialysis, the facility failed to ensure that R446's transportation needs related to dialysis were met as evidenced by the failure to schedule/confirm transportation to dialysis on 3/6/24. Findings include: Review of R446's clinical record revealed: 2/21/24 - R446 was admitted to the facility with diagnoses, including but not limited to, end-stage renal disease (ESRD) requiring hemodialysis. 2/21/24 - R446's care plan documented, The resident needs dialysis: hemo (hemodialysis) r/t (related to) renal failure with Interventions stating Dialysis (Mon/Wed/Fri) at [hemodialysis facility]. Chair time 7:20 AM. Pick up 6:00 - 6:30 AM. 3/6/24 7:15 AM - The Surveyor observed R446 sitting in a wheelchair in the facility lobby. E1 (NHA) confirmed that R446's ride to hemodialysis did not pick her and the facility was arranging another ride to get her to her dialysis treatment. This hemodialysis treatment was exactly 14 days (2 weeks) from R446's admission date. 3/6/24 9:35 AM - R446 was driven to her hemodialysis treatment in the facility bus. 3/6/24 9:53 AM - During an interview, E30 (ADON) stated, Transport to dialysis is arranged by the hospital for the first two weeks after discharge and then it is the dialysis center social worker's job to arrange the transport. 3/7/24 8:52 AM - During an interview, E48 (LPN) stated, Normally the dialysis transport is longstanding, if they were on dialysis in the community. So [E62] (unit clerk) calls the dialysis center and lets them know where the resident is now housed and arranges for them to pick the resident up here. 3/7/24 3:35 PM - The Surveyor reviewed the facility's Long Term Facility Outpatient Dialysis Services Coordination Agreement, which stated, Consistent with this definition, Renal Dialysis Services shall not include transportation of the ESRD residents to and from the ESRD Dialysis Unit . Obligations of Long Term Care Facility and/or Owner - .5. Transport and referral of ESRD Residents: A. The Long Term Care Facility shall be responsible for arranging for suitable and timely transportation of the ESRD resident to and from the ESRD Dialysis Unit, including the selection of the mode of transportation, qualified personnel to accompany the ESRD resident, transportation equipment usually associated with this type of transfer or referral in accordance with the applicable federal and state laws and regulations and all costs or transportation expenses associated with such transfer. 3/13/24 3:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (Corporate Clinical Operations), E4 (Regional Clinical Specialist) and representatives from the Ombudsman office.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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2a. Review of R198's clinical record revealed: 2/15/23- A physicians order was revised for R198 to receive Olanzapine [antipsychotic] 7.5 mg at bedtime for schizoaffective disorder. The original order was 3/16/22. 3/7/23 7:41 PM - A progress note written by E12 (NP) documented, Patient is seen today for follow up schizoaffective disorder and medication review. Mood remains stable .Patient with mild tremors of the hands possibly extrapyramidal effects, will discuss with psych team about starting on cogentin as requested by patient. 3/10/23- A physicians order was written for R198 to receive Bentropine/cogentin 0.5mg ordered for dystonia[tremors], a side effect of antipsycotic medication use. 3/16/23 8:14 PM - A physicians note written by E65(MD) documented, Late Entry: Patient is seen for follow up after started on cogentin for tremors secondary to antipsycotic medications. She is having improvement in her tremors. 4/21-23 - A physicians order was written for R198 to receive AIMS testing now and every 92's day, quarterly. 6/15/23 - AIMS testing completed for R198. Prior AIMS test was completed on 10/27/22. During an interview on 3/12/24 at 3:16 PM E2 (DON) confirmed AIM's assessments for monitoring of side effects of antipsycotic use was not complete from November 2022 through 2b. The facility's pharmacy policy on unavailable medications last updated 4/20/23 indicated, if the ordered medication is unavailable in the emergency stock supply a licensed nurse calls the pharmacy's answering service and request to speak with the registered pharmacist on call to determine a plan of action with may include: emergency delivery, use of emergency back up pharmacy. March 2023 -Review of R198's MAR revealed the Olanzapine was given to the resident 3/20/23 through 3/27/23. 3/20/23 11:22 PM - An orders administration note documented in R198's clinical record documented that the Olanzapine was not given because the facility was awaiting delivery. 3/24/23 10:24 PM - An orders administration note documented R198's Olanzapine was, unavailable. Pending pharmacy delivery. 3/26/23 10:46 PM - An orders administration note documented R198's Olanzapine was, Awaiting delivery. 3/27/23 10:42 PM - An orders administration note documented R198's Olanzapine was not administered because the facility was Waiting for a medication order from the pharmacy, pharmacy has been notified. During an interview on 3/13/24 at 10:49 AM E2 (DON) confirmed that R198's Olanzapine was not avaialble for 7 days and the facility only utilizes one pharmacy at this time for fulfilling orders. E2 stated, We are in the process of setting up a system with a back up pharmacy but have not just yet. During an interview on 3/13/24 at 1:08 PM E64 (LPN) who was assigned to R198 on 3/20 and 3/24, it was confirmed that R198's Olanzapine was not available and not administered. 3/13/24 3:45 PM -Findings were reviewed with E1 (NHA), E2 (DON), E3 (Corporate Clinical Operations) and E4 (Regional Clinical Specialist) and representatives from the Ombudsman Office. Based on clinical record review and interview, it was determined that for one (R2) out of five residents reviewed for unnecessary medications, the facility failed to complete an AIMS assessment for R2 a resident taking anti-psychoactive medications. For one (R198) out of one residents reviewed for behavioral-emotional distress the facility failed to effectively monitor R198 for side effects related to use of an antipsychotic medication when AIMS testing was not completed November 2022 - May 2023 during which the resident continued to receive antipsychotic medications. Additionally the facility failed to administer R198's antipsychotic medication [olanzapine] for seven doses due to lapse in pharmacy delivery. Findings include: Review of the facility's policy and procedure titled Behavior and Psychoactive Management Program last updated 4/1/20, documented . 1. Monitoring for any adverse side effects of medications, which includes completion of Abnormal Involuntary Movement Scale (AIMS) as per recognized standards of practice. 1. Review of R2's clinical record revealed: 3/10/23 - R2 was readmitted to the facility with a diagnosis of dementia, psychotic disorder with delusions, anxiety, and major depressive disorder. 4/21/23 6:00 PM - A review of R2's MAR (Medication Administration Record) documented, 1.Nurse to complete AIMS quarterly one time a day every 92 days. 3/11/24 11:00 AM - Review of R2's clinical record lacked evidence that a quarterly AIMS had been completed for the use of Seroquel 25 mg two times a day and Seroquel 50 mg at bedtime for major depressive disorder and delusions for the month of October 2023. 3/11/24 11:19 AM - During an interview E37 (RN) revealed R2's AIMS evaluation is done quarterly. E37 confirmed R2's clinical record lacked a quarterly AIMS evaluation for the month of October 2023. 3/11/24 12:00 PM - An interview with E2 (DON) revealed R2's AIMS evaluation should have been done in October 2023. 3/12/24 12:41 PM - During an interview E2 confirmed, I was not able to find R2's AIMS evaluation for October 2023.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

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Based on observation and interview, it was determined that for two (R27 and R28) randomly observed residents, the facility failed to ensure that the residents received the selected food and drinks from the menu. Findings include: 2/29/24 12:15 PM - During a random dining observation of R28's lunch tray, the meal ticket did not match when R28 did not receive cranberry juice or sauteed spinach. E45 (CNA) confirmed the finding. 3/5/24 8:10 AM - During a random dining observation of R27's breakfast tray, the meal ticket did match when R27 was not served oatmeal. E40 (LPN) confirmed the finding. 3/8/24 12:58 PM - During a random dining observation of R28's lunch tray, the meal ticket did not match when R28 did not receive cranberry juice. E48 (LPN) confirmed the finding. 3/13/24 3:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (Corporate Clinical Operations) , E4 (Regional Clinical Specialist) and representatives from the Ombudsman Office.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment. Findings include: Review of the 4/1/22 facility policy for Glucometers revealed the following: -Purpose: Disinfection of Blood Glucose Monitoring -Procedure: .3. Use EPA approved disinfectant to disinfect glucometer per glucometer manufacturer's guidelines. The manufacturers guidelines for cleaning and disinfecting state that the glucometer should be cleaned and disinfected after use on each patient. 3/6/24 7:45AM - During a medication observation, E26 (LPN) obtained a blood glucose level on R27 using a glucometer, E26 did not clean or disinfect the glucometer after using it. At 7:56 AM, E26 obtained a blood glucose reading on R15 using the same glucometer that had not been cleaned or sanitized after it had been used on R27. E26 confirmed the findings at 8:05 AM. 3/13/24 3:45PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (Corporate Clinical Operations), E4 (Regional Clinical Specialist) and representatives from the Ombudsman Office.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0940 (Tag F0940)

Could have caused harm · This affected 1 resident

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Based on interview and review of facility documentation, it was determined that the facility failed to develop, implement, and maintain an effective training program for staff, consistent with their expected roles. Findings include: Review of the facility Nursing Orientation Check List revealed that nephrostomy (tube placed to drain urine) care was not on the checklist. Review of R296's clinical record revealed: 6/30/23 - R296 was admitted to the facility with multiple diagnoses, including kidney cancer and chronic kidney disease. R296 had a nephrostomy tube placed in his left kidney during a recent hospitalization. R296's left kidney was unable to drain urine because of his kidney cancer. 7/15/23 - A physician's order was written to flush R296's nephrostomy tube with 10 ml saline flush daily, every day shift. R296 was hospitalized seven times from 7/16/23 through 2/28/24, and the facility physician's order for the nephrostomy flush resumed with R296's facility readmissions. 3/7/24 1:30 PM - During an observation E40 (LPN) flushed R296's nephrostomy tube. During an interview, E40 stated that she had not received facility training to flush a nephrostomy tube, but that she was familiar with the procedure from doing it at another facility. 3/7/24 3:24 PM - During an interview E28 (Staff Developer) confirmed that she has not done nephrostomy tube flush education with nursing staff yet. 3/13/24 3:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (Corporate Clinical Operations), E4 (Regional Clinical Specialist) and representatives from the Ombudsman office.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

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Based on record review and interview, it was determined that for five (R37, R63, R96, R446, R447) out of twenty-three residents reviewed for care plans, the facility failed to meet professional standards of the Delaware Board of Nursing Scope of Practice by having LPNs complete the admission assessment and admission progress note. Findings include: Delaware State Board of Nursing - RN, LPN and NA/UAP Duties 2023 . admission Assessments * - RN . *= Once a care plan is established, the LPN may do assessments . The Braden Scale is a validated tool designed to assess a patient's risk of developing pressure ulcers. National Library of Medicine, Nov. 21, 2022. Cross refer F660, F695, F677 1. Review of R37's clinical record revealed: 2/17/24 - R37 was admitted to the facility. 2/17/24 - E68 (LPN) completed the dehydration risk and the Braden scale for prediction of pressure ulcer risk evaluations in R37's electronic medical record (EMR). 2/17/24 4:00 AM - E68 (LPN) wrote R37's clinical admission note in R37's EMR. 2/24/24 - E31 (LPN) completed the elopement form in R37's EMR. An LPN, not an RN as required by the Delaware State regulation for Board of Nursing Scope of Practice, completed the admission process for R37. 2. Review of R63's clinical record revealed: 1/29/24- R63 was admitted to the facility. 1/29/24 - E69 (LPN) completed R63's clinical admission form, elopement, fall risk, dehydration risk and Braden scale for prediction of pressure ulcer risk evaluations in R63's EMR. 1/29/24 5:49 PM - E69 wrote R63's clinical admission note in R63's EMR. An LPN, not an RN as required by the Delaware State regulation for Board of Nursing Scope of Practice, completed the admission process for R63. 3. Review of R96's clinical record revealed: 11/18/23 - R96 was admitted to the facility. 11/18/23 - E31 (LPN) completed R96's clinical admission form, elopement, fall risk, dehydration risk and Braden scale for prediction of pressure ulcer risk evaluations in R96's EMR. 11/18/23 5:20 PM - E31 wrote R96's clinical admission note in R96's EMR. An LPN, not an RN as required by the Delaware State regulation for Board of Nursing Scope of Practice, completed the admission process for R96. 4. Review of R446's clinical record revealed: 2/21/24 - R446 was admitted to the facility. 2/21/24 - E69 (LPN) completed R446's clinical admission form, elopement, fall risk, dehydration risk and Braden scale for prediction of pressure ulcer risk evaluations in R446's EMR. 2/21/24 9:19 PM - E69 wrote R446's clinical admission note in R446's EMR. An LPN, not an RN as required by the Delaware State regulation for Board of Nursing Scope of Practice, completed the admission process for R446. 5. Review of R447's clinical record revealed: 2/19/24 - R447 was admitted to the facility. 2/19/24 - E70 (LPN) completed R447's clinical admission form, elopement, fall risk, dehydration risk and Braden scale for prediction of pressure ulcer risk evaluations in R447's EMR. 2/19/24 10:50 PM - E70 wrote R446's clinical admission note in R447's EMR. An LPN, not an RN as required by the Delaware State regulation for Board of Nursing Scope of Practice, completed the admission process for R447. 3/7/24 4:51 PM - During an interview, E69 (LPN) confirmed that he completed the admission process for R63 on 1/29/24 and R446's admission paperwork on 2/21/24. 3/6/24 9:23 AM - During an Interview, E31 (LPN) stated that whichever nurse is assigned the room for the new admit patient, that nurse completes the admission process paperwork. 3/6/24 10:01 AM - During an interview, E58 (RN Unit manager) stated, If an admission comes in on day shift, the Unit manager processes the admission by calling the NP/MD and verifying the hospital orders for medications and treatments and then puts the orders in the computer [EMR]. Then the unit manager starts the care plan. If a patient is admitted on an off shift, the nursing supervisor is suppose to complete the admission process paperwork. The admission process includes the clinical admission form, the elopement risk evaluation, the fall risk evaluation, the dehydration evaluation and the Braden scale for prediction of pressure ulcers evaluation. It also includes writing a general admission note in the EMR. 3/11/24 10:57 AM- During an interview, E30 (ADON) stated that the word assessment is not in any of the admission paperwork. When asked where the State required RN admission assessment was for these residents, E30 stated that she did not know and to check with the DON. 3/13/24 3:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (Corporate Clinical Operations), E4 (Regional Clinical Specialist) and representatives from the Ombudsman office.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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2. The Wareforce dish washing machine [brand used by the facility] manual indicated 140°F temperature and chlorine/bleach required for sanitization of dishes. https://www.jacksonwws.com/wp-content/uploads/2018/11/WAREFORCE-I-Manual-Rev-K.pdf. The [undated] facility policy on Warewashing indicated, all dish machine washing temperatures will be maintained in accordance with manufacturer recommendations for high temperature or low temperature machines. During the follow up kitchen tour on 3/1/24 at 10:29 AM - 10:47 AM the following was observed: 10:39 AM - Single rack dish washing machine wash cycle 130 degree's F, with no chemical sanitization attached. 10:42 AM - Single rack dish washing machine wash cycle 130 degree's F, with no chemical sanitization attached. 10:45 AM - E42 (DDS) confirmed the dishwashing temperatures and stated, We use bleach attached to sanitize, it has had issues but has been fine lately. We have had maintenance come out. The Surveyor requested E42 (DDS) to point out the attached sanitizing agent/bleach. E42 then confirmed it was not attached. 10:47 AM - E42 (DDS) retrieved a replacement of sanitizer/bleach and connected it to the dishwashing machine. Nearby dishes were re-ran the dish washing machine with the added sanitization/bleach. 3/13/24 3:45 PM -Findings were reviewed with E1 (NHA), E2 (DON), E3 (Corporate Clinical Operations) , E4 (Regional Clinical Specialist) and representatives from the Ombudsman Office. Based on observation and interview during the initial kitchen tour, it was determined that the facility failed to ensure that proper sanitation practices were in place and that food was stored in accordance with professional standards. Additionally, it was determined that the facility failed to ensure dishes were chemically sanitized when dish washing machine temperatures failed to rise to the degree required for heat sanitization. Findings include: 1. 2/29/24 from 9:00 AM to 9:20 AM, observation of the kitchen with E42 (Dietary Services Director) revealed the following: E43 (Dietary Aide) did not have a hair net or beard covering in place. The hand washing sink had no paper towels available. The walk-in freezer had two containers of what appeared to be soup and one container of what appeared to be gravy, all without content description labels, dates of preparation and expiration. The above findings were immediately confirmed with E42.

MINOR (B) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Minor Issue - procedural, no safety impact

Safe Environment (Tag F0584)

Minor procedural issue · This affected multiple residents

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Based on observation and interview, it was determined that for two out of two shower rooms reviewed, the facility failed to provide services necessary to maintain a clean and sanitary environment. Findings include: 3/4/24 9:24 AM - During an observation of the East and [NAME] wings shower rooms, several large areas (where the walls met the tiles) of blackened substance were observed. Multiple areas of chipped and broken floor and wall tiles were also observed. 3/4/24 9:45 AM - During an environmental tour, it was observed that floors in rooms E101 through E122 were coated with a thick, blackened, greasy substance. An observation of rooms W101 through W122 revealed blackened, greasy substance on the floors as well. 3/5/24 11:00 AM - The shower rooms and the residents' rooms continued to have the same blackened substance on the walls, and the floors. 3/5/24 1:30 PM - Findings were confirmed with E5 (Cooperate Resource Manager) and E6 (Maintenance/Housekeeping Director Findings were reviewed with E1 (NHA), E2 (DON), E3 (Corporate Clinical Operations), E4 (Regional Clinical Specialist) and representatives from the Ombudsman Office.

MINOR (B) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Minor Issue - procedural, no safety impact

Medical Records (Tag F0842)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R42's clinical record revealed: 4/22/20 - R42 was admitted to the facility. 12/13/23 - E66 (NP) ordered UA (urinalysis) and C&S (culture and sensitivity) to R/O (rule out) UTI (urinary tract infection). 12/18/23 10:28 AM - Urine culture results reported in R42's EMR stated, Growth- 1 organism growth. R42's EMR did not have readily accessible documentation of the culture results naming the organism and the sensitivities identifying which antibiotic the organism could be treated with. Upon the Surveyor's request, the facility was able to produce a printout from the [laboratory's] website with the 12/15/23 urine culture results, which revealed the organism was Klebsiella oxytoca ESBL (extended-spectrum beta-lactamases). Of note, only a limited number of people have account access to the [laboratory] website. The Surveyor was unable to find evidence of the urine microbiology culture results that showed the organism and sensitivities and documentation of MDRO colonization in R42's EMR . 3. Review of R63's clinical record revealed: 9/22/23 - R63 was admitted to the facility. 12/6/23 - E66 (NP) ordered UA and C&S to R/O UTI. 12/8/23 - Urine culture results reported in R63's EMR stated, Growth- 1 organism growth. R63's EMR did not have readily accessible documentation of the culture results naming the organism and the sensitivities identifying which antibiotic the organism could be treated with. Upon the Surveyor's request, the facility was able to produce a printout from the [laboratory's] website with the 12/6/23 urine culture results, which revealed the organism was Klebsiella pneumoniae ESBL. Of note, only a limited number of people have account access to the [laboratory] website. The Surveyor was unable to find evidence of the urine microbiology culture results that showed the organism and sensitivities and/or documentation of MDRO colonization in R63's EMR . 4. Review of R76's clinical record revealed: 6/5/23- R76 was admitted to the facility. 2/25/24 - E52 (MD) ordered UA and C&S secondary to increased confusion. 2/29/24 - Urine culture results reported in R76's EMR stated, Growth- 1 organism growth. R76's EMR did not have readily accessible documentation of the culture results naming the organism and the sensitivities identifying which antibiotic the organism could be treated with. Upon the Surveyor's request, the facility was able to produce a printout from the [laboratory's] website with the 2/27/24 urine culture results, which revealed the organism was Klebsiella pneumoniae ESBL. Of note, only a limited number of people have account access to the [laboratory] website. The Surveyor was unable to find evidence of the urine microbiology culture results that showed the organism and sensitivities and/or documentation of MDRO colonization in R76's EMR . 5. Review of R107's clinical record revealed: 9/15/23 - R107 was admitted to the facility. 9/25/23 - E12 (NP) ordered UA and C&S to R/O UTI. 9/29/23 - Urine culture results reported in R107's EMR stated, Growth- 1 organism growth. R107's EMR did not have readily accessible documentation of the culture results naming the organism and the sensitivities identifying which antibiotic the organism could be treated with. Upon the Surveyor's request, the facility was able to produce a printout from the [laboratory's] website with the 9/27/23 urine culture results, which revealed the organism was Klebsiella pneumoniae ESBL. Of note, only a limited number of people have account access to the [laboratory] website. The Surveyor was unable to find evidence of the urine microbiology culture results that showed the organism and sensitivities. 6. Review of R108's clinical record revealed: 5/10/23 - R108 was admitted to the facility. 1/21/24 - E63 (NP) ordered UA and C&S to R/O UTI. 1/24/24 - Urine culture results reported in R107's EMR stated, Growth- 1 organism growth. R108's EMR did not have readily accessible documentation of the culture results naming the organism and the sensitivities identifying which antibiotic the organism could be treated with. Upon the Surveyor's request, the facility was able to produce a printout from the [laboratory's] website with the 1/22/24 urine culture results, which revealed the organism was Klebsiella pneumoniae ESBL. Of note, only a limited number of people have account access to the [laboratory] website. The Surveyor was unable to find evidence of the urine microbiology culture results that showed the organism and sensitivities and/or documentation of MDRO colonization in R108's EMR . 3/12/24 8:35 AM- During an interview, E1 (NHA) stated, The providers have access to the [laboratory] website to get the names of the organisms. We don't upload the results into the EMR. 3/13/24 3:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (Corporate Clinical Operations), E4 (Regional Clinical Specialist) and representatives from the Ombudsman. Based on record review and interview, it was determined that for six (R42, R47, R63, R76, R98 R107, R108) out of twenty-three residents records reviewed, the facility failed to maintain and safeguard medical records information on each resident against loss and ensure the records are complete, accurately documented and readily accessible. Findings include: 1. R98's clinical record revealed: 3/5/22 - R98 was admitted to the facility and discharged [DATE]. Review of the R98's paper chart and the electronic clinical record lacked evidence of R98's admission agreement with the facility upon admission on [DATE]. 3/11/24 at 3:51 PM - In response to a written request for R98's admission agreement, E3 (Corporate Clinical Operations) documented, we do not have the document.

MINOR (C)

Minor Issue - procedural, no safety impact

Drug Regimen Review (Tag F0756)

Minor procedural issue · This affected most or all residents

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Based on record review and interview, it was determined that the facility failed to provide a MRR policy with time frames for response from the provider for irregularities and a complete process for following up regarding an urgent action irregularity which included time frames for informing the provider of the urgent finding and what to do if the provider fails to response in a certain time frame. Findings include: 3/1/24 - The Surveyor reviewed the Medication Regimen Review policy dated 4/1/20 provided by the facility. Medication Regimen Review . Policy Explanation and Compliance Guidelines: . 7. Timelines and responsibilities for Medication Regimen Review a. The pharmacist shall communicate any recommendations and identified irregularities via written communication within 10 working days of the review. b. If the pharmacist should identify an irregularity that requires urgent action to protect a resident, the DON or designee is informed verbally. c. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. The facility was unable to provide evidence within their Medication Regimen Review policy of stated time frames for response from the provider for pharmacist identified and reported irregularities. The facility was also unable to provide evidence within their Medication Regimen Review policy of a complete process for pharmacist identified and reported urgent action irregularities with stated time frames for informing the provider of the urgent finding and the process the facility must take if the provider fails to response in a designated time frame. 3/13/24 3:45 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (Corporate Clinical Operations), E4 (Regional Clinical Specialist) and representatives from the Ombudsman office.

Mar 2023 5 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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Based on interview and clinical record review, it was determined that for one (R3) out of three residents reviewed for admission, the facility failed to develop and implement a baseline care plan that addressed R3's two surgical wounds. Findings include: R3's clinical record revealed: 9/21/22 at 12:15 AM - R3 was admitted to the facility following a VP shunt placement at the hospital. 9/21/22 at 4:40 PM and 4:42 PM - The facility forms entitled Nonpressure Wound Documentation revealed that R3 had surgical wounds on the right side of his abdomen measuring 5 cm x 4 cm and on the back of his head, right side. Review of R3's baseline care plan revealed the absence of a care plan that addressed R3's surgical wounds. 3/10/23 at 10:33 AM - During an interview, E2 (DON) reviewed R3's care plan with the Surveyor. The facility lacked evidence of a care plan for R3's surgical wounds. 3/14/23 at 12:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2, E3 (ADON) and E4 (VPO).

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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Based on interview and clinical record review, it was determined that for one (R2) out of three residents reviewed for Activities of Daily Living (ADL) care, the facility failed to provide bathing in accordance to the resident's preference and scheduled frequency. Findings include: R2's clinical record revealed: 11/25/22 at 5:30 PM - R2 was admitted to the facility. 11/25/22 at 6:09 PM - R2's preferences evaluation documented that his bathing preference for a shower/bed bath was very important. According to the November and December 2022 CNA Documentation Survey Reports, R2 was scheduled to have a shower every Sunday (day shift) and Wednesday (evening shift). From 11/25/22 to 12/22/22, R2 received five out of eight scheduled showers/bed baths. The facility documented that R2 refused or not applicable for three bathing opportunities, however, a nurse's note on 12/8/22 at 12:36 AM documented R2 as being compliant with care. There was no evidence of follow-up as to why R2 refused or whether staff offered a shower at another time. 3/13/23 at approximately 12:00 PM - During an interview, E3 (ADON) reviewed R2's showers with the Surveyor and acknowledged the missing scheduled showers. 3/14/23 at 12:30 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (DON), E3 and E4 (VPO).

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on interview and review of the clinical record and facility documentation as indicated, it was determined that for one (R2) out of three residents reviewed for pressure ulcers (PUs), the facility failed to ensure that a resident admitted with a pressure ulcer received the necessary treatment and services consistent with professional standards of care. Findings include: The facility's policy and procedure entitled Treatment/Services to Prevent/Heal Pressure Ulcers, dated 4/1/20, stated, .2. Upon admission, the resident will receive a head to toe skin check to identify any skin issues . 4. When the resident is admitted with a pressure sore(s) the admitting nurse will document the size, location, odor (if any), drainage (if any), and current treatment ordered. 5. Interventions will be implemented in the resident's plan of care to prevent deterioration and promote healing of the pressure sore. 6. The admitting nurse will notify the attending physician as well as the resident and/or resident's representative of the condition of the pressure sore on admission . 8. The nurse will notify the physician anytime the pressure sore is showing signs of nonhealing or infection and request treatment order changes. The facility's Skin and Wound Care Management Program, dated 4/1/20, stated, . admission: -Nursing will complete the Clinical admission Documentation assess the resident from head to toe to determine the residents current skin condition . -Each resident standard mattress is pressure reducing/reduction mattress. -Ulcers will be identified as pressure . Weekly: -A licensed nurse performs a head-to-toe skin check of the resident and documents the findings in the EMR . Planning: -The Interdisciplinary Team develops a person-centered care plan to prevent or treat skin breakdown based on resident assessments, preferences and goals. Include mobility, activity, moisture, nutrition, sensation, and friction. Implementation: -The Interdisciplinary Team ensure that planned interventions and treatments are carried out as written in the Care Plan . -Teach residents and their families what they can do to help prevent pressure ulcers . R2's clinical record revealed: 11/25/22 at 5:30 PM - R2 was admitted to the facility. 11/25/22 at 11:40 PM - The Clinical admission documented that R2 was alert and oriented and that he had no skin issues. 11/25/22 at 11:55 PM - The nurse's admission summary note documented that R2 had intact skin with mild skin tears on both knees and open blister on the left heel. This note contradicts the Clinical admission document of no skin issues. The facility failed to document the characteristics of the left heel open blister, for example the size, odor (if any), drainage (if any), wound bed color, surrounding skin, and temperature to use as a baseline for monitoring the effectiveness of interventions/treatments. 11/25/22 at 11:27 PM - R2's Braden Scale for predicting pressure ulcer risk, a facility assessment tool, documented that R2 scored a 17 (at risk). *A score of 19 or higher would indicate that a resident was at low risk, with no treatment at this time. 11/26/22 at 12:48 AM - A Physician's order by E5 (PA) stated to cleanse the left heel wound with normal saline solution and apply Optifoam (type of wound dressing) every day shift. 11/26/22 - Despite being admitted with a left heel open blister, R2 was care planned for potential for alteration in skin integrity related to impaired mobility, decreased activity, potential for alteration in nutrition and potential for friction. Interventions included: -barrier cream as ordered; -monitor for adequate nutrition and hydration; -offload heels while in bed; -pressure reducing cushion to wheelchair; -pressure reducing mattress to bed; -skin check every two hours and report abnormalities to nurse; -turn and reposition every two hours and as needed; and -weekly and quarterly skin checks as ordered. 11/26/22 (day shift) - While the eTAR documented that R2 refused the left heel wound treatment, there was no corresponding nurse's note as to why the treatment was refused and no evidence of notification to the Physician of R2's refusal. The treatment was discontinued on 11/26/22 at 5:00 PM. 11/26/22 at 4:53 PM - Approximately 24 hours after admission, the facility's form entitled Nonpressure Wound form documented that R2 had a left heel fluid filled blister measuring 5 cm (length) x 9 cm (width), Deep Tissue Injury, no drainage, no odor, healthy condition of the surrounding tissue and no wound related pain. Treatment was initiated and the Provider (MD/PA/NP) was notified. 11/26/22 at 5:03 PM - A verbal Physician's order by E8 (Physician) stated to apply skin prep to both heels twice a day. Make sure left heel is offloaded every day and evening shift. Review of the eTAR from 11/27/22 through 12/13/22 revealed that nursing staff was signing off that this treatment was done twice a day despite Physician orders dated 11/28/22 and 11/29/22 changing the treatments to R2's left heel DTI. The 11/26/22 Physician order was not discontinued until 12/13/22. 11/26/22 at 11:12 PM - A late entry Physician note by E5 (PA) documented that a physical exam was performed and R2's skin was warm and dry with positive turgor. The note lacked evidence of R2's left heel DTI and the treatment plan. 11/28/22 at 7:41 AM - A Nutrition note documented there were no concerns at this time related to R2's skin integrity. The facility lacked evidence that the Registered Dietician was notified of R2's left heel DTI. 11/28/22 at 11:04 AM - A Physician's order by E8 (Physician) stated to cleanse R2's left heel wound with normal saline solution, apply ABD (wound treatment) and wrap with kling (dressing) every day. While R2's left heel DTI treatment was changed, there was no wound assessment documented to reflect the current condition of his left heel. Review of R2's November 2022 eTAR revealed that the treatment was signed off as done by nursing on 11/28/22. The treatment was discontinued on 11/29/22 at 1:26 PM. 11/29/22 (untimed) - The Wound Care Consultant, C1 (Medical Doctor), evaluated R2's left heel. C1 documented that R2 had an unstageable pressure injury to the left heel and to continue offloading and turn per facility protocol. 11/29/22 at 1:27 PM - A Physician's order by C1 (MD) stated to clean the left heel wound with normal saline solution, apply collagen wound filler (wound treatment) and bordered gauze every other day. Review of R2's November and December 2022 eTARs revealed that the treatment was signed off as done by nursing from 11/30/22 through 12/14/22. 11/29/22 - Despite being admitted with a left heel DTI on 11/25/22, R2 was care planned for actual impairment to skin integrity related to an unstageable wound to the left heel. Interventions included: -encourage good nutrition and hydration in order to promote healthier skin; -follow facility protocols for treatment of injury; -monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs/symptoms of infection, maceration (softening of tissue by soaking in fluid), etc. to MD (Medical Doctor). -weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, exudate and any other notable changes or observations. 11/29/22 at 1:38 PM - A Physician's note by E5 (PA) documented that R2 was seen and examined. The Physician's note lacked evidence of R2's changes in skin integrity, specifically the left heel DTI upon admission and now an unstageable PU. 11/30/22 at 6:42 AM - A nutrition note documented that nursing reported that R2 had a wound to the left heel and nutritional interventions were recommended. 12/1/22 at 3:25 PM - A history and physical by E7 (Physician) documented that R2 was seen and examined. The Physician's note lacked evidence of R2's unstageable left heel PU. 12/3/22 at 5:05 PM - A late entry Physician note by E5 (PA) documented that R2's condition and medications were reviewed. The Physician's note lacked evidence of R2's left heel PU. 3/13/22 at approximately 12:00 PM - During an interview, E3 (ADON) reviewed R2's care with the Surveyor and acknowledged that R2's nursing assessments of his left heel were incomplete. E3 also stated that the facility was using the Nonpressure Wound Documentation form on 11/26/22 to document R2's PU, but the facility changed to a pressure ulcer form. 3/14/22 at 12:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 and E4 (VPO).

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0710 (Tag F0710)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of clinical records and review of other documentation as indicated, it was determined that for two (R1 and R3) out of three residents reviewed for admission, the facility's providers failed to provide orders for each residents' immediate care and needs. Findings include: 1. Cross refer to F760 R1's clinical record revealed: 9/30/22 at 1:06 PM - The facility received a 13 page fax that included an interagency form and discharge instructions for R1 from an acute rehabilitation hospital. Review of the fax, which included R1's discharge medications and possible side effects of each medication listed on pages 1 through 9, revealed that pages 2, 4, 6 and 8 were missing. 9/30/22 at 2:50 PM - R1 was admitted to the facility with multiple diagnoses. 10/1/22 at 12:37 AM - A nursing note documented that R1's medication regimen was reviewed and reconciled by telephone with E6 (on-call NP). 10/1/22 at 2:08 PM - A Physician note by E5 (PA) documented that R1's hospital record was reviewed and his medications were reconciled. Medications listed as reviewed and reconciled in E5's note were: -Aplisol (used to test for Tuberculosis, a contagious lung infection); -Acetaminophen (for pain); -Bisacodyl / Fleet enema / Milk of Magnesia (for constipation); -Amlodipine (for high blood pressure); -Carvedilol (for high blood pressure); -Clopidogrel Bisulfate (for blood clot prevention); -Aspirin (for coronary artery disease/heart attack); -Gabapentin (for nerve pain); -Cholecalciferol (for Vitamin D); -Cyanocobalamin (for Vitamin B-12 deficiency); -Atorvastatin (for high Cholesterol); -Multivitamins (supplement); -Heparin (blood thinner); -Desmopressin (controls urine output); -Sodium Chloride (regulates the amount of water in the body), -Fish Oil (for high Cholesterol); and -Insulin Aspart (for high blood sugars). 10/3/22 at 1:00 PM - A care conference was held with R1 and F1 (R1's family member). F1 was provided with a copy of R1's ordered medications during this conference. 10/3/22 at 2:50 PM - A Physician note documented that E5 (PA) performed a review of recent labs, medications and blood sugars for R1. Medications listed as reviewed and reconciled in E5's note were identical to the 10/1/22 Physician note. 10/4/22 at 10:11 AM - A Physician note documented that E7 (MD) performed an admission History and Physical, reviewed the hospital record, did medication reconciliation and examined R1. Medications reconciled were the same medications listed on E5's (PA) progress notes dated 10/1/22 and 10/3/22. 10/4/22 at 2:52 PM - In response to F1 (R1's family member) informing the facility that R1's medication list was incomplete, the facility contacted the acute rehabilitation hospital and requested a faxed list of R1's discharge medications. 13 medications were not ordered when R1 was admitted on [DATE]: Despite multiple PA/Physician assessments, including review of R1's hospital course and medication reconciliation, 13 medications were not detected as missing and ordered until 10/4/22, four days after admission to the facility. 2. Review of R3's clinical record revealed: 9/21/22 at 12:15 AM - R3 was admitted to the facility following a VP shunt placement at the hospital. 9/21/22 at 11:32 AM - A Physician note by E5 (PA) documented that a hospital record review and medication reconciliation was done. The note documented that R3 underwent VP shunt placement on 9/7. The physical exam and assessment/plan by E5 failed to address R3's surgical wounds on the head and on the right side of his abdomen. 9/21/22 to 9/26/22 - R3's clinical record revealed the absence of Physician orders for treatment and to monitor R3's two surgical wounds. 3/10/23 at 10:16 AM - During an interview with E1 (NHA), the Surveyor was informed that E5 (PA) was no longer working in the facility as of 2/13/22. 3/14/22 at 12:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON), E3 (ADON) and E4 (VPO).

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and clinical record review, it was determined that for one (R1) out of three residents reviewed for admission, the facility failed to ensure that R1 was free of any significant medication errors when thirteen (13) medications weren't ordered upon admission, resulting in R1 missing multiple doses of each medication. Findings include: Cross refer to F710 R1's clinical record revealed: 9/30/22 at 1:06 PM - The facility received a 13 page fax that included an interagency form and discharge instructions for R1 from an acute rehabilitation hospital. Review of the fax, which included R1's discharge medications and possible side effects of each medication listed on pages 1 through 9, revealed that pages 2, 4, 6 and 8 were missing. 9/30/22 at 2:50 PM - R1 was admitted to the facility with diagnoses including, but not limited to, adrenal insufficiency (a rare disorder where the adrenal glands don't make enough of certain hormones. Symptoms include weight loss, loss of appetite, nausea, vomiting, diarrhea, muscle weakness, fatigue, low blood pressure, low blood sugar and patchy or dark skin), high blood pressure, hypothyroidism (underactive thyroid) and fractures of the rib and spine. 10/1/22 at 12:37 AM - A nursing note documented that R1's medication regimen was reviewed and reconciled by telephone with E6 (on-call NP). 10/1/22 at 2:08 PM - A Physician note by E5 (PA) documented that R1's hospital record was reviewed and his medications reconciled. The note captured R1's medical history as .Hyponatremia (low sodium from dilution, loss of sodium in urine from taking medication to reduce fluid or Addison's disease) thought to be secondary to taper of hydrocortisone (a steroid medication) on prior recent hospital discharge back in August 2022 as patient has hypopituitarism (a deficit or shortage of one or more of the pituitary hormones) secondary to hypophysectomy (surgery done to remove the pituitary gland) done back in 1990s. Patient follows with outpatient endocrinologist (Physician with special training including glands and organs that make hormones) . consulted endocrinology team who recommended increasing hydrocortisone back to 20 mg (milligrams) once each morning and 10 mg once each evening (ideally between 2 PM and 3 PM) and recommended patient be discharged on this regimen with follow up outpatient . Patient was also on home desmopressin (medication that controls urine output) which was also adjust for patient's hyponatremia given significant excessive urine output . Medications listed as reviewed and reconciled in E5's note were: -Aplisol (used to test for Tuberculosis, a contagious lung infection); -Acetaminophen (for pain); -Bisacodyl / Fleet enema / Milk of Magnesia (for constipation); -Amlodipine (for high blood pressure); -Carvedilol (for high blood pressure); -Clopidogrel Bisulfate (for blood clot prevention); -Aspirin (for coronary artery disease/heart attack); -Gabapentin (for nerve pain); -Cholecalciferol (for Vitamin D); -Cyanocobalamin (for Vitamin B-12 deficiency); -Atorvastatin (for high Cholesterol); -Multivitamins (supplement); -Heparin (blood thinner); -Desmopressin (controls urine output); -Sodium Chloride (regulates the amount of water in the body), -Fish Oil (for high Cholesterol); and -Insulin Aspart (for high blood sugars). 10/3/22 at 1:00 PM - A care conference was held with R1 and F1 (R1's family member). F1 was provided with a copy of R1's ordered medications during this conference. 10/3/22 at 2:50 PM - A Physician note documented that E5 (PA) performed a review of recent labs, medications and blood sugars for R1. Medications listed as reviewed and reconciled in E5's note were identical to the 10/1/22 Physician note. 10/4/22 at 10:11 AM - A Physician note documented that E7 (MD) performed an admission History and Physical, reviewed the hospital record and medication reconciliation and examined R1. Medications reconciled were the same medications listed on E5's (PA) progress notes dated 10/1/22 and 10/3/22. 10/4/22 at 2:52 PM - In response to F1 (R1's family member) informing the facility that R1's medication list was incomplete, the facility contacted the acute rehabilitation hospital and requested a faxed list of R1's discharge medications. The following 13 medications were not ordered when R1 was admitted on [DATE]: -Hydrocortisone for Adrenal Insufficiency (life-threatening medical condition where the body does not make enough hormone cortisol .cortisol also controls blood pressure and affects how a person's immune system works); -Levothryoxine for Hypothyroidism (decrease production of thyroid hormones); -Lisinopril for high blood pressure; -Hydralazine for high blood pressure; -Morphine for severe pain; -Calcium Carbonate for Hypocalcemia (low calcium levels in the blood); -Acetaminophen for pain; -Pantoprazole for acid reflux; -Tizanidine for muscle spasms; -Trazadone for major depressive disorder; -Ubiquione for supplement; -Albuterol inhaler for shortness of breath as needed; and -Desmopressin (used to control the amount of urine the kidneys make) second Physician's order based on his urine output as needed. Review of R1's October 2022 eMAR revealed that R1 missed the following medications from 10/1/22 through 10/11/22: -five (5) doses of Hydrocortisone for Adrenal Insufficiency (life-threatening medical condition where the body does not make enough hormone cortisol .cortisol also controls blood pressure and affects how a person's immune system works); -five (5) doses of Levothryoxine; -four (4) doses of Lisinopril; -eight (8) doses of Hydralazine; -thirty-one (31) doses of Morphine for severe pain; -eight (8) doses of Calcium Carbonate; -nine (9) doses of Acetaminophen for pain; -four (4) doses of Pantoprazole; -thirty-one (31) doses of Tizanidine; -four (4) doses of Trazodone; -seven (7) doses of Ubiquione; and -eleven (11) doses of Desmopressin. 3/10/23 at 10:16 AM - During an interview with E1 (NHA), the Surveyor was informed that E5 (PA) was no longer working in the facility as of 2/13/23. 3/14/23 at 12:30 PM - Findings were reviewed during the exit conference with E1, E2 (DON), E3 (ADON) and E4 (VPO).

Aug 2022 14 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, it was determined that for one (R3) out of one resident sampled for privacy, the facility failed to ensure that personal care and discussion of personal health information was provided in a way that promoted privacy. Findings include: Review of R3's clinical record revealed: 9/19/21 - R3 was admitted to the facility with chronic wounds to the lower legs and was provided services from a Wound Care Doctor. 8/11/22 11:33 AM - At the nurses station within hearing range of other residents and families, the Surveyor observed E28 (Wound Care Doctor) loudly saying he had sent [R3] to the vascular doctor, he is non-compliant, that his wounds will never heal, and that he was going to lose his legs. 8/11/22 1:20 PM - During an observation, it was noted that R3 was in his wheelchair in his room, approximately five feet from the door with dressings off of his legs exposing R3's multiple wounds. E28 (Wound Care Doctor) and E27 (ADON) were present in R3's room. The curtain and the door were left open and R3's treatment could be seen from the hallway. E28 spoke in a loud voice to R3 with R3's curtain and door open to the hallway. E28 stated that R3's non-compliance with care and if R3 did not accept treatment from the facility, then he was going to lose his legs. After some discussion between E27 (ADON) and E28 regarding R3's treatment, E27 and E28 exited R3's room into the hallway. E28 aggressively removed his surgical gown and stated, I can't do this anymore. There is nothing that I can do. E27 inquired about what kind of treatment (dressings) to apply to R3's legs and E28 replied loudly, Put whatever treatment on them (R3's legs) that he will allow. During the entire assessment the door and curtain were open to the hallway. The resident was visible to others and the discussion of his care could be heard by others. R3's legs and wounds were extremely red from R3's knees down to R3's toes and leaking fluid onto the floor. E27 and E28 proceeded to walk up the hall, did not apply dressings to R3's legs, and left the door open. 8/12/22 approximately 10:30 AM - During an interview, E27 (ADON) confirmed that R3's care was loudly discussed by herself and E28 (Wound Care Doctor) at the nurses station and with the door fully open to his room. Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 8/17/22, at approximately 2:00 PM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observation and interview, it was determined that for one (R69) randomly selected resident room for a safe, clean comfortable, home like environment, the facility failed to provide a safe, clean, comfortable, homelike environment. Findings include: 8/10/22 12:35 PM - FM1 (family member) requested the Surveyor to visit R69's room. 8/10/22 12:40 PM - During an interview with FM1, the following concerns were expressed by FM1 and observed by the Surveyor: - Approximately 40-50 fruit flies flew up from the cracked and soiled fall mat on the right side of the bed. The fruit flies encircled FM1 and the Surveyor. There were also fruit flies circling R69's uncovered lunch tray. - The area surrounding R69's bed, on the floor, had soiled dried food and debris. Under the bed was a used plastic cup and a medicine cup. On the floor between the bed and the bedside table there was a soiled washcloth. - The wall on both sides of the air conditioner approximately eight inches from the floor and towards the right and left corners of R69's room were stained and black. To the immediate right of the air conditioner, the wall was bowed out in an area approximately 2-3 inches in length exposing a blackened wooden board and a black area behind the drywall. - A bedside commode to the left of R69's bed had dark yellow foul smelling urine in it. During the observation, FM1 revealed that the condition of R69's room was brought to the nurses attention multiple times. It was further revealed that FM1 was told that the facility would deep clean R69's room, but it was never done. FM1 stated that R69 does not get out of bed because it is not comfortable and R69 becomes anxious. 8/10/22 at approximately 12:50 PM - During an observation and interview E6 (LPN), E10 (Maintenance Director) and E11 (Housekeeping Manager) confirmed the abovementioned condition of R69's room. On 8/10/22 at approximately 1:00 PM, an additional Surveyor confirmed the following: - In the area where the fall mat used to be, the floor was visibly dirty and bugs were swarming at the residue. - The area by the window had a black discolored wall. 8/10/22 1:16 PM - During an interview, E1 (NHA) confirmed the room required attention and stated that Maintenance and Housekeeping were in the room to address the concerns. 8/10/22 1:52 PM - During an observation and interview with E10 (Maintenance Director) and E11 (Housekeeping Manager) in R69's room, E10 had removed the air conditioner, all of the molding the length of the left side of the bed and was removing the black stained drywall from the wall around the air conditioner. During the observation and interview E11 stated that Housekeeping personnel were not allowed to move the fall mats or R69's bed when she was in it, because it was a safety issue for R69. Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 8/17/22, at approximately 2:00 PM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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Based on record review and interview, it was determined that for two (R56 and R60) out of four residents reviewed for hospitalization, the facility failed to provide each resident and/or resident representative with a bed hold notice. Findings include: 1. R56's clinical record revealed: 4/16/22 to 4/22/22 - R56 was hospitalized . 4/26/22 to 4/28/22 - R56 was hospitalized . The facility lacked evidence that R56 and/or the resident's representative was provided a bed hold notice each time the resident was hospitalized in April 2022. 8/10/22 at 10:50 AM - During an interview, E3 (VPO) confirmed the finding. 2. R60's clinical record revealed: 7/7/22 to 7/20/22 - R60 was hospitalized . The facility lacked evidence that R60 and/or the resident's representative was provided a bed hold notice when the resident was hospitalized in July 2022. 8/10/22 at 10:50 AM - During an interview, E3 (VPO) confirmed the finding. 8/17/22 at approximately 2:00 PM - Finding was reviewed during the exit conference with E1 (NHA) and E2 (DON).

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on record review and interviews, it was determined that for one (R13) out of two residents reviewed for dental, the facility failed to revise the care plan to reflect current resident needs when R13 refused dental cleaning despite the dentist's recommendation. Additionally, for one (R7) out of four residents reviewed for pain management, the facility failed to monitor for effects of sedation from taking opioid medication. Findings include: 1. Review of R13's clinical record revealed the following: 5/14/20 - Resident was admitted to the facility. 3/29/22 - A dental exam note documented that R13 wanted her teeth extracted, but she did not want a cleaning. R13 was recommended to have a cleaning. 8/4/22 12:54 PM - In an interview, R13 told the Surveyor that she saw the dentist a few months ago for a tooth extraction. R13 added that she did not want dental cleaning services. 8/7/22 - R13's Care plan for active dental infection, initiated on 3/30/22, indicated that the problem was resolved as of 8/7/22. 8/8/22 1:15 PM - During an interview, E6 (LPN) stated that R13 had a tooth extraction and was on antibiotic therapy for a dental abscess. E6 also stated that R13 was recommended by the dentist for dental cleaning, but R13 refused. E6 further commented, I just asked resident (R13) again about the dental cleaning, but she refused. 8/9/22 10:45 AM - In an interview, E9 (RN UM) stated that R13 has a behavior of refusing dental cleanings and further confirmed that her dental care plan should have been revised to include the behavior of refusing dental cleanings. 8/9/22 11:44 AM - Findings were discussed with E2 (DON). Findings were reviewed with E1 (NHA) and E2 during the exit conference on 8/17/22 at approximately 2:00 PM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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3. Review of R70's clinical record revealed the following: 5/15/15 - R70 was admitted to the facility with a diagnosis of Cerebral Palsy. 6/3/22 - A care plan problem for R70 stated, Resident has a self-care deficit related to a decrease in functional mobility, strength, balance, and endurance. Care plan interventions included Encourage independence in ADL care, but to offer assistance as needed. 7/14/22 - R70's quarterly MDS assessment revealed a BIMS of 15 (Intact cognitive response/decisions consistent) and required one person physical assistance with personal hygiene. July 2022 - The electronic documentation Survey Report revealed that R70 needed staff assistance with personal hygiene, including toothbrushing, that occurred seven out of thirty one evenings. 8/5/22 10:01 AM - An interview with R70 revealed that her evening toothbrushing routine is very important to her because she wants her mouth as clean as possible during the overnight sleeping hours. R70 stated that her Cerebral Palsy limits her ability to thoroughly clean her teeth in the evenings, so she routinely asks for staff assistance to brush her teeth in the evenings. R70 stated that staff do not provide her the requested assistance, instead telling R70 that she can do the task independently. 8/8/22 4:00 PM - During an interview with E9 (RN) and E20 (RN) concerning R70's requests to have staff assistance to help R70 brush her teeth in the evenings, E9 stated that the toothbrushing assistance was detailed in R70's care plan, so the aides know to help the resident. Review of R70's care plan lacked staff assistance with toothbrushing. 8/8/22 4:15 PM - E20 (CNA) was interviewed about the extent of help E20 gives R70 with ADLs in the evening, including assisting R70 to brush her teeth. E20 stated that she provides assistance, including toothbrushing, each time she works with R70 in the evening. 8/9/22 9:09 AM - R70 was asked if she received staff assistance to brush her teeth last evening. R70 said that she did not receive staff assistance with toothbrushing last evening, even after requesting staff assistance. Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 8/17/22, at approximately 2:00 PM. Based on observation, interview and record review, it was determined that for two (R70 and R236) out of two residents reviewed for assistance with ADL's, the facility failed to provide R236 with devices to assist the resident with toileting and for R70, the assistance to brush their teeth. Additionally, for one (R234) out of four residents reviewed for communication, the facility failed to provide an assistive device to maintain the resident's communication. Findings include Review of R236's clinical record revealed: 7/26/22 - R236 was admitted to the facility with multiple diagnoses including a broken left ankle. 7/26/22 - R236's care plan for ADL's included interventions to provide one person assistance with bed mobility, two person assist with transfers, toileting, bathing and dressing, set up with meals, encourage independence with ADL care, but offer assistance as needed, and provide adaptive equipment as ordered. The care plan lacked interventions that specified R236's preference to use a urinal for toileting needs. 7/29/22 1:07 PM - A plan of care note documented, admission bowel and bladder evaluation completed. He is continent of both and toilets with two person assist. Staff will assist him at his request. 8/2/22 - An admission MDS assessment documented R236 as being cognitively intact and requiring extensive assistance of one person for toileting and being occasionally incontinent of both bladder and bowel. During an interview on 8/4/22 at 11:36 AM, R236 stated, I sat in the bed over an hour waiting on a urinal. R236 was observed with a cast to the left leg and reported to the Surveyor that he preferred to use a urinal in bed. Observation of R236's room and bathroom revealed no urinals for R236 to use for toileting. During an interview on 8/9/22 at 9:48 AM, E25 (CNA) was able to show the Surveyor two urinals in R236's room. When asked how the CNA's know which residents prefer a urinal and where that information was located, E25 stated she ask's the resident and the nurse and checks the electronic record for instructions. Review of R236's electronic record lacked documentaion of R236's preference to use a urinal. During an interview on 8/9/22 at 11:29 AM, E2 (DON) confirmed R236 did not have a care plan that addressed the residents toileting needs. E2 stated, Because he is continent, he doesn't have a care plan. Every resident is able to express themselves and the staff would offer them a urinal. The staff should offer him to use it. If he didn't want to use it staff would help him to the bathroom. 2. Review of R234's clinical record revealed: 7/23/22 - R234 was admitted to the facility with multiple diagnoses, including bilateral unspecified hearing loss and intellectual disability. 7/23/22 9:09 PM - A physician note documented, Multiple medical comorbidities including mental retardation and severe hearing loss. 7/25/22 - An admission MDS assessment documented R234 as having moderate difficulty hearing, hearing aide no. 7/25/22 - A baseline care plan completed for R234 documented for staff to ensure that adaptive equipment that the resident needs is provided and functional, hearing aide communication board reminder cue support goal involvement encouragement. 7/25/22 4:02 AM - A note in R234's clinical record documented, Alert and oriented to person, place, time, with hearing impairment, able to communicate by reading with communication board and make needs known verbally. 8/4/22 1:45 PM - R234 was observed sitting in a geri-chair, hearing aide was on the bedside table. R234's communication board was at the bedside. 8/5/22 - A care plan for communication problem was created with a goal to restore communication losses. Interventions included to refer to audiology for heating consult as ordered; Monitor document nonverbal indicators of discomfort distress and follow up as needed; OT/PT/Nurse to evaluate resident dexterity/ability to use communication board, writing, use computer or sign language as alternate communication to speech; and Refer to audiology as ordered. 8/5/22 10:26 AM - R234 was observed in bed, no hearing aides in, no communication board visible. 8/5/22 11:07 AM through 11:15 AM - R234 was observed in therapy no hearing aides observed in ear, no communication board observed being used. 8/8/22 12:41 PM - R234 was observed in geri-chair. The Surveyor asked E12 (CNA) assigned to R234 if the resident wore hearing aides. E12 stated, R234 Doesn't have any, I think they were going to get them. E12 was unable to locate R234's communication board. When asked how E12 communicates with R234, E12 stated, We talk, she can hear some. 8/8/22 12:59 PM - E29 (COTA) was observed leaving R234's room, when asked how E29 communicates with R234, E29 stated, I speak loudly communicate she can hear. R234 did not have hearing aides in, and no communication board was observed. 8/9/22 9:16 AM - E12 (CNA) stated, I followed up on R234 and the nurse keeps the hearing aides so the resident should have them now. E12 confirmed she was unaware of the location of communication board. 8/9/22 10:58 AM - R234's hearing aides were observed on the table. E30 (LPN) stated, Her daughter said they are not working, I think the ADON is working on that. At 11:00 AM E30 then stated, The group came and they said that one [hearing aide] is working. E30 then confirmed she was unaware of the location of R234's communication board. The the clinical record lacked evidence that R234 had a daughter. 8/9/22 12:31 PM - E31 (ST) was asked whether R234 needed the communication board and hearing aides to communicate with staff. E31 stated, I can't answer that. The white board was taken by the group home when they replaced the hearing aides, then they took it back. R234 can hear within functional limits. 8/9/22 12:45 PM - E2 (DON) reported to the Surveyor that R234's communication board was located. E2 stated, R234's roommate had it in her possession. 8/9/22 2:28 PM - A note in R234's clinical record documented, Pt's (patient's) white erase board is within her reach along with dry erase marker. Review of the CNA task list lacked evidence of awareness to ensure resident had communication board.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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Cross refer F656 Based on observations, interviews and record review, it was determined that for one (R27) out of one resident reviewed for ROM (Range of Motion), the facility failed to ensure that R27's palm guard was in place on her right hand to keep the fingers extended. Findings include: Review of R27's clinical records revealed the following: 3/12/20 - R27 was admitted to the facility with diagnoses including muscle weakness affecting the dominant right side. 2/20/22 - A CNA flowsheet for R27's restorative Splint/Brace Assistance Program revealed an instruction for CNA to ensure that palm guard is in place to R27's right hand. Remove for hygiene . 4/18/22 - An OT (Occupational Therapy) treatment note documented, .Therapeutic carrot fitted & donned to R (right) hand to facilitate functional position of R hand. Pt. (patient) tolerated therapeutic carrot for approximately 4 hours on this date. 4/18/22 - R27 was discharged from OT services as she had reached the highest practical level. R27's current level of function was good with consistent staff follow through. 7/20/22 - A care plan was initiated for R27's contracture of the right wrist with interventions including CNA to ensure that palm guard is in place to R27's right hand and to provide assistance with the application of devices to prevent the formation of contractures. 7/28/22 - R27 had a physician's order for CNA to ensure that palm guard is in place to R27's right hand, remove for hygiene, check skin and report changes in skin and to remove at bedtime. 8/5/22 3:34 PM - During an observation, R27's right hand was closed. Subsequent observations on 8/8/22 at 9:50 AM, 8/822 at 3:21 PM and 8/9/22 at 4:02 PM revealed that R27's right hand continued to be closed. 8/9/22 4:02 PM - E6 (LPN) entered R27's room to check R27's right hand and confirmed that R27 did not have the palm guard on her right hand. E6 asked R27 if her right hand was hurting to which R27 moaned in response to pain. 8/10/22 11:28 AM - Review of R27's July 2022 CNA flowsheet on restorative Splint/Brace Assistance Program documentation revealed that for 20 out of 43 opportunities, R27's splint assistance was documented as Not Applicable. 8/10/22 11:45 AM - Review of a new OT evaluation and plan of treatment, dated 8/10/22, revealed that R27 has Palm guard managed by nursing, at baseline Pt (patient) presents with decreased right shoulder and wrist ROM. OT services recommended for splint management to increase ROM in shoulder, wrist and hand decreasing risk for further contracture. 8/10/22 12:03 PM - During an interview, E7 (OT) stated that on R27's discharge from OT services on 4/18/22, R27 was recommended for continued use of the palm guard to be placed on her right hand for skin integrity, to keep her nails from digging into her skin and to help with some extension of her fingers. 8/10/22 3:24 PM - In an interview, E3 (VPO) confirmed that when CNAs marked the flowsheet as Not Applicable, it meant it was not done. 8/11/22 12:17 PM - Review of R27's 8/1/22 through 8/10/22 CNA flowsheet on restorative Splint/Brace Assistance Program documentation revealed that for 7 out of 10 opportunities, R27's splint assistance was documented as Not Applicable. Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 8/17/22, at approximately 2:00 PM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, it was determined that for one (R40) out of three residents reviewed for pain, the facility failed to treat the residents pain to the extent possible by not providing R40's pain relief gel at the bedside per physicians orders. Findings include: The facility policy on pain management, last updated 4/1/20, indicated that Pain is whatever a resident says it is . Review of R40's clinical record revealed: 6/10/22 - R40 was admitted to the facility with multiple diagnoses, including compression fracture of the back, history of a broken foot and osteoarthritis. 6/11/22 - A care plan was created for R40 for pain related to thoracic [back] compression fracture with a goal to have pain controlled to a level that is comfortable and acceptable to the resident. Interventions included, administer pain medications as ordered, report and document complaint, reposition for comfort, and try non-pharmacological interventions. 6/16/22- An admission MDS assessment documented R40 as cognitively intact, receiving scheduled and as needed pain medication interventions for frequent pain of 10 out of 10, (on a scale of 0-10). 7/13/22 - An order was written for R40 to receive a pain relief gel with the following instructions, Apply to both shoulders topically every 4 hours as needed for shoulder pain unsupervised self-administration, please give patient tube, she may self-administer. 7/27/22 10:30 AM - A physician's note documented, The patient presented with back pain and was diagnosed with a T9 thoracic compression fracture . The patient was seen and examined at bedside. The patient says that her shoulder pain is still present although generally improved following the injection several weeks ago. R40 says she has still not yet had [pain relief] gel put on her shoulders. She has not been able to get the tube of gel despite asking repeatedly . During an interview on 8/4/22 at 10:44 AM, R40 reported pain of a 4 out of 10 in the shoulders and stated, I've been asking for my pain relief gel for my shoulder several weeks. They keep saying they are ordering it. I'm supposed to be able to keep it here. The Surveyor received permission to look in R40's bedside drawer and was unable to locate pain relief gel. During an interview on 8/8/22 at 11:48 AM, R40 rated her pain as a 3 out of 10 and stated, It mostly hurts when I have to pull myself, reposition, or go to therapy. I was just repositioning myself. When asked if R40 received her pain relief gel, R40 stated, Nobody ever gives it to me. 8/8/22 11:51 AM - E12 (LPN) accompanied the Surveyor to the treatment cart and showed the Surveyor R40's pain relief gel. E12 was asked whether the resident could have it at the bedside. E12 stated No. E12 and the Surveyor reviewed R40's medication orders on the computer attached to the medication cart, that indicated the resident could have the pain relief gel at the bedside. E12 then stated, I will take it there now. E12 entered R40's room with the pain relief gel to place it at the bedside. Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 8/17/22, at approximately 2:00 PM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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Based on observations, record review, and interview, it was determined that the facility failed to ensure that it was free of a medication error rate of 5% or greater. During a medication pass observation on 8/10/22, two medication errors out of twenty seven opportunities were identified, resulting in a medication error rate of 7.40%. Findings include: The facility's policy titled, Staff Administered Medication, with an effective date of 4/1/20, documented: The majority of medications administered in the Nursing Home are in a pre-packaged system from an approved pharmacy. The medications are administered by staff members as indicated by State regulations. Review of R382's clinical record and observation revealed: 8/10/22- A physician's order for Budesonide Suspension 0.5 MG/2ML-2 ml inhale orally via nebulizer two times a day for breathing issues. 8/10/22- A physician's order for Arformoterol Tartrate Nebulization Solution 15 MCG/2ML-2 ml inhale orally via nebulizer two times a day for breathing issues. 8/10/22 10:30- During a random medication pass observation, E26 (LPN) administered the above medications to R382 as a single nebulized medication treatment, rather than as two separate medications as ordered. 8/10/22 11:00- During an interview, E26 confirmed that the medications were mixed together and administered as a single nebulizer treatment. 8/10/22 11:30- During an interview, E6 (LPN) confirmed that the physician order for Budesonide Suspension 0.5 MG/2ML-2 ml and Arformoterol Tartrate Nebulization Solution 15 MCG/2ML-2 ml did not include directions that the medications should be mixed together prior to administration. Findings were reviewed with E1 (NHA) and E2 (DON) on 8/17/22, at approximately 2:00 PM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview, it was determined that the facility failed to adhere to a food preference for one (R56) resident observed during a random meal observation. Findings include: Review of R56's clinical record revealed the following: 1/5/22 - R56 was admitted to the facility. 3/4/22 - A Physician's Order for a pureed renal diet and that R56 may order off of the renal diet as the resident requested. 8/12/22 beginning at 12:45 PM - A random lunch meal observation was conducted and R56 verbalized that she was served what she thought was pureed ham. R56 stated that she was only eating a small amount due to the salt content and stated that she was not supposed to have ham or sausage. Review of R56's meal ticket stated no sausage or ham. 8/12/22 1:00 PM - An interview with E13 (Food Service Director) revealed that R56 was served either a pureed ham or sausage which she should not have been served. 8/16/22 01:55 PM - Findings were confirmed with E1 (NHA) and E2 (DON). 8/17/22 at approximately 2:00 PM - Finding was reviewed during the exit conference with E1 and E2.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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3. A CDC guideline for Hand Hygiene in Healthcare Settings (https://www.cdc.gov/handhygiene/providers/indes.html), updated January 2021, recommends: When cleaning hands with soap and water, wet hands first with water, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and use disposable towels to dry. Use towel to turn off the faucet. 8/10/22- During a random medication administration, E26's (LPN) handwashing times were observed to be 7 seconds and 12 seconds respectively, before and after medication administration. E26 then turned off the water with her bare hands after handwashing, thus contaminating her hands. Findings were reviewed with E1 (NHA) and E2 (DON) on 8/17/22, at approximately 2:00 PM. 2. The facility policy on blood sampling (finger sticks), last updated September 2014, indicated that staff should Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. During medication observations on 8/5/22 the following was observed: 9:58 AM - E11 (LPN) performed hand hygiene [HH], removed a glucometer from a drawer of the medication cart, entered R19's room and obtained the residents blood sugar. E11 then performed HH, entered R234's room, obtained the residents blood sugar and performed HH, then exited the room. E11 did not disinfect the glucometer between resident uses. 10:03 AM - E11 (LPN) placed the glucometer in the medication cart drawer and locked the medication cart. E11 did not disinfect the glucometer. 10:06 AM - E11 (LPN) confirmed the findings and stated, I grab them [disinfectant wipes] from the documentation cart [station]. I usually clean it between each use, but didn't. E11 then attempted to obtain a disinfectant wipe from the documentation station in the hall, but it was empty. E11 had no disinfectant wipes on the medication cart. E11 locked the medication cart, went to obtain disinfectant wipes at 10:08 AM, returned at 10:11 AM and cleaned the glucometer. Based on observations, interviews and review of facility policy and procedure, it was determined that the facility failed to maintain an effective infection prevention and control program by: failing to wear the appropriate PPE (personal protective equipment - gloves) when providing direct care to residents in their rooms and cleaning a resident's room during an outbreak of COVID-19; failing to disinfect the glucometer between resident use; and failing to complete adequate hand hygiene during medication administration. Findings include: 1. Due to an outbreak of COVID-19, the facility implemented nursing staff to wear full PPE (N95 masks, gowns, eye protection and gloves). Observations of facility staff on the nursing units on 8/16/22 revealed: - at 8:42 AM, observed E22 (CNA) and E23 (OT) on each side of R238's bed lifting the sheets to reposition the resident. E22 was observed not wearing gloves during this care, while E23 was wearing gloves. Finding was immediately discussed and confirmed with E22 upon exiting R238's room. - at 9:55 AM, observed E24 (Housekeeping) in R286's room wearing only a glove on his right hand and wiping around the sink while the ungloved left hand was holding a pink plastic container with toiletries. After removing the glove, E24 sanitized his hands before collecting clean linens from the cart in the hallway. E24 went back in the room without donning gloves and proceeded to put clean linens on B bed, touching the footboard of B bed, then lifting the mattress to tuck in the linens. E24 then turned around and picked up his sweeper and dustpan and proceeded to clean the floor, then walked over to A bed and pulled the privacy curtain without wearing gloves. Finding was immediately discussed and confirmed with E24 upon exiting R286's room. The facility failed to ensure staff followed infection control practices when providing direct care to residents and cleaning a resident's room during an outbreak of COVID-19.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

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Based on record review and interview, it was determined that for one (R131) out of six residents reviewed for COVID-19 immunizations, the facility failed to provide evidence that R131 or her family received the current information regarding the additional doses, including any changes in the benefits or risks and potential side effects associated with the COVID-19 vaccine. In addition, the facility lacked evidence that R131 or her family had the opportunity to accept or refuse the COVID-19 vaccine. Findings include: Review of R131's clinical record revealed the following: 6/12/21 - R131 was admitted to the facility. 7/9/21 11:40 AM - A nurse progress note documented, This writer informed this resident that she is eligible for her second dose of vaccine this morning. Resident has PNA (pneumonia) and continues on abt (antibiotic) Augmentin. Reached out to (doctor) if we should hold vaccine due to PNA, and ordered to continue to vaccinate resident at this time since she has been on abt for so many days already and is not contraindicated. Will be vaccinated today with dose #2 and resident made aware. 7/9/21 4:00 PM - A nurse progress note documented that R131 received her COVID-19 vaccine in her right arm with no signs or symptoms of adverse reactions noted. 8/16/22 10:34 AM - During a closed record review, R131's clinical record revealed that the facility lacked evidence that R131 or her family received the current information regarding the additional doses, including any changes in the benefits or risks and potential side effects associated with the COVID-19 vaccine. In addition, the facility lacked evidence that R131 or her family had the opportunity to accept or refuse the COVID-19 vaccine. 8/17/22 10:20 AM - In an interview with E5 (ICP), it was confirmed that R131's signed consent form was not found in the paper chart. 8/17/22 11:15 AM - Findings were discussed with E2 (DON). Findings were reviewed with E1 (NHA) and E2 during the exit conference on 8/17/22 at approximately 2:00 PM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0943 (Tag F0943)

Could have caused harm · This affected 1 resident

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Based on record review and interview, it was determined that the facility failed to ensure that required dementia management training was completed for one E14 (CNA) out of five CNA's reviewed for annual training's. Findings include: 8/15/22 - CNA'S E14, E15, E16, E17, and E18 were reviewed on the staff training and vaccination worksheet for compliance with required annual dementia training. E14's most recent dementia training was documented as 11/6/20 and corresponding transcripts documented the same date. During an interview on 8/15/22 at 1:36 PM, E5 (RN Staff Development Coordinator) confirmed the education dates provided on the staff training worksheet and corresponding education transcripts. Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 8/17/22, at approximately 2:00 PM.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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2. The following issues were observed during the second kitchen visit on 8/5/22 at approximately 10:30 AM: -The fume hood was dusty and greasy. -The walls and table surfaces by the stove area were not clean. Findings were reviewed and confirmed by E12 (FSD) on 8/5/22, at approximately 11:00 AM. Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 8/17/22, at approximately 2:00 PM. Based on observations and interview, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Findings include: 1. During the initial kitchen tour on 8/4/22 at 9:27 AM, 22 slices of uncovered watermelon were observed plated and placed onto trays in the walk-in refridgerator. E12 (FSD) immediately confirmed the finding and stated the watermelon was sliced yesterday.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• 40% turnover. Below Delaware's 48% average. Good staff retention means consistent care.

Concerns

• 48 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
• $29,309 in fines. Higher than 94% of Delaware facilities, suggesting repeated compliance issues.
• Grade C (55/100). Below average facility with significant concerns.

Bottom line: Mixed indicators with Trust Score of 55/100. Visit in person and ask pointed questions.

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About This Facility

What is Excelcare At Newark Llc's CMS Rating?

CMS assigns EXCELCARE AT NEWARK LLC an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Delaware, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Excelcare At Newark Llc Staffed?

CMS rates EXCELCARE AT NEWARK LLC's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 40%, compared to the Delaware average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Excelcare At Newark Llc?

State health inspectors documented 48 deficiencies at EXCELCARE AT NEWARK LLC during 2022 to 2025. These included: 2 that caused actual resident harm, 43 with potential for harm, and 3 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Excelcare At Newark Llc?

EXCELCARE AT NEWARK LLC is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by EXCELCARE, a chain that manages multiple nursing homes. With 101 certified beds and approximately 91 residents (about 90% occupancy), it is a mid-sized facility located in NEWARK, Delaware.

How Does Excelcare At Newark Llc Compare to Other Delaware Nursing Homes?

Compared to the 100 nursing homes in Delaware, EXCELCARE AT NEWARK LLC's overall rating (4 stars) is above the state average of 3.3, staff turnover (40%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting Excelcare At Newark Llc?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Excelcare At Newark Llc Safe?

Based on CMS inspection data, EXCELCARE AT NEWARK LLC has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Delaware. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Excelcare At Newark Llc Stick Around?

EXCELCARE AT NEWARK LLC has a staff turnover rate of 40%, which is about average for Delaware nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Excelcare At Newark Llc Ever Fined?

EXCELCARE AT NEWARK LLC has been fined $29,309 across 2 penalty actions. This is below the Delaware average of $33,372. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Excelcare At Newark Llc on Any Federal Watch List?

EXCELCARE AT NEWARK LLC is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 101
Avg. Residents: 91
Occupancy: 90.2%
Ownership: For profit - Corporation
Chain: EXCELCARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
4-Star Rating: +30
2 Actual Harm citations: -10
48 Deficiencies: -10
Fines ($29,309): -5
Final Score: 55/100

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Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 085025